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Background Cataract surgery is one of the most frequent surgeries in the world. It is a very safe procedure mostly performed under topical anesthesia in outpatients centers. Due to the growing lack of anesthesiologists, cataract surgeries are more frequently performed without an anesthesiologist present in the operating room. Although extremely rare, life-threatening complications may occur. Cases presentation We report two cases of cataract surgery complicated by severe hypotension that required emergency resuscitation in the immediate postoperative period and hospitalization in intensive care unit. Anaphylactic shock was confirmed in the first case and suspected in the second. Conclusions and importance Even though cataract surgery is a very safe procedure, it is essential to ensure the presence of an anesthesiologist to manage potential, though extremely rare, life-threatening complications such as anaphylactic reactions.

BACKGROUND: Deliberate hypotension is one way to achieve a bloodless surgical field in endoscopic sinus surgery (ESS). We compared two anaesthesia regimens to induce deliberate hypotension and attempted to determine the most efficient one. METHODS: Fifty-nine patients undergoing ESS were minimized into two groups. In the CLO group, patients received I.V. sufentanil 0.15 µg/kg together with I.V. clonidine 2-3 µg/kg. In the REMI group, patients received remifentanil at a rate of up to 1 µg/kg/min. Fromme scores were collected 15 min after the incision and at the end of the procedure. Mean arterial pressure readings (MAP), heart rate readings, time to eyes opening, time to extubation, pain scores, analgesic requirements, and oxygen needs were collected and compared. RESULTS: There were no significant differences in Fromme scores between the two groups. The averaged MAP from 15 min to the end of the procedure was significantly lower in the REMI group; these patients also received more ephedrine. Significantly fewer patients in the CLO group needed oxygen therapy to keep their Pulse Oximeter Oxygen Saturation within 3% of their preoperative values. Patients in this group also needed less piritramide in the recovery room, and their pain scores were lower at discharge from the recovery room. DISCUSSION: Although both anaesthesia regimens offered a similar quality of surgical field, this study suggests that clonidine had a better average safety profile. Furthermore, patients who received this regimen required fewer painkillers immediately after surgery.

Objectives: To determine the main causes for unplanned admission of children to the paediatric intensive care unit (PICU) following anaesthesia in our centre. To compare the results with previous publications and propose a data sheet for the prospective collection of such information. Methods: Inclusion criteria were any patient under 16 years who had an unplanned post-anaesthetic admission to the PICU from 1999 to 2010 in our university hospital. Age, ASA score, type of procedure, origin and causes of the incident(s) that prompted admission and time of the admission decision were recorded. Results: Out of a total of 44,559 paediatric interventions performed under anaesthesia during the study period, 85 were followed with an unplanned admission to the PICU: 67% of patients were younger than 5 years old. Their ASA status distribution from I to IV was 13, 47, 39 and 1%, respectively. The cause of admission was anaesthetic, surgical or mixed in 50, 37 and 13% of cases, respectively. The main causes of anaesthesia-related admission were respiratory or airway management problems (44%) and cardiac catheterisation complications (29%). In 62%, the admission decision was taken in the operating room. Conclusion: Unplanned admission to the PICU after general anaesthesia is a rare event. In our series, most cases were less than 5 years old and were associated with at least one comorbidity. The main cause of admission was respiratory distress and the main type of procedure associated with admission was cardiac catheterisation.

BACKGROUND: Evidence suggests that sleep deprivation associated with night-time working may adversely affect performance resulting in a reduction in the safety of surgery and anaesthesia. OBJECTIVE: Our primary objective was to evaluate an association between nonelective night-time surgery and in-hospital mortality. We hypothesised that urgent surgery performed during the night was associated with higher in-hospital mortality and also an increase in the duration of hospital stay and the number of admissions to critical care. DESIGN: A prospective cohort study. This is a secondary analysis of a large database related to perioperative care and outcome (European Surgical Outcome Study). SETTING: Four hundred and ninety-eight hospitals in 28 European countries. PATIENTS: Men and women older than 16 years who underwent nonelective, noncardiac surgery were included according to time of the procedure. INTERVENTION: None. MAIN OUTCOME MEASURES: Primary outcome was in-hospital mortality; the secondary outcome was the duration of hospital stay and critical care admission. RESULTS: Eleven thousand two hundred and ninety patients undergoing urgent surgery were included in the analysis with 636 in-hospital deaths (5.6%). Crude mortality odds ratios (ORs) increased sequentially from daytime [426 deaths (5.3%)] to evening [150 deaths (6.0%), OR 1.14; 95% confidence interval 0.94 to 1.38] to night-time [60 deaths (8.3%), OR 1.62; 95% confidence interval 1.22 to 2.14]. Following adjustment for confounding factors, surgery during the evening (OR 1.09; 95% confidence interval 0.91 to 1.31) and night (OR 1.20; 95% confidence interval 0.9 to 1.6) was not associated with an increased risk of postoperative death. Admittance rate to an ICU increased sequentially from daytime [891 (11.1%)], to evening [347 (13.8%)] to night time [149 (20.6%)]. CONCLUSION: In patients undergoing nonelective urgent noncardiac surgery, in-hospital mortality was associated with well known risk factors related t

