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Rationale, aims and objectives Cardiac surgery (CS) is facilitated by multiple perioperative guidelines and protocols. Use of a clinical pathway (CP) may facilitate the care of these patients. Methods This is a pre-post design study in the ICU of a tertiary referral centre. A CP for CS patients in the ICU was developed by ICU-nurses and enabled them to execute proactively predefined actions in accordance with and within the preset boundaries which were part of a variance report. A tailored implementation strategy was used. Primary outcome measure was protocol adherence above 80% on the domains of blood pressure control, action on chest tube blood loss and electrolyte control within the CP. Results In a 4-month period, 84 consecutive CP patients were included and compared with 162 matched control patients admitted in the year before implementation; 3 patients were excluded. Propensity score was used as matching parameter. CP patients were more likely to receive early adequate treatment for derangements in electrolytes (96% vs 47%, P < .001), blood pressure (90% vs 49%, P < .001) and adequate treatment for chest tube blood loss (90% vs 10%, P < .001). We found no differences in hospital and ICU LOS, ICU readmission or mortality. Conclusion Use of the CP improved postoperative ICU treatment for cardiac surgical patients. Implementation of a CP and the use of a special variance report could be a blueprint for the implementation and use of a CP in low-volume high complex surgery. [ABSTRACT FROM AUTHOR]

Background: Physical activity (PA) reduces the risk of cardiovascular disease and physically active survivors of a cardiac event are at lower risk of recurrent events. We hypothesized that patients with a decreased PA, undergoing cardiac surgery, are at higher risk for a postoperative complicated recovery (PCR).Methods: Three thousand three hundred eighty two patients undergoing elective cardiac surgery between January 2007 and December 2013 were included. The group was divided into three subgroups: group A, aged ≤ 65 years (N = 1329); group B, aged > 65 years and ≤ 75 years (N = 1250); and group C aged >75 years (N = 803). To assess PA, the criteria of the Corpus Christy Heart Project were used. A PCR consists of the occurrence of a major postoperative event, defined as any of the following complications: reoperation, deep sternal wound infection, renal failure, stroke, postoperative ventilation > 2 days, intensive care stay ≥ 5 days, hospital stay ≥ 10 days, or hospital mortality.Results: One thousand three hundred sixty seven patients (40%) were considered as patients with a decreased PA. Both in group B (p = 0.001) and in group C (p = 0.003), patients with a decreased PA were significantly associated with an increased risk of a PCR, which was not the case in group A (p = 0.28). Logistic regression analysis identified a decreased PA as an independent predictor for PCR in groups B (p = 0.003, odds 1.71) and C (p = 0.033, odds 1.48), but not in group A (p = 0.11, odds 0.71).Conclusion: Decreased physical activity is an independent predictor for a PCR in patients aged 65 years or older undergoing elective cardiac surgery. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The objective of this study was to compare male-female differences with respect to baseline characteristics and short-term outcome in a contemporary nationwide cohort of patients who underwent isolated mitral valve (MV) surgery. METHODS: All patients [N = 3411; 58% males (N = 1977)] who underwent isolated MV surgery (replacement: N = 1048, 31%; reconstruction: N = 2364, 69%) in the Netherlands between January 2007 and December 2011 were included in this study. Differences in patient and procedural characteristics and in-hospital outcome were compared between male and female patients. RESULTS: Female patients were generally older (mean age, 64 vs 61 years, P < 0.001), presented more often with pulmonary hypertension (P = 0.03) and had higher logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) I (P < 0.001). Male patients presented more often with prior coronary artery bypass graft surgery (P < 0.001) and active endocarditis (P = 0.002). Female patients underwent MV replacement more often (P < 0.001) and, in case of replacement, received stented bioprostheses more often (P < 0.001). In-hospital mortality rates after MV replacement were 7% (n = 33) and 7% (n = 40) in male and female patients, respectively (OR 1.08, 95% CI 0.67-1.75; P = 0.75). In-hospital mortality rates after MV reconstruction were 1.4% (n = 21) and 1.3% (n = 11) in male and female patients, respectively (OR 0.88, 95% CI 0.42-1.84; P = 0.74). CONCLUSIONS: There are substantial male-female differences in patient presentation and procedural aspects in isolated MV surgery in the Netherlands. Female patients are older, have more severe disease at the time of surgery and undergo valve repair less often. Future studies are needed to identify potentially modifiable patient factors to improve the outcome of female patients with MV disease. [ABSTRACT FROM AUTHOR]

