Post-infarction ventricular septal defect: percutaneous or surgical management in the UK national registry.

AIMS: Post-infarction ventricular septal defect (PIVSD) is a mechanical complication of acute myocardial infarction (AMI) with a poor prognosis. Surgical repair is the mainstay of treatment, although percutaneous closure is increasingly undertaken. METHODS AND RESUTS: Patients treated with surgical or percutaneous repair of PIVSD (2010-2021) were identified at 16 UK centres. Case note review was undertaken. The primary outcome was long-term mortality. Patient groups were allocated based upon initial management (percutaneous or surgical). Three-hundred sixty-two patients received 416 procedures (131 percutaneous, 231 surgery). 16.1% of percutaneous patients subsequently had surgery. 7.8% of surgical patients subsequently had percutaneous treatment. Times from AMI to treatment were similar [percutaneous 9 (6-14) vs. surgical 9 (4-22) days, P = 0.18]. Surgical patients were more likely to have cardiogenic shock (62.8% vs. 51.9%, P = 0.044). Percutaneous patients were substantially older [72 (64-77) vs. 67 (61-73) years, P < 0.001] and more likely to be discussed in a heart team setting. There was no difference in long-term mortality between patients (61.1% vs. 53.7%, P = 0.17). In-hospital mortality was lower in the surgical group (55.0% vs. 44.2%, P = 0.048) with no difference in mortality after hospital discharge (P = 0.65). Cardiogenic shock [adjusted hazard ratio (aHR) 1.97 (95% confidence interval 1.37-2.84), P < 0.001), percutaneous approach [aHR 1.44 (1.01-2.05), P = 0.042], and number of vessels with coronary artery disease [aHR 1.22 (1.01-1.47), P = 0.043] were independently associated with long-term mortality. CONCLUSION: Surgical and percutaneous repair are viable options for management of PIVSD. There was no difference in post-discharge long-term mortality between patients, although in-hospital mortality was lower for surgery.

Arrhythmogenic gene remodelling in elderly patients with type 2 diabetes with aortic stenosis and normal left ventricular ejection fraction.

NEW FINDINGS: What is the central question of this study? Type 2 diabetes is associated with a higher rate of ventricular arrhythmias compared with the non-diabetic population, but the associated myocardial gene expression changes are unknown; furthermore, it is also unknown whether any changes are attributable to chronic hyperglycaemia or are a consequence of structural changes. What is the main finding and its importance? We found downregulation of left ventricular ERG gene expression and increased NCX1 gene expression in humans with type 2 diabetes compared with control patients with comparable left ventricular hypertrophy and possible myocardial fibrosis. This was associated with QT interval prolongation. Diabetes and associated chronic hyperglycaemia may therefore promote ventricular arrhythmogenesis independently of structural changes. Type 2 diabetes is associated with a higher rate of ventricular arrhythmias, and this is hypothesized to be independent of coronary artery disease or hypertension. To investigate further, we compared changes in left ventricular myocardial gene expression in type 2 diabetes patients with patients in a control group with left ventricular hypertrophy. Nine control patients and seven patients with type 2 diabetes with aortic stenosis undergoing aortic valve replacement had standard ECGs, signal-averaged ECGs and echocardiograms before surgery. During surgery, a left ventricular biopsy was taken, and mRNA expressions for genes relevant to the cardiac action potential were estimated by RT-PCR. Mathematical modelling of the action potential and calcium transient was undertaken using the O'Hara-Rudy model using scaled changes in gene expression. Echocardiography revealed similar values for left ventricular size, filling pressures and ejection fraction between groups. No difference was seen in positive signal-averaged ECGs between groups, but the standard ECG demonstrated a prolonged QT interval in the diabetes group. Gene expression of KCNH2 and KCNJ3 were lower in the diabetes group, whereas KCNJ2, KCNJ5 and SLC8A1 expression were higher. Modelling suggested that these changes would lead to prolongation of the action potential duration with generation of early after-depolarizations secondary to a reduction in density of the rapid delayed rectifier K+ current and increased Na+ -Ca2+ exchange current. These data suggest that diabetes leads to pro-arrythmogenic changes in myocardial gene expression independently of left ventricular hypertrophy or fibrosis in an elderly population.

