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Aims To test the predictive value of medical variables, covering the complete medical course from birth until the present, for long-term behavioural and emotional problems in adulthood, in patients operated for congenital heart disease in childhood. [ABSTRACT FROM PUBLISHER]

Aims Since knowledge about the psychosocial function of adult patients with congenital heart disease is limited, we compared biographical characteristics, and emotional and social functioning of these patients with that of the reference groups.Methods and results Patients with congenital heart disease (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(N=362\) \end{document}, aged 20–46 years), belonging to five diagnostic groups, were subjected to extensive medical and psychological examination, 20–33 years after their first open heart surgery. All the patients were seen by the same psychologist, who examined their psychosocial functioning using a structured interview and questionnaires. The majority (78%)was living independently and showed favourable outcome regarding the marital status. Among married/cohabitant patients, 25–39-year-olds showed normal offspring rates. None of the 20–24-year-old patients had any children. The offspring rate dropped after the age of 40. The proportion of adult patients with a history of special education was high (27%). Accordingly, patients showed lower educational and occupational levels compared to reference groups. As regard to the emotional and social functioning (leisure-time activities), the sample showed favourable results.Conclusions Overall, this sample of patients with congenital heart disease seemed capable of leading normal lives and seemed motivated to make good use of their abilities. [ABSTRACT FROM PUBLISHER]

Objective: We retrospectively investigated the short and mid-term outcome of non-emergent primary isolated coronary artery bypass graft (CABG) surgery in relation to risk stratification in the fully equipped university location (FE) and the low volume, limited facility location (LVLF) of our department. Methods: Between September 1995 and December 1996, 832 patients were referred to our department to undergo a primary isolated CABG operation. The surgical team selected 482 patients (58%) as being at low-risk. These were treated in the LVLF hospital. The other 350 patients with mixed-risk were treated in the FE hospital. The selection consisted primarily of exclusion of patients with moderate or poor left ventricular function, severe COPD or renal impairment, from surgery in the LVLF location. Finally, the prognostic value of the EuroSCORE and the Parsonnet score was tested on our patient population. Results: Overall in-hospital mortality was 1.6% (13 patients). One patient died in the LVLF group (0.2%) and 12 patients (3.4%) in the FE group. LVLF patients experienced less complications during the hospital period compared to the FE patients (5 versus 21%; P=0.0001). The Parsonnet risk model and the EuroSCORE risk model showed both a good relation with in-hospital mortality. After discharge, an increased risk of late mortality was observed up to 1 year postoperative in the FE group compared to the LVLF group (2.7 versus 0.5%; P=0.01). Risk factors for 5-year mortality were pre-operative renal impairment (blood creatinine >150 μmol/l) (hazard ratio (HR): 2.8; 95% confidence interval (CI): 1.4–5.5), diabetes (HR: 2.1; 95% CI: 1.3–3.5), impaired LVEF (HR: 1.9; 95% CI: 1.2–3.0), COPD (HR: 1.9; 95% CI: 1.1–3.5) and older age (HR: 1.07 per year; 95% CI: 1.01–1.10). Lipid-lowering therapy was a predictor of lower mortality at 5-years (HR: 0.5; 95% CI: 0.4–0.9). Conclusion: By careful decision making, selection of low-risk patients for a low volume and limited facility location resulted in excellent in-hospital survival with very low complication rates. [Copyright &y& Elsevier]

In order to study the safety of ‘rescue’ strategies in the treatment of patients with failed thrombolysis, all 548 patients admitted with evolving myocardial infarction to the Thoraxcenter, Rotterdam, from January 1997 until April 1999 were reviewed. Of these patients, 49% had received thrombolysis. Of patients treated with thrombolysis and not referred from other hospitals (n=154) 36% received rescue therapy for failed thrombolysis. Three rescue therapies were used after failed thrombolysis: percutaneous coronary intervention (74%), retreatment with thrombolysis (39%) and platelet glycoprotein (GP) IIb/IIIa receptor blockers (53%), often in combination. Platelet GP IIb/IIIa receptor blockers were administered in 64% of patients treated with rescue percutaneous coronary intervention. Major bleeding occurred in 14% of all thrombolysis treated patients, and in 30% of patients who received multiple rescue therapies. Bleeding was related to heparin usage and platelet GP IIb/IIIa receptor blockers, as was the insertion of catheters for percutaneous coronary intervention or intra-aortic balloon pumps. Major bleeding resulted in one death due to a ruptured ventricle, one haemorrhagic stroke, and three cases of tamponade for which surgery was needed. Four of these patients had received combination rescue therapy. Rescue therapy is a widely used strategy for failed thrombolysis, but is associated with a high bleeding rate. Alternative reperfusion strategies to avoid failed thrombolysis should be considered in high risk patients. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved. [ABSTRACT FROM PUBLISHER]