Background: The predictive performance of static risk prediction models such as EuroSCORE deteriorates over time. We aimed to explore different methods for continuous updating of EuroSCORE (dynamic modeling) to improve risk prediction.Methods and Results: Data on adult cardiac surgery from 2007 to 2012 (n=95 240) were extracted from the Netherlands Association for Cardio-Thoracic Surgery database. The logistic EuroSCORE predicting in-hospital death was updated using 6 methods: recalibrating the intercept of the logistic regression model; recalibrating the intercept and joint effects of the prognostic factors; re-estimating all prognostic factor effects, re-estimating all prognostic factor effects, and applying shrinkage of the estimates; applying a test procedure to select either of these; and a Bayesian learning strategy. Models were updated with 1 or 3 years of data, in all cardiac surgery or within operation subgroups. Performance was tested in the subsequent year according to discrimination (area under the receiver operating curve, area under the curve) and calibration (calibration slope and calibration-in-the-large). Compared with the original EuroSCORE, all updating methods resulted in improved calibration-in-the-large (range -0.17 to 0.04 versus -1.13 to -0.97, ideally 0.0). Calibration slope (range 0.92-1.15) and discrimination (area under the curve range 0.83-0.87) were similar across methods. In small subgroups, such as aortic valve replacement and aortic valve replacement+coronary artery bypass grafting, extensive updating using 1 year of data led to poorer performance than using the original EuroSCORE. The choice of updating method had little effect on benchmarking results of all cardiac surgery.Conclusions: Several methods for dynamic modeling may result in good discrimination and superior calibration compared with the original EuroSCORE. For large populations, all methods are appropriate. For smaller subgroups, it is recommended to use data from multiple years or a Bayesian approach. [ABSTRACT FROM AUTHOR]

Background Quality of Life (QoL) studies concerns the difference in QoL between the baseline and the post-surgical assessment. Many such studies, however, suffer from incomplete QoL-data with regard to patients with a proven survival - the drop-outs. Our hypothesis is that patients with a low preoperative QoL, high operative risk and older age are at higher risk for drop-out, which may result in a biased conclusion. Methods This study includes 1675 patients, all of whom were operated between July 1, 2009 and July 1,2012 and have a proven one-year survival, as well as a complete preoperative EuroQoL registration (EQ-5D and EQ-VAS). Based on the calculated 30 and 70 percentiles of age, EuroSCORE risk, and EQ-5D and EQ-VAS values, the group was split into three different subgroups. We studied whether (1) there was a correlation between age, risk, preoperative QoL and postoperative QoL and (2) if the drop-outs were correlated to age, risk and preoperative QoL. Results There is a statistically significant correlation between postoperative QoL and both age (p = 0.029) and risk (p = 0.002). Both relations have a negative Pearson's r. There is also a statistically significant (p = 0.0001) correlation between pre- and postoperative QoL, now with a positive Pearson's r. The percentage of drop-outs increases in a statistically significant manner with an increased risk (p = 0.001), older age (p = 0.001) and a low preoperative QoL (EQ-5D ,p = 0.001 and EQ-VAS, p = 0.003). Conclusion We conclude that QoL post cardiac surgery is overestimated, certainly for older, high risk patients and patients with a low preoperative QoL. [ABSTRACT FROM AUTHOR]