Rigid bronchoscopy under general anesthesia enables performing diagnostic and/or therapeutic procedures in the tracheobronchial tree. This technique is characterized by specific technical problems, insofar as the anesthesiologist and the operators share the same space, namely the airway. Several potential complications (hemorrhage inside the airway, threat to ventilation ...) may arise. These challenges render the ability to use the variable available techniques essential, as well as knowledge of the complications they could entail, and the ability to rapidly solve them. General anesthesia is usually total intravenous anesthesia, using short acting agents. Ventilation can be spontaneous, but more often insured using high-frequency jet ventilation. The hospital infrastructure and staff must have the expertise to perform this particular procedure, in order to limit the complication rate.

Objectifs Les techniques vidéo-assistées sont en plein essor et sont en train de changer nos algorithmes de prise en charge des patients difficiles à intuber. Nous avons comparé deux techniques, l’Airtraq™ et le Glidescope™, avec la laryngoscopie directe en étudiant, en particulier, la facilité d’accès des voies aériennes (score de difficulté d’intubation [IDS], durée et succès d’intubation) et le retentissement hémodynamique de ces deux techniques chez des patients dont l’IMC est supérieur à 30. Type d’étude Étude prospective randomisée par minimisation. Patients et méthodes Quatre-vingt patients ont été randomisés par minimisation en quatre groupes : deux groupes ont été intubés avec le Glidescope™, un groupe par expérimentateur, et deux autres avec l’Airtraq™. Des médecins diplômés en anesthésie et réanimation ont pris en charge cette étude. L’induction de l’anesthésie a été standardisée : anesthésie intraveineuse totale (rémifentanil en perfusion continue, propofol en mode anesthésie intraveineuse à objectif de concentration [AIVOC] et rocuronium en bolus). Les paramètres suivants ont été analysés : succès de l’intubation basé sur le temps d’intubation et le niveau de désaturation, sa durée, son retentissement hémodynamique, score IDS et d’éventuels traumatismes dentaires. Résultats Le succès de l’intubation était de 100 % pour le Glidescope™ et de 80,6 % pour l’Airtraq™ (p = 0,009). L’Airtraq™ permet une meilleure visualisation de l’orifice glottique (Score Cormack et Lehane moindre) par rapport au Glidescope™. En revanche, le recours aux techniques alternatives pour réaliser l’intubation était significativement plus fréquent avec l’Airtraq™ qu’avec le Glidescope™. Aucune différence n’a pu être détectée entre les deux systèmes au niveau de la stabilité hémodynamique. Conclusion Chez le patient obèse, le Glidescope™ permet de réaliser une intubation sans recourir à d’autres techniques, et ce avec une certaine facilité.

Objectif : Chez les patients sévèrement dénutris, un support nutritionnel préopératoire permet de réduire l’impact péjoratif de la dénutrition sur l’évolution postopératoire. Un pré-requis indispensable est d’identifier cette dénutrition. Nous avons voulu savoir si la consultation pré-anesthésique (non obligatoire en Belgique) était un outil permettant d’atteindre ces objectifs de dépistage préopératoire chez des patients opérés d’une chirurgie abdominale. Méthode : Notre méthode de travail s’est articulée en trois étapes. Après avoir déterminé notre situation de départ, nous sommes intervenus en insérant le Nutritionnal risk screening (NRS) 2002 dans notre protocole de consultation informatisé et en créant une procédure permettant de coupler notre consultation à celle de diététique le même jour. Nous avons ensuite analysé l’efficacité de nos interventions. Résultats : Nous avons reçu 87,8 % des patients opérés électivement d’une chirurgie abdominale à la consultation pré-anesthésique. Grâce à l’informatisation du NRS 2002, notre dépistage nutritionnel est passé de 60,8 % à 86,1 %. Tout patient à risque de dénutrition a été référé le jour même au service de diététique pour une évaluation nutritionnelle et un support nutritionnel si nécessaire. Cette procédure a réduit au maximum les retours des patients à l’hôpital. Le délai moyen de 13 à 15 jours entre la consultation pré-anesthésique et la chirurgie était suffisant pour mettre en place un support nutritionnel préopératoire. Conclusion : La consultation pré-anesthésique est ainsi devenue un outil de dépistage pour la prise en charge nutritionnelle préopératoire.