Identification of the Beagle 2 lander on Mars.

The 2003 Beagle 2 Mars lander has been identified in Isidis Planitia at 90.43° E, 11.53° N, close to the predicted target of 90.50° E, 11.53° N. Beagle 2 was an exobiology lander designed to look for isotopic and compositional signs of life on Mars, as part of the European Space Agency Mars Express (MEX) mission. The 2004 recalculation of the original landing ellipse from a 3-sigma major axis from 174 km to 57 km, and the acquisition of Mars Reconnaissance Orbiter High Resolution Imaging Science Experiment (HiRISE) imagery at 30 cm per pixel across the target region, led to the initial identification of the lander in 2014. Following this, more HiRISE images, giving a total of 15, including red and blue-green colours, were obtained over the area of interest and searched, which allowed sub-pixel imaging using super high-resolution techniques. The size (approx. 1.5 m), distinctive multilobed shape, high reflectivity relative to the local terrain, specular reflections, and location close to the centre of the planned landing ellipse led to the identification of the Beagle 2 lander. The shape of the imaged lander, although to some extent masked by the specular reflections in the various images, is consistent with deployment of the lander lid and then some or all solar panels. Failure to fully deploy the panels-which may have been caused by damage during landing-would have prohibited communication between the lander and MEX and commencement of science operations. This implies that the main part of the entry, descent and landing sequence, the ejection from MEX, atmospheric entry and parachute deployment, and landing worked as planned with perhaps only the final full panel deployment failing.

Left ventricular apical masses: distinguishing benign tumours from apical thrombi.

Differential diagnoses for cardiac left ventricular apical masses presenting following acute myocardial infarction include thrombi and cardiac tumours. We present two such cases and the multidisciplinary assessment that is required to assist with diagnosis.

Total arterial revascularisation: effect of avoiding cardiopulmonary bypass on in-hospital mortality and morbidity in a propensity-matched cohort.

OBJECTIVE: The combination of total arterial revascularisation and avoidance of cardiopulmonary bypass may provide additional benefits to patients receiving complete arterial grafting with cardiopulmonary bypass. We performed a propensity-matched cohort study of complete arterial off-pump and on-pump coronary surgery and examined differences in in-hospital mortality and morbidity. METHODS: Three hundred and sixty patients who underwent off-pump coronary surgery with complete arterial grafting between April 1997 and September 2002 were matched to 360 patients who received coronary surgery with cardiopulmonary bypass and complete arterial grafting. To match off-pump with unique on-pump patients, logistic regression was used to develop a propensity score for off-pump surgery. The C statistic for this model was 0.79. Off-pump patients were matched to unique on-pump patients with an identical 5-digit propensity score. If this could not be done, we then proceeded to a 4-, 3-, 2-, or 1-digit match. RESULTS: Patient characteristics were well matched. There was no difference in in-hospital mortality between the groups. Off-pump patients were less likely to develop sternal wound infections compared to the on-pump group (2.5 versus 5.8%; P=0.03), and had significantly lower blood loss (675 versus 780 ml; P<0.001), red blood cell unit transfusion (8.6 versus 38.9%; P<0.001), enzyme rises (13 versus 23 U/l; P<0.001), inotrope support (11.9 versus 28.9%; P<0.001), and ventilation times (5 versus 8 h; P<0.001). Intensive care unit and hospital stay were also significantly lower in the off-pump patients. CONCLUSIONS: Off-pump coronary surgery with complete arterial revascularisation can significantly reduce in-hospital morbidity and lengths of stay compared to conventional on-pump coronary surgery.

Effect of preoperative aspirin use in off-pump coronary artery bypass operations.