Abstract: Background: Preoperative renal failure is a risk factor for adverse events in cardiac surgery. Serum creatinine (SCr) is the most used test for renal failure. However, patients can have significantly decreased glomerular filtration rates with normal SCr levels. More accurate approximation of renal function can be obtained using the Cockroft–Gault equation to calculate an estimated creatinine clearance (CrCl) rate from SCr. Methods: This study included 627 patients undergoing an isolated CABG between January 2003 and September 2004. CrCl was calculated using the Cockroft–Gault formula. Patients were divided in group A-SCr, 576 patients (91.1%) with a good renal function, SCr ≤1.20mg/dL for women and ≤1.40mg/dL for men, and a group B-SCr, with impaired renal function, 51 patients (8.1%). CrCl ≤50mL/min was chosen to reflect renal impairment. Group A-CrCl (555 patients, 88.5%) had a normal renal function and group B-CrCl (72 patients,11.5%) an impaired renal function. The studied outcomes were hospital mortality, hospital morbidity, and postoperative renal failure. Results: There was no statistical significant difference between A-SCr and B-SCr group according to the studied outcomes. On the contrary, using the CrCl there was a statistical significant difference between A-CrCl and B-CrCl for the percentage of postoperative renal failure 10 patients (1.8%) versus 5 patients (6.9%) (p =0.00), hospital morbidity 75 patients (13.5%) versus 16 patients (22.2%) (p =0.04). Hospital mortality, 11 patients (2%) versus 4 patients (5.6%), was not significantly (p =0.06) different. Postoperative dialysis, four patients (0.7%) versus three patients (4.2%) (p =0.00), stroke, three patients (0.5%) versus three patients (4.2%) (p =0.00), and hospital stay (7.6 days vs 11.0 days) (p =0.01) were significantly different. Conclusion: This study documents that the association between preoperative renal failure and adverse outcomes after CABG is stronger with the estimated CrCl than with the routinely used SCr. Routine estimation or measurement of glomerular filtration rate should be preferred to SCr as screening method for the detection of higher risk patients undergoing CABG. [Copyright &y& Elsevier]

Objective: The objective of this study is to find out whether follow-up information is registered by a non-organized follow-up representative for mortality and morbidity after myocardial revascularization. Methods: The follow-up information registered by an organized (OFU) and a non-organized (NOFU) follow-up method is compared. The organized follow-up consists of an annual survey directly to the patient. The non-organized follow-up contains information provided by cardiologists and general practitioners. 1722 patients undergoing a CABG between 1999 and 2002 were included in this study. Completeness of the follow-up was registered as well as mortality and events, defined as return of angina, myocardial infarction, rhythm disturbances, heart failure, stroke and PTCA. Results: The OFU was 98% complete and the NOFU 51.8% (P<0.05). The NOFU registered only 10 deaths; however, in the OFU another 21 patients who died during the first year postoperative were registered (P<0.05). In the OFU, 137 patients were registered with an event and in the NOFU 53 (P<0.05). In NOFU, the mean was 108±91 days and median was 78 days. Conclusion: OFU improves the completeness of the follow-up, as expected, but informs superior about mortality and events. That in the NOFU, for 50% of the patients, the information is at the most 78 days postoperative old, let us suppose that a lot of early (6 months) postoperative information is even missed by an NOFU. The establishment of an organized follow-up and feedback of mortality and events after myocardial revascularization becomes indispensable. [Copyright &y& Elsevier]

: ObjectiveTo construct a predictive model for a prolonged stay in the intensive care unit (ICU) for coronary artery bypass graft surgery (CABG).: MethodsEight hundred and eighty-eight patients undergoing CABG were studied by univariate and multivariate analysis. Prolonged stay in the ICU was defined as ≥3 days stay. Stepwise selective procedure (P≤0.05) was used to identify a subset of variables with prognostic value for prolonged stay. This subset was used to calculate a prognostic score S and predicted probability P (P=1/1+e−S). Sensitivity analysis was used for evaluation.: ResultsSignificant risk factors for prolonged stay in the ICU were: lung disease, no-sinus rhythm, no-mild valve pathology, reoperation, no-elective operation, and no-off-pump procedure. The receiver operating characteristic curve gave an area under the curve value of 0.68 for prolonged stay in ICU. Observed probabilities compared well with the predicted probabilities. Patients were classified into low (5%), intermediate (15%), high (30%), and very high-risk groups (40%). A predicted probability of ≥0.40 was used as cut-off point for the prognostic test. The specificity of this test for prolonged stay in the ICU was 99%; sensitivity 9%; positive predictive value 60%; and negative predictive value 89%.: ConclusionsThe results show that individual patients presented for CABG, can be stratified according to their risk for prolonged stay ≥3 days in the ICU. [Copyright &y& Elsevier]