PURPOSE: Report a case of a patient, who benefitted from the I-gel, during an elective urological surgery and who presented severe laryngeal hemorrhage at the time of its withdrawal. CLINICAL FEATURES: A 71-year-old male patient had been admitted in the operating room for the insertion of a ureteral stent. He had a history of usual interstitial pneumonia (UIP) requiring corticosteroids and oxygen therapy and a severe obstructive sleep apnea syndrome treated with nasal continuous positive airway pressure (NCPAP). After intravenous induction of anesthesia, a size 5 I-gel (Intersurgical, Wokhingam, UK) was easily inserted in the first attempt. Anesthesia was maintained with sevoflurane. As soon as the procedure ended, the I-Gel was removed. After two minutes, the patient presented a respiratory distress and started spitting significant quantity of blood. Oropharyngeal fiberscopy was performed in emergency and highlighted active bleeding of the left aryepiglottic fold. Hemostasis was obtained by local compression. The patient was transferred to the intensive care unit. He was extubated the following day without complications. No additional procedure was necessary to stop the bleeding. CONCLUSION: Authors reported the first severe complication associated with the use of size 5 I-gel. Additional studies have to be carried out to specify the advantages and risks associated with the use of this recent material.

BACKGROUND: To assess the influence on myocardial protection of the rate of infusion (continuous vs intermittent) of cold blood cardioplegia administered retrogradely during prolonged aortic cross-clamping. The end-points were ventricular performance and biochemical markers of ischemia. METHODS: Seventy patients undergoing myocardial revascularization for three-vessel disease were prospectively randomized to receive intermittent or continuous retrograde cold blood cardioplegia. Hemodynamic measurements were obtained using a rapid-response thermodilution catheter and included right ventricular ejection fraction, cardiac output, left and right ventricular stroke work index, and systemic and pulmonary vascular resistance. Blood samples were obtained from the coronary sinus before cross-clamp application and immediately after cross-clamp removal for determinations of lactate and hypoxanthine. RESULTS: The left ventricular stroke work index trend was significantly superior (p = 0.038) by repeated-measures analysis in continuous cardioplegia. Other hemodynamic measurements revealed a similar trend. The need for postoperative inotropic drugs support was reduced in continuous cardioplegia. The release of lactate in the coronary sinus after unclamping was 2.30 +/- 0.12 mmol/L after intermittent cardioplegia and 1.97 +/- 0.09 mmol/L after continuous cardioplegia (p = 0.036). The release of hypoxanthine was 20.47 +/- 2.74 micromol/L in intermittent cardioplegia and 11.77 +/- 0.69 micromol/L in continuous cardioplegia (p = 0.002). CONCLUSIONS: Continuous cold blood cardioplegia results in improved ventricular performance and reduced myocardial ischemia in comparison with intermittent administration.

PURPOSE OF REVIEW: Recent advances in technology as well as new indications for implantation have appeared in the field of ventricular assist devices. Progress has also been made in the understanding of the underlying mechanisms of myocardial recovery after ventricular assist device support. RECENT FINDINGS: Technological progress includes the development of fully implantable pulsatile and continuous flow pumps, either axial flow or centrifugal, for left ventricular and total heart assistance. Among the new indications for ventricular assist device support, the most important is the use of the device as permanent treatment for end-stage cardiac failure patients. Increased knowledge has been acquired regarding the effects of mechanical assistance and of unloading of the heart on haemodynamics, as well as on the cellular, molecular and electrophysiological characteristics of the failing heart. All these findings suggest that depressed myocardial function can sometimes recover with ventricular assist device therapy. Ventricular assist device support, however, still carries a high rate of complications: the device itself can fail, bleeding and thromboembolism are common, immunity is disturbed and the incidence of infection remains high. SUMMARY: In patients with end-stage heart failure, ventricular assist devices can be used as a bridge to transplantation or to recovery, but they are now also considered as a long-term myocardial replacement therapy. Which device is the most appropriate for each indication, however, remains to be defined. Even if the underlying mechanisms of myocardial recovery are progressively clarified, the use of ventricular assist devices as a bridge to recovery still has limited clinical success. Clinical trials with the fully implantable devices are in their early stages, but these pumps appear promising in terms of efficacy, reliability and complication rate, as well as being easy to implant. Because more patients will benefit from ventricular as

