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Objective Endoscopic vein harvesting (EVH) is increasingly used as an alternative to open vein harvesting (OVH) for coronary artery bypass graft (CABG) surgery. Concerns about the safety of EVH with regard to midterm clinical outcomes following CABG have been raised. The objective of this study was to assess the impact of EVH on short-term and midterm clinical outcomes following CABG. Design This was a retrospective analysis of prospectively collected multi-centre data. A propensity score was developed for EVH and used to match patients who underwent EVH to those who underwent OVH. Setting Blackpool Victoria Hospital, Plymouth Derriford Hospital and the University Hospital of South Manchester were the main study settings. Patients There were 4709 consecutive patients who underwent isolated CABG using EVH or OVH between January 2008 and July 2010. Main outcome measures The main outcome measure was a combined end point of death, repeat revascularisation or myocardial infarction. Secondary outcome measures included in-hospital morbidity, in-hospital mortality and midterm mortality. Results Compared to OVH, EVH was not associated with an increased risk of the main outcome measure at a median follow-up of 22 months (HR 1.15; 95% CI 0.76 to 1.74). EVH was also not associated with an increased risk of in-hospital morbidity, in-hospital mortality (0.9% vs 1.1%, p=0.71) or midterm mortality (HR 1.04; 95% CI 0.65 to 1.66). Conclusions This multi-centre study demonstrates that at a median follow-up of 22 months, EVH was not associated with adverse short-term or midterm clinical outcomes. However, before the safety of EVH can be clearly determined, further analyses of long-term clinical outcomes are required.

Objective: To develop a multivariate prediction model for major adverse cardiac events (MACE) after percutaneous coronary interventions (PCIs) by using the North West Quality Improvement Programme in Cardiac Interventions (NWQIP) PCI Registry. Setting: All NHS centres undertaking adult PCIs in north west England. Methods: Retrospective analysis of prospectively collected data on 9914 consecutive patients undergoing adult PCI between 1 August 2001 and 31 December 2003. A multivariate logistic regression analysis was undertaken, with the forward stepwise technique, to identify independent risk factors for MACE. The area under the receiver operating characteristic (ROC) curve and the Hosmer-Lemeshow goodness of fit statistic were calculated to assess the performance and calibration of the model, respectively. The statistical model was internally validated by using the technique of bootstrap resampling. Main outcome measures: MACE, which were in-hospital mortality, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accidents. Results: Independent variables identified with an increased risk of developing MACE were advanced age, female sex, cerebrovascular disease, cardiogenic shock, priority, and treatment of the left main stem or graft lesions during PCI. The ROC curve for the predicted probability of MACE was 0.76, indicating a good discrimination power. The prediction equation was well calibrated, predicting well at all levels of risk. Bootstrapping showed that estimates were stable. Conclusions: A contemporaneous multivariate prediction model for MACE after PCI was developed. The NWQIP tool allows calculation of the risk of MACE permitting meaningful risk adjusted comparisons of performance between hospitals and operators. [ABSTRACT FROM AUTHOR]

Background: The relationship between cardiac enzyme (CE) release following coronary artery bypass surgery (CABG) and medium term outcome is unclear. We sought to determine the relationship between post-operative CE release and one-year survival following isolated CABG. Methods: Over three years 3,024 consecutive patients underwent isolated CABG. Patient characteristics were prospectively recorded in a cardiac surgical database. CE release, taken as the highest single measurement recorded in the first 24 hours post-op, was abstracted from an electronic archive. All cause mortality was taken from a national registry of deaths. Results: Data were complete for 2,860 (94.6%) patients. CK-MB isoenzyme (reference range 5-24 U/l) was recorded in 2,568 (89.8%), total CK in 292 (10.2%). CE release three or more times the upper limit of the reference range (ULR) were recorded in 498 (17.4%) patients, 163 (5.7%) patients had CE more than six times ULR. There were 122 deaths (4.3%). Cox proportional hazards analysis showed that CE release 3-6 times ULR (adjusted HR 2.1 [95% CI: 1.6 to 2.6], p = 0.002) and CE release six or more times the ULR (adjusted HR 5.0 [95% CI: 4.5 to 5.4], p < 0.001) were independently associated with increased one-year mortality. Conclusion: Cardiac enzyme release following CABG is associated with increased one-year allcause mortality. The definition of peri-operative myocardial infarction following CABG should include elevation of CK-MB three or more times the upper limit of normal. [ABSTRACT FROM AUTHOR]

Abstract: Background: To investigate the incidence and associated factors for enzyme release following percutaneous coronary intervention comparing assessment with creatine kinase MB (CK-MB) and troponin T (TnT). Method: TnT and CK-MB were measured post procedure in a consecutive series of 933 patients undergoing elective percutaneous coronary intervention between 1/4/2003 and 1/5/2004 at a single regional cardiac centre. Results: CK-MB level significantly correlated to TnT levels (R =0.747, p <0.001) and a CK-MB level of above 3 times the upper limit of the local reference range (>3×ULN) was predicted with 95% sensitivity (48% specificity) at a TnT level of 0.11. Multivariate predictors of >3×ULN CK-MB release for uncomplicated percutaneous coronary intervention (n =898) were multi-vessel angioplasty (OR=2.51, 95% CI=1.57 to 4.01; p <0.001), saphenous venous graft angioplasty (OR=5.5, 95% CI=1.94 to 13.00; p =0.005) and lack of Clopidogrel preloading (OR=2.02, 95% CI=1.30 to 4.38; p =0.027). Conclusions: TnT was found to be a sensitive although not a highly specific marker of CK-MB release. In this study a TnT level above a threshold of 0.11 would identify 95% of the prognostically important 3-fold CK-MB releases. Replacing the >3×ULN CK-MB threshold with a TnT level of 0.1ng/l following percutaneous coronary intervention would increase the apparent rate of myocardial infarction from 11% to 20%. Lack of Clopidogrel preloading was independently associated with a >3×ULN CK-MB release following uncomplicated elective percutaneous coronary intervention. [Copyright &y& Elsevier]