BACKGROUND: The effect of preoperative aspirin use until the day of operation on mortality rate and bleeding risks in patients who had on-pump coronary artery bypass operation has been well documented. However, the effect of aspirin use in patients undergoing off-pump coronary artery bypass operation (OPCAB) with regard to postoperative blood loss and morbidity has not been studied. We aimed to determine the effects of continuing aspirin therapy preoperatively. METHODS: We performed a retrospective study of 340 patients who had first-time OPCAB between January 1998 and September 2001. A propensity score for receiving aspirin until the day of operation was constructed from core patient characteristics. All aspirin users (n = 170) were matched with unique 170 nonaspirin users by identical propensity score. The primary outcome measures were in-hospital mortality rate and hemorrhage-related outcomes (postoperative blood loss in the intensive care unit, reexploration for bleeding, and blood product requirements). Secondary outcome measures were stroke, myocardial infarction, gastrointestinal bleeding, and sternal wound infections. RESULTS: There were no differences in patient characteristics between aspirin users and nonaspirin users. The average postoperative blood loss (845 mL versus 775 mL; p = 0.157) and the rate of reexploration for bleeding (3.5% versus 3.5%; p > 0.99) were similar in aspirin users and nonaspirin users. We found no significant difference between blood product requirements for the two groups. Similarly, we found no significant difference in the incidence of the secondary outcomes. CONCLUSIONS: Preoperative aspirin did not increase bleeding-related complications, mortality rate, or other morbidities in patients who had off-pump coronary artery operation.

Coronary surgery in patients with peripheral vascular disease: effect of avoiding cardiopulmonary bypass.

BACKGROUND: An increasing number of patients with peripheral vascular disease are undergoing coronary artery bypass grafting. Such patients have an increased risk of adverse outcomes. Our aim was to quantify the effect of avoiding cardiopulmonary bypass in this group of patients. METHODS: Between April 1997 and March 2002, 3,771 consecutive patients underwent coronary artery bypass grafting performed by five surgeons. Four hundred and twenty-two (11.2%) had peripheral vascular disease and of these, 211 (50%) received off-pump surgery. We used multivariate logistic regression analysis to assess the effect of off-pump surgery on in-hospital mortality and morbidity, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score, which was the probability of receiving off-pump surgery and included core patient characteristics. The C statistic for this model was 0.8. RESULTS: Off-pump patients were more likely to have preoperative renal dysfunction, previous gastrointestinal surgery, and less extensive disease. The left internal mammary artery was used more in off-pump compared to on-pump cases (90.1% vs 82.9%; p = 0.033). In the univariate analyses, off-pump patients were less likely to have a postoperative stroke (p = 0.007), and had shorter postoperative hospital stays (p < 0.001). However, the incidence of new atrial arrhythmia was higher (p = 0.028). After adjustment for differences in case-mix (propensity score), avoidance of cardiopulmonary bypass was still associated with a significant reduction in postoperative stroke (adjusted odds ratio 0.09 [95% confidence interval 0.02 to 0.50]; p = 0.005), and shorter postoperative hospital stay (p = 0.001). CONCLUSIONS: Off-pump coronary surgery is safe in patients with peripheral vascular disease, with acceptable results. The incidence of postoperative stroke is substantially reduced when avoiding cardiopulmonary bypass in patients with peripheral vascular disease.

Functional assessment of skeletal muscle ventricles after pumping for up to four years in circulation.