OBJECTIVE: The objective of this study was to assess improved myocardial protection by performing coronary artery bypass grafting (CABG) on the beating heart. A case-matched study was conducted among patients who underwent CABG either on-pump (group 1), or off-pump (group 2). METHODS: Forty-five pairs of patients, having a similar clinical profile, were selected on the basis of five variables: age, gender, body surface area, ejection fraction, extent of coronary disease. Operative risk predicted by the The Society of Thoracic Surgeons national database was 1.80+/-0.35% in group 1, and 1.89+/-0.37% in group 2 (NS). Cold blood cardioplegia and 28 degrees C cardiopulmonary bypass were used in group 1. In group 2, beating heart coronary grafting was achieved with the Octopus 1 and 2 stabilizers. The average number of distal anastomoses was 2.8+/-0.1 in group 1 and 2.3+/-0.1 in group 2 (P=0.015). RESULTS: There was no significant difference among the groups regarding the trend in cardiac index, left and right ventricular stroke work indexes, and systemic and pulmonary vascular resistance indexes. However, heart rate trend was slower in group 2 (P=0.05). Pharmacological support was required in 65% of the patients in group 1, and in 33% in group 2 (P<0.001). The total amount of Dobutamine and/or Dopamine administered during the first 48 h was 3914+/-1306 gamma/kg in group 1 and 1645+/-697 gamma/kg in group 2 (P=0.049). Release of creatine kinase MB mass isoenzyme (CK-MB mass) was markedly reduced in group 2 (P<10(-4)). CONCLUSIONS: Hemodynamic outcome following off-pump CABG is similar to on-pump CABG but the need for inotropic support is significantly reduced and CPK-MB mass release is markedly lower.

Doppler-derived left ventricular (LV) rate of pressure rise (Dop LV DeltaP/Deltat) is described as an index of LV performance in the presence of mitral regurgitation (MR). This study was designed to define more accurately the accuracy of the method in the presence of severe MR. Ten pigs were anesthetized and monitored. MR was gradually created. At each grade of MR, preload was manipulated with the intent of modifying LV end-diastolic area value within a range of +/-20%. Concurrently, the mean left atrial pressure (LAP) was recorded, MR was quantified by the mitral to aortic velocity-time integral ratio (mitroaortic VTI ratio), Dop LV DeltaP/Deltat was calculated, and peak LV dP/dt was derived from LV catheterism data. During the procedure Dop LV DeltaP/Deltat gradually underestimated peak LV dP/dt. This difference was correlated to the mean LAP (P < 10(-5)) and mitroaortic VTI ratio (P < 10(-5)) and became clinically significant when the mean LAP was superior to 21 mm Hg.

A case of patent foramen ovale opening was observed concomitantly to a defibrillation threshold determination in the setting of an internal cardioverter defibrillator implantation. The subsequent transient right-to-left shunt was confirmed by a peroperative transoesophageal echocontrast study. The underlying mechanism of this incident may be related to a transient reversal of the interatrial gradient, due to the pre-existence of pulmonary hypertension and tricuspid regurgitation, associated with ongoing mechanical ventilation and modifications of intracardiac pressures regimen secondary to the succeeding ventricular tachyarrhythmia and defibrillation. Paradoxical embolism can be an aetiology for neurologic injury during internal cardioverter defibrillator implantation.