Aims The purpose of this study is to compare the long-term outcome (up to 20 years) of coronary artery bypass surgery (CABG) with percutaneous transluminal coronary angioplasty (PTCA) in a consecutive patient series at a single centre. Survival is similar after CABG and PTCA up to 8 years follow-up in patients with multivessel disease, with a reduced need for repeat revascularization after CABG. As coronary artery disease is a lifetime disease, longer-term follow-up of these revascularization therapies is necessary to help clinical decision-making.Methods and Results The CABG study population consisted of the first 1041 consecutive patients who underwent a first elective coronary bypass surgery between 1970 and 1980. The PTCA study population consisted of 702 consecutive patients who underwent a first elective coronary angioplasty procedure between 1980 and 1985. Mortality and subsequent revascularization up to 20 years were captured. Survival rates were adjusted using proportional hazards methods to account for baseline differences.Results The unadjusted survival rates were 92%, 77%, 57% and 49% after CABG at respectively, 5-, 10-, 15- and 17 years and 91%, 80%, 64% and 59% after PTCA. In the multivessel disease subgroup, survival was similar with a benefit apparent after CABG in the first 8 years of follow-up. The therapy chosen, CABG or PTCA, was a univariate predictor of mortality in favour of PTCA (RR: 1·28; 95% CI: 1·10–1·49), but after correction for baseline characteristics, the relative risk of mortality for CABG vs PTCA was comparable (RR: 1·03; 95% CI: 0·87–1·24). The adjusted survival curves in the subgroup of diabetic elderly patients with multivessel disease were similar after the tenth year with only a slightly better survival in the CABG population in the first 10 years. Repeat intervention was more frequently required after PTCA during the first 8 years, but after this time more frequently in the CABG group.Conclusion When comparing CABG and PTCA it can be concluded that both strategies are equally effective in terms of 20-year survival. In particular, after more than 10 years all differences tend to disappear. While repeat intervention was significantly higher in the first year after PTCA, after 7–8 years, reintervention was greater in patients who had initial CABG. [ABSTRACT FROM PUBLISHER]

Aims This study reports the clinical outcome, up to 17 years, of the first 856 consecutive patients treated by coronary angioplasty at a single centre and attempts to identify a subgroup of patients at low risk of adverse events.Methods and Results Follow-up status was established via hospital and general practitioner records and the civil registry. Median follow-up was 16 years. The overall 5-, 10-, 15- and 17-year survival was 90%, 78%, 64% and 58%, respectively and corresponding event-free survival was 53%, 33%, 22% and 19%. After 32% of patients had experienced a major adverse cardiac event in the first year, the annual coronary re-intervention incidence thereafter and, even beyond year 10, remained at 2%–3%. Using multivariable Cox regression, significant independent predictors of mortality were advanced age, diabetes, multivessel disease and impaired left ventricular function at the time of PTCA. A subgroup of 26% of the patients with none of these risk factors had a survival rate similar to the general Dutch population matched for age and gender (at 5 years: 96%, at 10 years: 89% and at 15 years: 83%).Conclusion Although the majority of patients (>80%) experienced a further cardiac event during the 17 years after their first angioplasty procedure, in those non-diabetics under 60 years with single-vessel disease and good left ventricular function, prognosis was similar to the general population. [ABSTRACT FROM PUBLISHER]