BACKGROUND: The successful treatment of cardiac failure by heart transplantation is severely limited by the shortage of donor organs, and alternative surgical approaches are needed. An experimental approach that holds considerable promise is the skeletal muscle ventricle (SMV), an auxiliary blood pump formed from a pedicled graft of latissimus dorsi muscle and connected to the circulation in a cardiac assist configuration. Adaptive transformation, or conditioning, by electrical stimulation enables the skeletal muscle to perform a significant proportion of cardiac work indefinitely without fatigue. METHODS: In 10 dogs, SMVs were constructed from the latissimus dorsi muscle, lined internally with pericardium, and conditioned by electrical stimulation to induce fatigue resistant properties. The SMVs were connected to the descending thoracic aorta via two 12-mm Gore-Tex conduits and the aorta was ligated between the two grafts. The SMV was stimulated to contract during the diastolic phase of alternate cardiac cycles. The animals were monitored at regular intervals. RESULTS: At initial hemodynamic assessment, SMV contraction augmented mean diastolic blood pressure by 24.6% (from 61 +/- 7 to 76 +/- 9 mm Hg). Presystolic pressure was reduced by 15% (from 60 +/- 8 to 51 +/- 7 mm Hg) after an assisted beat. Four animals died early, 1 from a presumed arrhythmia, and 3 during propranolol-induced hypotension. The other 6 animals survived for 273, 596, 672, 779, 969, 1,081, and 1,510 days. Diastolic augmentation was 27.4% at 1 year (93 +/- 9 vs 73 +/- 6 mm Hg; n = 5), 34.7% at 2 years (85 +/- 6 vs 63 +/- 7 mm Hg; n = 3), 21.2% (89 +/- 10 vs 73 +/- 8 mm Hg; n = 2) at 3 years, and 34.5% (78 vs 58 mm Hg; n = 1) after 4 years in circulation. After 4 years, the isolated SMV was able to maintain a pressure of over 80 mm Hg while ejecting fluid at 20 mL/s. No animal showed evidence of SMV rupture or thromboembolism. CONCLUSIONS: The SMVs in this study provided effective and stable hemodynamic assistance over an extended period of time. There was no evidence that the working pattern imposed on the muscular wall of the SMV compromised its viability. Areas of fibrofatty degeneration were suggestive of early damage that future protocols should seek to minimize.

Neurological outcomes in coronary surgery: independent effect of avoiding cardiopulmonary bypass.

BACKGROUND: Recent studies examining neuroprotective effects of off-pump coronary artery bypass grafting (CABG) have shown inconsistent results. We examined our database to quantify the independent effects of avoidance of cardiopulmonary bypass (CPB) and aortic manipulation on neurologic outcomes after CABG. METHODS: A total of 2,327 consecutive cases undergoing isolated CABG between April 1997 and May 2001 were identified at our two institutions. Patients were divided into three groups: on CPB, off-pump with aortic manipulation, and off-pump without aortic manipulation. To control for the confounding effects of other risk factors, we performed a multivariate logistic regression analysis. Potential covariates considered in the logistic model included age, sex, redo operations, diabetes, chronic obstructive pulmonary disease, neurologic disease, peripheral vascular disease, ejection fraction, and priority of operation. RESULTS: A total of 1,210 cases were performed on CPB, compared with 520 off-pump with aortic manipulation, and 597 off-pump without aortic manipulation. The incidence of focal neurologic deficit was 1.6% (n = 19) in the on-pump group, 0.4% (n = 2) in the off-pump with aortic manipulation group, and 0.5% (n = 3) for the off-pump without aortic manipulation group (p for trend = 0.027). The results of the multivariate logistic regression analysis demonstrated that use of CPB was a risk factor for focal neurologic deficit, with an odds ratio of 3.82 (95% confidence interval, 1.41 to 10.34; p = 0.005). Aortic manipulation did not significantly influence neurologic outcome in off-pump patients. CONCLUSIONS: Off-pump operation, with or without aortic manipulation, reduces adverse neurologic outcomes compared with on-pump procedures.

'Shunt shuffle'-a simple technique of introducing intracoronary shunts for off-pump coronary artery bypass.

Intracoronary shunting is a useful method for maintaining distal perfusion as well as providing a bloodless field during off-pump coronary revascularization. Intracoronary shunts require insertion of both ends through a limited arteriotomy, which sometimes can be troublesome. We describe the 'shunt shuffle' as a simple technique, which allows rapid, atraumatic and easy insertion of intracoronary shunts.

Effect of avoiding cardiopulmonary bypass in non-elective coronary artery bypass surgery: a propensity score analysis.