OBJECTIVES: To evaluate the results of laparoscopic resection of phaeochromocytoma with a focus on pre- and intra-operative endocrinological and pharmacological aspects. DESIGN: Retrospective study based on review of case notes and intraoperative anaesthetic records. PATIENTS: Eight patients (four men, four women) aged 13 to 70 (median: 45) years with symptomatic phaeochromocytoma (two patients with MEN IIa syndrome) diagnosed 6-36 months before adrenalectomy in four patients and just before operation in the four remaining patients. All patients presented with hypertension. MEASUREMENTS: Pre- and postoperative blood pressure (BP) was assessed using a sphygmomanometer, intraoperative measurements being obtained by intra-arterial line. Adrenaline (A), noradrenaline (NA), metadrenaline (metA), normetadrenaline (normetA) and vanillylmandelic acid (VMA) were measured in 24-h urine samples. Adrenal imagery consisted in all patients of abdominal computed tomography and [131I] metaiodobenzylguanidine (MIBG) scintigraphy, and in 2 patients, adrenal magnetic resonance imaging and octreotide scintigraphy. Determination of plasma volume was performed by isotopic method. RESULTS: Median (range) preoperative systolic and diastolic BP was 140 (130-240) and 90 (80-150) mm Hg, respectively. Predominant catecholamine secretion consisted of A in four patients (A pattern) and of NA (NA pattern) in the other four. Tumours smaller than 30 mm usually secreted A while larger ones secreted NA. Pre- and intra-operative BP control was straightforward in all but two patients with preferential NA secretion. The median number of systolic and diastolic BP peaks were higher in patients with NA pattern (n = 6, range: 3-9) than in those with A pattern (n = 1.5, range: 1-6). Total duration of pneumoperitoneum ranged from 120 to 240 (median: 195) min. Intra- and post-operative complications included intra-abdominal bleeding, laparoscopically controlled (in one case), and upper pole kidney ischaemia in

BACKGROUND: The estimation of left ventricular (LV) contractility is difficult in the presence of significant mitral regurgitation (MR). Prediction of LV performance after MR repair is even more problematic. The intraoperative Doppler-derived LV rate of pressure rise (LV delta P/delta t) analyzed before cardiopulmonary bypass (CPB) was presumed to be a useful predictive parameter for LV performance. Therefore, its relation to perioperative inotropic requirements (PIR) necessary for separation from CPB after surgical MR repair was investigated. METHODS: Twenty-eight patients scheduled for surgical MR repair fulfilled the selection criteria. Pre-CPB LV delta P/delta t, pre-CPB echocardiographic LV fractional area change (LV FAC), and pre-CPB thermodilution-derived cardiac index (CI) were recorded. After MR repair, separation from CPB was performed with regard to standardized guidelines. PIR during the first 60 minutes following separation were recorded. RESULTS: Pre-CPB LV delta P/delta t could be assessed in 22 patients. Pre-CPB LV delta P/delta t was 882 +/- 450 mmHg/sec, pre-CPB LV FAC was 49% +/- 9%, and pre-CPB CI was 2.0 +/- 0.2 L/kg/min. Pre-CPB LV delta P/delta t was significantly correlated with pre-CPB LV FAC (r = 0.56), and with pre-CPB CI (r = 0.72). Inotropic support was necessary in 16 patients (73%), and was best predicted by the pre-CPB LV delta P/delta t, by means of logistic regression (p = 0.026). CONCLUSIONS: Doppler-derived LV delta P/delta t was assessable in most patients with severe chronic MR, and was the best intraoperative predictive parameter of post-CPB inotropic requirements after surgical MR repair.

Validation of Doppler-derived left ventricular Delta P/Delta t determination in presence of unstable acute mitral regurgitation in pigs

Introduction: Left ventricular (LV) rate of pressure rise (LV DP/Dt) derived from the continuous Doppler profile of mitral regurgitant jet has been proven to be a reliable [1] and reproducible [2] index of peroperative LV performance in the presence of mild to moderate mitral regurgitation (MR). This study was designed to precise the accuracy of the method in presence of severe acute MR....

BACKGROUND: Shortening of atrioventricular delay (AVD) by sequential cardiac pacing has been proposed to improve hemodynamics in patients with end-stage heart failure. In addition, optimization of prolonged AVD may be associated with a decrease of presystolic mitral insufficiency. The aim of this study was to explore the incidence of prolonged AVD during the early postcardiopulmonary bypass (CPB) period and to evaluate the hemodynamic benefit of its shortening by using sequential cardiac pacing. METHODS: Fifty consecutive patients scheduled for coronary artery bypass grafting were prospectively screened. AVD was measured immediately after separation from CPB. Patients presenting with AVD greater than or equal to 200 ms entered the study. Sequential cardiac pacing was introduced with programmed AVD starting at 80 ms and randomly increased by steps of 20 ms until resumption of native anterograde atrioventricular node conduction. Cardiac index (CI) was derived from transesophageal echocardiographic data during each step of this procedure. RESULTS: Nineteen patients were included. Median native AVD was 220 ms. Median optimal AVD was 140 ms. Mean native CI (CI-nat) was 2.59 +/- 0.42 L/min/m2. Mean optimal CI (CI-opt) was 3.12 +/- 0.45 L/min/m2. CI-opt/CI-nat was 1.20 +/- 0.07. CI-opt/CI-nat was significantly inversely correlated with preoperative left ventricular ejection fraction (r = -0.83). CONCLUSIONS: Prolonged AVD is a common occurrence after CPB. Its artificial shortening by sequential cardiac pacing is always associated with a significant increase of CI. The magnitude of this hemodynamic improvement is inversely correlated with preoperative left ventricular ejection fraction.