Abstract: Objective: Steroids are beneficial in reducing the inflammatory response accompanying surgery with cardiopulmonary bypass. However, chronic steroid therapy has been implicated as a risk factor for abdominal complications and mortality following surgery. We assessed the impact of chronic steroid therapy had on outcome following cardiac surgery. Methods: During the period January 1999 to March 2003 there were 98 patients on chronic steroid therapy (Group S) who underwent cardiac surgery at our institution. These patients were matched with a control group of 98 patients who were not on steroids (Group C). A propensity score was used to perform the matching. The C statistic for this model was 0.72. Results: Ninety (93.7%) of the 98 patients in Group S had been on oral prednisolone for a median of 9.5 years (25th and 75th percentile of 5 and 12 years) with a median dose of 5mg (25th and 75th percentile of 4 and 8.75mg). Preoperative characteristics were well matched between both groups. There was no difference in the post-operative outcome between the two groups with respect to mortality, stroke, renal failure, abdominal complications, wound infections, requirement for inotropic support and myocardial infarction. Patients in Group S were more likely to develop atrial arrhythmias and to require prolonged ventilation, although this did not reach statistical significance. Conclusions: Chronic steroid therapy was not associated with increased mortality or overall morbidity following cardiac surgery. However, patients on chronic steroids may be at greater risk of developing atrial arrhythmias or of requiring prolonged ventilation. [Copyright &y& Elsevier]

Abstract: Objective: We examined the effect of cardiac comorbidity on mortality and postoperative complications following surgery for primary non-small cell lung cancer. Methods: Between October 2001 to December 2005, 1067 consecutive patients underwent lung resection for primary cancer within a single centre; patient data was collected prospectively. Two hundred and seventy-one patients had a history of cardiac comorbidity, which included 196 angina, 118 myocardial infarction, 36 revascularisation, 10 congestive cardiac failure and 19 rhythm disorders (numbers not mutually exclusive). To account for differences in case-mix we used logistic regression to develop a propensity score for cardiac comorbidity group membership and then performed a propensity-matched analysis. Kaplan–Meier curves were used to assess follow-up mortality. Results: Patients with cardiac comorbidity were more likely to be hypertensive, have severe dyspnoea, diabetes, current or ex-smokers and were older. After performing propensity matching to account for these differences we successfully matched 199 patients with cardiac comorbidity to 398 patients with no cardiac history. There was no difference in in-hospital mortality (2.5% vs 3%, p =0.73), myocardial infarction (0.5% vs 0.3%, p >0.99), arrhythmia (15.6% vs 14.1%, p =0.62), renal failure (2% vs 1.5%, p =0.65), stroke (0.5% vs 0.3%, p >0.99), respiratory insufficiency (4% vs 3.3%, p =0.64), reintubation (1% vs 2.5%, p =0.35), tracheostomy (4% vs 7.8%, p =0.08), intensive care readmission (8.5% vs 6.5%, p =0.37) and length of stay (8 days vs 8 days, p =0.98). Three-year survival was similar (61.4% vs 56.2%, p =0.39). No differences in outcomes existed with different cardiac conditions. Conclusion: With careful assessment and patient selection, patients with cardiac comorbidity were not found to be at increased risk of mortality and morbidity following lung resection for primary non-small cell lung cancer in a propensity-matched population. [Copyright &y& Elsevier]

Abstract: Chronic refractory angina is an increasingly prevalent, complex chronic pain condition, which results in frequent hospitalization for chest pain. We have previously shown that a novel outpatient cognitive-behavioral chronic disease management program (CB-CDMP) improves angina status and quality of life in such patients. In the present study of 271 chronic refractory angina patients enrolled in our CB-CDMP, total hospital admissions were reduced from 2.40 admissions per patient per year to 1.78 admissions per patient per year (P <0.001). The rising trend of total hospital bed day occupancy prior to enrollment fell from 15.48 days per patient per year to a stable10.34 days per patient per year (P <0.001). There were 32 recorded myocardial infarctions prior to enrollment compared to eight in the year following enrollment (14% vs. 2.3%, P <0.001) and overall mortality was lower that comparable groups treated with surgery. This study shows that educating patients and demystifying angina using a brief outpatient CB-CDMP produces an immediate and sustained reduction in hospital admission costs that represents a major potential health care saving. This benefit accrues in addition to the known effects of CB-CDMP on symptoms and quality of life. These data suggest that a CB-CDMP approach to symptom palliation represents a low cost alternative to palliative revascularization. [Copyright &y& Elsevier]