OBJECTIVE: Non-elective coronary artery surgery (emergent/salvage or urgent) carries an increased risk in most risk-stratification models. Off-pump coronary surgery is increasingly used in non-elective cases. We aimed to investigate the effect of avoiding cardiopulmonary bypass on outcomes following non-elective coronary surgery. METHODS: Of the 3771 consecutive coronary artery bypass procedures performed by five surgeons between April 1997 and March 2002, 828 (22%) were non-elective and 417 (50.4%) of these patients had off-pump surgery. Multivariate logistic regression was used to assess the effect of off-pump on in-hospital outcomes, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score from core patient characteristics, which was the probability of avoiding cardiopulmonary bypass. The C statistic for this model was 0.8. RESULTS: Off-pump patients were more likely to be hypertensive, stable, had less extensive disease and better left ventricular function. The left internal mammary artery was used in 91.8% (n=383) of off-pump patients compared to 79.3% (n=326) of on-pump cases (P<0.001). After adjusting for the propensity score, no difference in in-hospital mortality was observed between off-pump and on-pump (adjusted odds ratio (OR) 0.83 (95% confidence intervals (CI) 0.36-1.93); P=0.667). Off-pump patients were less likely to require intra-aortic balloon pump support (adjusted OR 0.44 (95% CI 0.21-0.96); P=0.039), less likely to have renal failure (adjusted OR 0.44 (95% CI 0.22-0.90); P=0.025), and have shorter lengths of stay (adjusted OR 0.51 (95% CI 0.37-0.70); P<0.001). Other morbidity outcomes were similar in both groups. CONCLUSIONS: In this experience, off-pump coronary surgery in non-elective patients is safe with acceptable results. Non-elective off-pump patients have a significantly reduced incidence of renal failure, and shorter post-operative stays compared to on-pump coronary artery bypass surgery.

Off-pump coronary artery bypass surgery does not reduce gastrointestinal complications.

OBJECTIVES: Gastrointestinal (GI) complications following on-pump coronary artery bypass grafting (CABG) are rare, but carry a high mortality rate. Prolonged cardiopulmonary bypass (CPB) has been associated with a higher incidence of such complications. Little is known about the effect of avoiding CPB on GI complications. Our hypothesis was that off-pump CABG might reduce such complications. METHODS: A total of 2327 consecutive cases undergoing isolated CABG between April 1997 and May 2001 were identified from four consultants' practice at the two cardiothoracic centres involved in this study. We performed a multivariable logistic regression analysis to identify the risk factors for development of post-operative GI complications. Potential risk factors considered in the logistic model were age, sex, angina, ejection fraction, peripheral vascular disease, renal dysfunction, redo operations, previous GI complications, priority of surgery and the use of CPB. RESULTS: A total of 1210 cases were performed on CPB, compared to 1117 off-pump. The incidence of GI complications was 1.2% (n = 14) in the on-pump group and 1.6% (n = 18) in the off-pump group (P = 0.347). The incidence of in-hospital mortality, in the patients who had a GI complication, was 28.6% (n = 4) and 22.2% (n = 4), respectively (P = 0.681). The results of the logistic regression analysis showed that renal dysfunction, advancing age and previous history of GI surgery are significant risk factors for GI complications after coronary bypass surgery whether CPB is used or not. CONCLUSIONS: Our study suggests that off-pump and on-pump techniques are similar in the rates of GI complications. We suggest that a properly designed randomized control trial is needed to verify our findings.

Comparison of the EuroSCORE II and Society of Thoracic Surgeons 2008 risk tools.