OBJECTIVE: To compare intraoperative hemodynamics profiles and recovery characteristics of propofol-alfentanil with fentanyl-midazolam anesthesia in elective coronary artery surgery. DESIGN: Prospective, randomized study. SETTING: University hospital. PARTICIPANTS: Fifty patients with impaired or good left ventricular function. INTERVENTIONS: In group 1, (n = 25) anesthesia was induced with an infusion of propofol, 3 to 4 mg/kg/h, alfentanil, 500 micrograms, and pancuronium 0.1 mg/kg, and maintained with propofol, 3 to 6 mg/kg/h (variable rate), and alfentanil infusions, 30 micrograms/kg/h (fixed rate). Additional boluses of alfentanil, 1 mg, were administered before noxious stimuli; group 2 (n = 25) received a loading dose of fentanyl, 25 micrograms/kg, midazolam, 1.5 to 3 mg, and pancuronium, 0.1 mg/kg for induction, followed by an infusion of fentanyl, 7 micrograms/kg/h, for maintenance. Additional boluses of midazolam (1.5 to 3 mg) and fentanyl (250 micrograms) were administered before noxious stimuli. MEASUREMENTS AND MAIN RESULTS. Cardiovascular parameters at eight intraoperative time points as well as time to extubation, morphine consumption, and pain scores were recorded. Induction of anesthesia was associated in both groups with a small but significant decrease in mean arterial pressure (1: 15 mmHg (15%); 2: 8 mmHg (8%) with significant decreases in cardiac index (1: 8%; 2: 8%) and left ventricular stroke work index (1: 24%; 2: 21%). Throughout surgery, hemodynamic profiles were comparable between groups except after intubation when the MAP was significantly lower in group 1 (75 +/- 12 mmHg) than in group 2 (89 +/- 17 mmHg). Group 1 required less inotropic support. Extubation was performed faster in group 1 (7.6 h) than in group 2 (18.0 h). Morphine requirements and pain scores were comparable between groups. CONCLUSIONS: Propofol-alfentanil anesthesia provides good intraoperative hemodynamics and allows early extubation after coronary artery surgery.

Coronary artery bypass grafting for the treatment of unstable angina is still associated with increased operative risk and postoperative morbidity. The impact of the extended use of arterial grafts on early results is incompletely defined. In a 7-year period (1986 to 1993), 474 patients (average age, 65 years; range, 34 to 85 years) underwent coronary artery bypass grafting for the treatment of unstable angina. Sixty-eight patients were operated on emergently and 406 urgently. They received an average of 3.0 distal anastomoses (range, 1 to 6). Seventy-nine patients had exclusively venous grafts, 316 had one internal thoracic artery graft, 79 had bilateral internal thoracic artery grafts, and 20 had inferior epigastric artery grafts. Sequential internal thoracic artery grafting was performed in 70 patients. Redo operations were performed in 26 patients. Thirty-four patients (7.2%) experienced a new myocardial infarction. Eighty-nine patients (18.8%) had an intraaortic balloon pump inserted preoperatively, intraoperatively, or postoperatively. Eight patients (1.7%) died intraoperatively and 24 patients (5.1%) died postoperatively. Seventy-seven patients (16.2%) had an adverse outcome, as shown by the need for an intraaortic balloon pump (intraoperatively or postoperatively) or hospital death, or by both. Forty variables were examined by multivariate analysis for their influence on the occurrence of an adverse outcome. Aortic cross-clamp time (p = 0.0004), transfer from the intensive care unit (p = 0.0023), female sex (p = 0.0023), operation performed in early years (p = 0.0041), left ventricular aneurysm (p = 0.0068), the number of diseased coronary vessels (p = 0.0312), and reoperation (p = 0.0318) were all found to be significant independent predictors of increased risk.(ABSTRACT TRUNCATED AT 250 WORDS)