Aims To determine very long-term survival and incidence of recurrent interventions following aorto-coronary bypass surgery using venous grafts.Methods and Results A group of 1041 consecutive patients operated upon between 1971 and 1980 were followed for a median of 19 years (range 13–26). Peri-operative mortality was 1·2%. Survival probability at 5, 10, 15, and 20 years was 92%, 77%, 57%, and 40%, respectively. After 5 or more years following operation the mortality was higher than in the matched Dutch population. Age, extent of coronary artery disease, and ejection fraction are independent predictors of mortality. Of the 593 deceased patients at least 63% died of a probable cardiac cause, while cardiovascular mortality is 40% in the general Dutch population. Repeat revascularization procedures (aorto-coronary bypass surgery or percutaneous transluminal coronary angioplasty) were performed in 343 patients (33%), with an increasing incidence after 7 years.Conclusion Aorto-coronary bypass surgery using vein grafts is safe and has a reasonable long-term prognosis for survival, although less than a matched population. After approximately 7 years both mortality and the need for repeated revascularizations increased. Since a majority of patients died of a cardiac cause and a substantial number of patients required repeated revascularization, aorto-coronary bypass surgery is a palliative treatment of a progressive disease. [ABSTRACT FROM PUBLISHER]

Aims To risk stratify and shorten hospital stay in patients with spontaneous (resting) chest pain and a non-diagnostic electrocardiogram (ECG).Methods and Results The study comprised 102 patients (mean age 58±12 years, 67 men) with spontaneous chest pain and a non-diagnostic ECG. Forty-three patients had suspected coronary artery disease and 59 had known (but of unknown actual significance) coronary artery disease. All patients underwent serial creatine kinase enzyme measurements, continuous ECG monitoring for at least 12h and early dobutamine–atropine stress echocardiography in patients with negative creatine kinase enzymes and normal findings at ECG monitoring. Dobutamine–atropine stress echocardiography was considered positive in patients with new or worsening wall thickening abnormalities. Patients with negative dobutamine–atropine stress echocardiography were discharged after the test. In-hospital and 6 month follow-up events noted were cardiac death, non-fatal myocardial infarction, unstable angina, and coronary artery bypass surgery or angioplasty. Thirteen patients had evidence of evolving myocardial infarction by elevated creatine kinase enzymes, or unstable angina by ECG monitoring. In the remaining 89 patients, dobutamine–atropine stress echocardiography was performed after a median observation period of 31h (range 12–68h). During dobutamine–atropine stress echocardiography no serious complications (death, non-fatal myocardial infarction, sustained ventricular tachycardia or ventricular fibrillation) occurred. Dobutamine–atropine stress echocardiography results were of poor quality in three, non-diagnostic in six, negative in 44 and positive in 36 patients. In the 80 patients with diagnostic dobutamine–atropine stress echocardiography, variables associated with in-hospital events (n=7) were history of exertional angina (P<0·005), chest pain score (P<0·005), stress-induced angina (P<0·001) and positive dobutamine–atropine stress echocardiography (P<0·005). Variables associated with follow-up events (n=11) were history of exertional angina (P<0·05), chest pain score (P<0·001), stress-induced angina (P<0·01) and positive dobutamine–atropine stress echocardiography (P<0·01). At multivariate analysis the only significant predictor of events was positive dobutamine–atropine stress echocardiography (P<0·01).Conclusion Early dobutamine–atropine stress echocardiography may safely distinguish between low- and high-risk subsets for subsequent cardiac events in patients with spontaneous chest pain and a non-diagnostic ECG. [ABSTRACT FROM PUBLISHER]