OBJECTIVES: Risk stratification in cardiac surgery is uniquely detailed, led latterly by the EuroSCORE and the Society of Thoracic Surgeons (STS) risk calculators. The recently published EuroSCORE II (ES2) algorithms update estimated mortality in a broad spectrum of cardiac procedures. The 2008 STS tool, in comparison, predicts multiple outcomes for specific procedures. We sought to identify and compare the external validity of both contemporaneous tools in our population. METHODS: Data from our hospital database were collated for the period February 2001 to March 2010. Logistic regression coefficients from the risk calculations were applied to the data and the results presented as receiver-operating characteristic (ROC) curves. Statistical analyses were performed using the area under the ROC curve (AUROC) and the Hosmer-Lemeshow (H-L) goodness-of-fit test, with comparisons using the DeLong method. RESULTS: A total of 15 497 procedures were identified, of which 14 432 were appropriate for STS risk scoring (i.e. valve and/or graft procedures with no tricuspid valve operations etc.). For all procedures, ES2 and STS were equivalent (AUROC 0.818 vs 0.805, respectively, P = 0.343). For procedures appropriate for STS risk scoring, results were similar (AUROC ES2 vs STS, 0.816 vs 0.810, P = 0.714), whereas for procedures excluded by STS, the result was marginally worse (AUROC ES2 vs STS, 0.773 vs 0.784, P = 0.751). Goodness of fit in all cases was poor, primarily where risk was higher than 15% (H-L P < 0.0001). CONCLUSIONS: EuroSCORE II and STS both provide equivalent discrimination in predicting mortality in a British population, including those undergoing procedures for which the STS does not normally predict. Accounting for decile-grouped Hosmer-Lemeshow tests not being ideal for the assessment of calibration, both tools show good calibration for patients with low to moderate risk, with divergence from ~15% predicted risk.

External validity of the Society of Thoracic Surgeons risk stratification tool for deep sternal wound infection after cardiac surgery in a UK population.

OBJECTIVES: Deep sternal wound infection (DSWI) is a devastating complication of cardiac surgery, with a historical incidence of 0.4-5%. Predicting which patients are at higher risk of infection may help instituting various preventive measures. Risk calculations for mortality have been used as surrogates to estimate the risk of deep sternal wound infection, with limited success. The Society of Thoracic Surgeons (STS) 2008 Risk Calculator modelled the risk of DSWI for cardiac surgical patients, but it has not been validated since its publication. We sought to assess the external validity of the STS-estimated risk of DSWI in a United Kingdom (UK) population. METHODS: Using our prospectively captured database, we retrospectively calculated the risk of DSWI for 14 036 patients undergoing valve, coronary artery bypass grafts or combined procedures between February 2001 and March 2010. DSWI was identified according to the Centre for Disease Control and Prevention definition. The receiver operator characteristic (ROC) curve was employed to test the performance of the model using the area under the ROC curve (AUROC). The calibration of the model was interrogated using the Hosmer-Lemeshow test for Goodness of Fit. RESULTS: A total of 135 (0.95%) patients developed DSWI. Although there was a statistically significant difference in the calculated risk of patients who contracted DSWI (0.44% ± 0.01) vs those who did not (0.28% ± 0.00, P < 0.0001), the AUROC of 0.699 (95% confidence interval: 0.6522-0.7414) denoted a modest discriminatory power, with the Hosmer-Lemeshow Goodness of Fit statistic (P < 0.001) suggesting poor calibration. A risk-adjusted modifier improved the calibration (P = 0.08). CONCLUSIONS: The STS risk calculator lacks adequate discriminatory power for estimating the isolated risk of developing deep sternal wound infection in a UK population. The discrimination is similar to the tool's validation c-statistic and may have a place in an integrated calculator.

Outcomes and predictors of prolonged ventilation in patients undergoing elective coronary surgery.