Objective: Despite advances in cardiac surgery, the risk of reoperative coronary artery bypass surgery (RECABG) still exceeds those of a primary myocardial revascularization and also the late results are not so favourable. In this study, long-term cardiac survival is analyzed. Methods: We analyzed long-term cardiac survival of 466 patients who survived the first 6 months after a RECABG between January 1987 and December 1998. Actuarial survival estimates were calculated and pre- and peroperative variables were analyzed to identify predictors of long-term cardiac related mortality. Results: Mean follow-up was 7.7±3.8 years (1–17 years), and follow-up was 95.6% complete. One-year cardiac survival was 98.2%, 5-year: 91.0%, 10-year: 78.7% and 14-year survival 60.2%. Cardiac survival was only significantly superior for patients under 65 years of age at the moment of the RECABG. Impaired left ventricular function was identified as the only independent predictor of late cardiac-related mortality. Conclusion: The long-term survival in patients undergoing RECABG is acceptable. Once patients survived the first 6 postoperative months, advanced age (>65 years) is affecting long-term cardiac survival and impaired left ventricular function is the only independent predictor of late cardiac mortality. [Copyright &y& Elsevier]

: BackgroundIdentify risk factors associated with mortality following repeat coronary revascularization (redoCABG) within the first 6 months following surgery.: MethodsFive hundred forty-one redoCABG patients (1987 to 1998) were studied by univariant and multivariant analysis. Mortality was assessed at three different points: hospital mortality (A) (36/541, 6.7%); mortality at 6 months (C) (75/541, 13.9%); and outpatient perioperative mortality, which is a death occurring from the time of hospital discharge to 6 months postoperatively (B) (39/541, 7.2%).: ResultsDiabetes, hypertension, peripheral vascular disease, renal insufficiency, lung disease, myocardial infarction (MI) before the first operation, MI between the first and redoCABG, lack of sinus rhythm, no IMA graft, acute/emergency operation, perfusion time, and perioperative MI were all identified as risk factors related to early mortality. MI before the first operation, antegrade cardioplegia, and the time period 1987 to 1992 all influenced hospital mortality (A). Diabetes, hypertension, renal insufficiency, lung disease, and valvular heart disease all influenced the outpatient mortality up to 6 months. Independent predictive factors for early mortality were: age more than 69 years; diabetes; vascular insufficiency; chronic lung disease; MI between first and redoCABG; no IMA-graft; acute preoperative MI; emergency operation; perfusion time; perioperative MI; and the time period 1987 to 1992. Risk factors for in-hospital death included MI between the first and redoCABG, cardiopulmonary bypass time, and the time period 1987 to 1992. Diabetes is an important risk factor during the outpatient perioperative phase. Emergency surgery and perioperative MI predict mortality regardless of the time period (A, B, or C).: ConclusionsEarly mortality after redoCABG is influenced by many variables during the first 6 months following surgery. Understanding these factors and their time course may better help to assess the true risk associated with reoperation for recurrent coronary insufficiency. [Copyright &y& Elsevier]

Objective. A scoring system to predict early mortality and morbidity in CABG, distinguishing low and high risk patients. Methods. 563 patients (1998) served as development dataset, 969 patients as validation set. Univariate and logistic regression analysis was used to identify risk factors. Results. Gender, hypertension, pulmonary disease, reoperation, age, operative status and left–ventricular function were predictive variables for early mortality. The area under the ROC curve was 0.81. We identified a low risk, mortality of 1.8% and a high-risk group, mortality of 13.4%. Diabetes, hypertension, kidney and lung disease, reoperation, operative status and left ventricular function were predictive variables for morbidity. The area under the ROC curve was 0.73. We identified a low risk, morbidity of 17%, and a high-risk group, morbidity of 41%. Conclusion. This scoring system is a simple system identifying a low and high-risk group for morbidity and early mortality. [Copyright &y& Elsevier]