Aims To investigate whether the benefit of thrombolytic therapy was sustained beyond the first decade. We report the 10–14 year outcome of 533 patients who were randomized to treatment with intracoronary streptokinase or to conventional therapy during the years 1980–1985.Methods and Results Details of survival and cardiac events were obtained from the civil registry, from medical records or from the patient’s physician. At follow-up, 158 patients (59%) of the 269 patients allocated to thrombolytic treatment and only 129 patients (49%) of the 264 conventionally treated patients were alive. The cumulative 1-, 5- and 10-year survival rates were 91%, 81% and 69% in patients treated with streptokinase and 84%, 71% and 59% in the control group, respectively (P=0·02). Reinfarction during 10-years of follow-up was more frequent after thrombolytic therapy, particularly during the first year. Coronary bypass surgery and coronary angioplasty were more frequently performed after thrombolytic therapy. At 10 years approximately 30% of the patients were free from subsequent cardiac events.Independent determinants of mortality were elderly age, indicators of impaired residual left ventricular function, multivessel disease and an inability to perform an exercise test at the time of hospital discharge.Conclusion Improved survival after thrombolytic therapy is maintained beyond the first decade. Age, left ventricular function, multivessel disease and an inability to perform an exercise test were independent predictors for long-term mortality, as they are predictors for early mortality. [ABSTRACT FROM PUBLISHER]

Aims The Cardiac Infarction Injury Score (CIIS) is an electrocardiographic classification system that was developed as a diagnostic tool to assess the extent of cardiac injury in acute myocardial infarction. We investigated the prognostic value of the CIIS in post-myocardial infarction patients. Methods and Results The prognostic values of the CIIS for total and cardiac mortality was assessed in a large series (n=3395) of patients who were enrolled in the ASPECT trial. Standard 12-lead electrocardiograms, recorded prior to hospital discharge were coded according to the CIIS and the Minnesota Code. Mean CIIS was 26 (range −8 to 59). After adjustment for other baseline characteristics, the CIIS was directly related to the risk of total mortality and cardiac mortality. At one-year follow-up the relative risks of CIIS ≥40, CIIS 30–40 and CIIS 20–30 were significantly higher than in those with a CIIS <20. The relative risks were, respectively, 2·3 (1·2–4·4), 2·2 (1·3–3·9) and 1·6 (0·9–2·9). At 3 year follow-up, the relative risks were, respectively, 2·1 (1·4–3·2), 1·7 (1·2–2·4) and 1·5 (1·0–2·1). The relative risks for total mortality were similar. When patients with major ECG abnormalities, as defined by the Minnesota code, were excluded, the associations were still significant in the CIIS classes 30–40 and >40. Conclusion The CIIS ECG scoring system is an important predictor for long-term cardiac mortality in post myo-cardial infarction patients. It can easily be automated and is efficient for classifying cardiac injury in epidemiological studies. [ABSTRACT FROM PUBLISHER]

To study the in-hospital outcome of all coronary angioplasty procedures performed in a single centre over a 1 year period, with regard to angiographic success and the clinical complications of death, myocardial infarction, emergency coronary bypass surgery and abrupt coronary occlusion necessitating reintervention.Methods:One thousand one hundred and thirty-three lesions were treated in 970 procedures in 799 patients between October 1993 and October 1994. Clinical, procedural, angiographic and outcome data were entered into a dedicated computer database and variables tested with respect to outcome using the chi-square test and univariate and multivariate analysis techniques.Results:Angioplasty was performed for stable angina in 473 (49%) patients, unstable angina in 410 (42%) and 80 procedures were emergency—primary myocardial infarction in 44 (4·5%) shock in two, abrupt closure in 34 (3·5%) and other indications in seven patients. There were 10(1·0%) deaths and 71 (7·3%) patients were documented to have suffered a myocardial infarction as a result of angioplasty. Nineteen (2·0%) patients underwent emergency coronary artery bypass surgery. Age >60 and a type C lesion were found to be associated with angiographic failure The chance of a complication was increased if the patient was aged >60 years, suffered unstable angina, had an ejection fraction <50%, was treated with a new device or suffered a significant dissection.Conclusion:Despite refinement in techniques and increased experience, coronary angioplasty retains a significant associated chance of angiographic failure The complication rate remains significant and there has been little reduction in mortality, infarction and abrupt closure rates over the last 15 years. The requirement for emergency coronary artery bypass surgery appears to be diminishing with the introduction of improved bail-out techniques, in particular intracoronary stenting. [ABSTRACT FROM PUBLISHER]

An abstract of the article "Contrast echocardiography improves interobserver agreement for wall motion score index and correlation with ejection fraction," by A. R. T. Van De Ven and colleagues is presented.