OBJECTIVES Despite the seriousness of prolonged mechanical ventilation (PMV) as a postoperative complication, previously proposed risk prediction models were met with limited success. The purpose of this study was to identify perioperative variables associated with PMV in elective primary coronary bypass surgery. PMV was defined as the need for intubation and mechanical ventilation for >72 h, after completion of the operation. METHODS Between April 1997 and September 2010, 10 ,977 consecutive patients were retrospectively reviewed. A series of two multivariate logistic regression analyses were carried out to identify preoperative predictors of prolonged ventilation and the impact of operative variables. RESULTS PMV occurred in 215 (1.96%) patients; 119 (55.3%) of these underwent tracheostomy. At multivariate analysis, predictors included NYHA higher than class II (odds ratio [OR], 1.77; 95% confidence intervals [CI], 1.34-2.34), renal dialysis (OR, 5.5; 95% CI, 2.08-14.65), age at operation (OR, 1.04; 95% CI, 1.02-1.06), reduced FEV(1) (OR, 0.99; 95% CI, 0.98-0.99), body mass index >35 kg/m(2) (OR, 1.73; 95% CI, 1.14-2.63). On serial logistic regression analyses, operative variables added little to the discriminatory power of the model. Kaplan-Meier survival curves showed reduced survival among PMV patients (P < 0.001) with an improved survival in the tracheostomy subgroup. CONCLUSIONS PMV after coronary bypass is associated with a reduction in early and mid-term survival. Risk modelling for PMV remains problematic even when examining a more homogenous lower risk group.

Monitoring cardiac output trends with end-tidal carbon dioxide pressures in off-pump coronary bypass.

The optimum method of intraoperative monitoring in patients undergoing off-pump coronary bypass remains debatable. Using capnography and end-tidal carbon dioxide pressure may be a helpful method of monitoring cardiac output trends, especially when grafting posterior and lateral vessels. After repositioning the heart, End-tidal carbon dioxide pressures that continue to trend down usually indicate decreased cardiac output and precede hemodynamic and electrical instability. The advantages of this method include simplicity, universal availability, and a short response time to changes in cardiac output.

Mitral valve involvement in Wegener's granulomatosis.

Wegener's granulomatosis is an autoimmune condition resulting in the granulomatous vasculitis of small-to-medium-sized vessels, and is characterized by granulomatous lesions in the renal and respiratory systems. Cardiac involvement in Wegener's granulomatosis has been previously reported. However, involvement of cardiac valves is extremely rare. We present a patient with Wegener's granulomatosis with an extensive mitral mass extending to the aortic valve.

Predictive accuracy of EuroSCORE: is end-diastolic dysfunction a missing variable?

OBJECTIVE: Left-ventricular function has been shown to be an important prognostic factor in estimating operative risk in cardiac surgery. As such, left-ventricular ejection fraction (LVEF) is included in the EuroSCORE. However, left-ventricular function is more comprehensively assessed by measures of both systolic and diastolic dysfunction. We hypothesised that end-diastolic dysfunction is an additional independent indicator for predicting outcome following coronary artery bypass grafting (CABG). METHODS: We retrospectively assessed all patients undergoing isolated off-pump CABG between October 2000 and September 2004 by two surgeons. Left-ventricular end-diastolic pressure (LVEDP), measured during cardiac catheterisation, was used as a measure of left-ventricular diastolic dysfunction. Logistic regression was used to assess the association between LVEDP (a continuous and dichotomous variable) and mortality, while adjusting for EuroSCORE. RESULTS: A total of 925 patients with complete LVEDP data were identified and stratified as follows: group 1 (LVEF >30% and LVEDP <20 mmHg), group 2 (LVEF <30% and LVEDP <20 mmHg), group 3 (LVEF >30% and LVEDP >20 mmHg) and group 4 (LVEF <30% and LVEDP >20 mmHg). Mortality increased progressively from group 2 (1.9%, odds ratio (OR) 1.22, RR 1.21, p 0.58) to group 3 (5.6%, OR 3.81, RR 3.66, p 0.07) and was highest in group 4 (7.4%, OR 5.18, RR 4.87, p 0.08). Receiver operating characteristic (ROC) curve c-characteristic improved from 0.7 to 0.78 when EuroSCORE was combined with LVEDP, identifying LVEDP as an independent predictor of mortality after adjusting for EuroSCORE. Logistic equation: odds of death = exp(-6.3283+[EuroSCORE x 0.1813]+[EDP x 0.0954]). CONCLUSIONS: LVEDP as a marker of diastolic dysfunction seems an important variable in predicting patient-specific risk and should be considered for incorporation in future risk models.