Objectives: Construct a predictive model for early mortality in coronary reoperations (RECABG). Methods: Five hundred and forty one RECABG (1987–1998) were studied by univariate and multivariate analysis. Stepwise selective procedure (p<0.05) was used to identify a subset of variables with prognostic value for early mortality. This subset was used to calculate a prognostic score ‘S’ and a predicted probability ‘P’ for early mortality, P=1/1+e−S. Sensitivity analysis was used for evaluation. Results: The best predictive variables for early mortality were diabetes, vascular-, lung-disease, a myocardial infarction between the primary and the RECABG, acute- and emergency operation and the operative period. The prognostic accuracy (receiver operating characteristics curve (ROC) area) was 80%. Observed probabilities compare well with the predicted probabilities, and patients were classified in low risk (5%), intermediate risk (15%), high risk (30%) and very high risk (40%). A predicted probability of ≥0.40 was used as cut-off point for the prognostic test. The specificity of this test was 97%, sensitivity 33%, predictive value of a positive test 63% and 90% for a negative test. Conclusions: The results show that individual patients presented for RECABG, can be stratified according to their early mortality risk. This information can be used to inform the patient, and also to discus the opportunity of the RECABG. [Copyright &y& Elsevier]

Aim: The aim of this study was to analyse the nephrological morbidity after myocardial revascularization.Methods and results: We analysed the pre- per and postoperative data of 3815 patients who underwent a primary isolated coronary bypass grafting between January 1987 and December 1995. Nephrological complications were divided into renal dysfunction and requiring dialysis. The increase in nephrological complications (1.2–4%) is the result of an increase of patients with renal dysfunction. Unifactorial risk analysis identified age, diabetes, hypertension, nephrological pathology, perfusion time, aortic cross-clamp time, emergency operation and perioperative myocardial infarction as risk factors. Multifactorial risk analysis identified age, diabetes, hypertension, nephrological pathology, perfusion time, perioperative myocardial infarction and the cohorts operated upon in 1990–92, 1993–95 as independent risk factors for renal dysfunction, and age, nephrological pathology and perioperative myocardial infarction for those needing dialysis.Conclusion: Several variables have been identified as risk factors for nephrological complications; especially important are pre-existing nephrological pathology and perioperative myocardial infarction. [Copyright &y& Elsevier]

Objective: To outline the changes of the patient population undergoing redo-coronary artery bypass surgery (RECABG). Methods: Preoperative data of 582 first RECABGs, January 1987–June 2000 were analyzed. Group A: 1987–1991 (n=193); group B: 1992–1995 (n=201); and group C: 1996–June 2000 (n=188). Results: These 582 RECABGs represent about 8.5% of the performed bypass surgeries during this period. Mean age (P=<0.001), percentage of patients with kidney disease (P=0.001), a preoperative PTCA (P<0.001) increased. Significant more elective operations (P<0.001) and lesser urgent operations (P=0.001) were performed in group C. There is a significant different distribution of vessel disease over the three periods (P=0.04). Significant more patients had a patent IMA graft (P<0.001). The angina-free period after CABG (P<0.001), the time period between both operations (P<0.001) and the period between the new onset of angina and the RECABG (P=0.012) increased significantly. Despite the importance of progression of atherosclerosis of any sort decrease significantly (P<0.001) over the whole study, there is a significant increase of patients reoperated for isolated progression of the disease in the native coronary arteries (P<0.001) in group C. The impact of late GF was not different for the total group (P=0.82), however, the percentage of RECABGs for isolated late GF increased significantly between group A and B (P<0.001) but there was a decrease from B to C, however, not significant (P=0.067). Conclusion: During the past few years there is a trend in RECABG of older patients, with more coexisting diseases. There are an increasing number of patients with patent arterial grafts, an increase of the event-free period after the CABG, the period between the CABG and RECABG and of the time period between the onset of new angina and the RECABG. Although the impact of atherosclerosis, as angiographic indication, decreased over the total group, there is the significant increase of the percentage of patients reoperated because of isolated progression of atherosclerosis in the native coronary arteries. [Copyright &y& Elsevier]

Abstract: Objective: Acute renal failure post-cardiac surgery (RF) is a major complication and is associated with increased postoperative morbidity and mortality. Early recognition and identification of risk factors for RF is therefore important. However, several definitions of RF are used. The intention of this study is to evaluate if the used definitions influence the incidence and the identification of risk factors for RF. Methods: We identified, after exclusion of 13 patients with preoperative dialysis, 995 consecutive patients undergoing cardiac surgery at the UMC St. Radboud Medical Center between January 2009 and 15 February 2010 as our study cohort. Apart from the definition used by the Society of Thoracic Surgeons, we selected five major international studies concerning RF, each using a different RF definition. These six definitions were used to evaluate the incidence of and identification of risk factors for RF in our study cohort. Results: There is not only a statistically significant difference in incidence (range 4.94–38.1%) of RF between the definitions (p <0.001), but also, the patients identified with RF differ. Univariate analysis identified for each definition several common but also several different risk variables. Multivariate analysis identified also different independent predictors, with different odds ratios for RF for each definition. Conclusion: This study shows that the used definition of RF influences not only the incidence of RF, but also patient identification and the identification of risk variables. [Copyright &y& Elsevier]

Objective: Obese patients are thought to have an increased risk for complications in coronary artery bypass surgery. Several risk stratification systems do not identify obesity as a variable for risk adjustment. The aim of this study is to evaluate the in-hospital and early (one year) mortality and morbidity in obese and non-obese patients after a CABG in the UMC St Radboud. Methods: The data of 1130 patients undergoing a myocardial revascularization from January 2000 to August 2002 were analyzed. Obesity was measured by the body mass index (BMI). A BMI≥30 kg/m2 was defined as obese. We compared 206 obese patients with 924 non-obese patients. Uni- and multivariate analysis were used to analyze the results. The 1-year survival was analyzed using Kaplan–Meier methods. Results: There were no significant differences between obese and non-obese patients according to postoperative myocardial infarction, re-operation for bleeding, in-hospital mortality, renal complications, neurological complications, pulmonary complications, gastrointestinal complications, re-intubation, re-admission on intensive care, ventilation time, days on intensive care, days in hospital and late mortality. Only the incidence of postoperative wound infections was increased in obese patients, 8.3% in the obese versus 4.4% in the non-obese (P=0.02). Multivariate analysis identified obesity only as risk factor for postoperative for wound infections (P=0.04, odds ratio: 1.97). Conclusions: Obese patients do not have an increased risk of in-hospital and early (1 year) mortality after CABG. However, obese patients have an increased risk of postoperative wound infections compared to non-obese patients. [Copyright &y& Elsevier]

BACKGROUND: The objective of this study was to evaluate implementation of an innovative intervention designed to prevent complications and stimulate early rehabilitation among frail elderly inpatients. METHODS: The program was implemented in April 2011. A mixed-methods process evaluation and before-after study were performed. Primary effect outcomes included incidence of hospital-acquired delirium, cognitive decline, and decline in activities of daily living (ADL) during hospital stay. Secondary endpoints included ADL performance 3 months postdischarge, readmission, and caregiver burden RESULTS: One hundred ninety-one preintervention and 195 postintervention patients aged 70 years or older were included. Overall, no significant differences in primary endpoints were found. Mean ADL between discharge and follow-up improved (3.2 vs 5.7, P = .058). Caregivers rated burden of care lower at 3 months postdischarge (.5 vs -- .6, P = .049 RESULTS: One hundred ninety-one preintervention and 195 postintervention patients aged 70 years or older were included. Overall, no significant differences in primary endpoints were found. Mean ADL between discharge and follow-up improved (3.2 vs 5.7, P = .058). Caregivers rated burden of care lower at 3 months postdischarge (.5 vs -- .6, P = .049 CONCLUSIONS: The CareWell in Hospital program was implemented satisfactorily. Although the low baseline delirium incidence (11%), higher comorbidity, and an increasing learning curve during a restricted implementation period potentially influenced the overall effects, this integrated care program may have beneficial effects on outcomes among frail elderly surgical patients. [ABSTRACT FROM AUTHOR]

Abstract: Background: This study investigates changes of quality of life (QOL), physical activity (PA) and symptomatic status (NYHA) at one-year post-coronary artery bypass grafting (CABG). Methods: Of 568 patients undergoing a primary isolated CABG for stable angina (NYHA