Search

Thymic carcinoid tumours constitute less than 1% of all carcinoids, and differ markedly from true thymomas in natural history, morphology, prognosis and therapeutic options. New clinical and diagnostic modalities are described in two brothers with thymic carcinoid associated with multiple endocrine neoplasia syndrome. Octreotide scintigraphy proved useful for diagnosis and follow-up, and somatostatin receptor positivity may provide new prospects for treatment of non-resectable or recurrent tumour. [ABSTRACT FROM AUTHOR]

Objective: Microwave ablation in conjunction with open heart surgery is effective in restoring sinus rhythm (SR) in patients with atrial fibrillation (AF). In patients assigned for isolated mitral valve surgery no prospective randomized trial has reported its efficacy. Methods: 70 patients with longlasting AF where included from 5 different centres. They were randomly assigned to mitral valve surgery and atrial microwave ablation or mitral valve surgery alone. Results: Out of 70 randomized, 66 and 64 patients were available for evaluation at 6 and 12 months. At 12 months SR was restored and preserved in 71.0 % in the ablation group vs 36.4 % in the control group (P=0.006), corresponding figures at 6 months was 62.5 % vs 26.5 % (P=0.003). The 30-day mortality rate was 1.4 %, with one death in the ablation group vs zero deaths in the control group. At 12 months the mortality rate was 7,1 % (Ablation n=3 vs Control n=2). No significant differences existed between the groups with regard to the overall rate of serious adverse events (SAE) during the perioperative period or at the end of the study. 16 % of patients randomized to ablation were on antiarrhytmic drugs compared to 6 % in the control group after 1 year (p=0.22). Conclusion: Microwave ablation of left and right atrium in conjunction with mitral valve surgery is safe and effectively restores sinus rhythm in patients with longlasting AF as compared to mitral valve surgery alone.

Secondary prevention, i.e. nonsmoking, exercise, weight control, correct nutrition and drugs affecting the prognosis, constitute the basis for the treatment of stable coronary artery disease. The most important drug affecting the prognosis is acetylsalicylic acid. Statin medication can be reduced on the basis of adverse effects only. Angiotensin convertase inhibitor medication is often forgotten in coronary artery disease patients who have undergone cardiac infarction or a temporary stage of cardiac insufficiency. Long-acting nitrate is not the first-line antianginal treatment, beta-blockers and calcium channel blockers being recommended instead.

Objective: Patients on long-term warfarin treatment have an inherent high risk of stroke and here we aimed to identify the determinants of postoperative stroke after coronary artery bypass grafting (CABG) in these patients., Methods: A consecutive series of 270 patients on long-term warfarin treatment who underwent isolated CABG in two university hospitals was assessed by logistic regression as well as classification and regression tree (CART) analysis., Results: Postoperative stroke occurred in 10 patients during in-hospital stay (3.7%). Logistic regression showed that CHADS(2) > 2 (p = 0.036), recent thrombolysis (p < 0.0001) and history of deep vein thrombosis (p = 0.025) were independent predictors of postoperative stroke (area under the ROC curve 0.77). CART analysis showed that CHADS(2) > 2, history of stroke/TIA, no preoperative use of aspirin and preoperative use of low molecular weight heparins were associated with an increased risk of stroke (area under the ROC curve of 0.77)., Conclusions: Both CART and logistic regression analyses showed that the patient characteristics included in CHADS(2) score are important also in the prediction of postoperative stroke risk. Preoperative antiplatelet treatment may be beneficial in the high risk patients and the preoperative bridging with low molecular weight heparins may even be harmful in this respect.

Aim: The aim of this study was to evaluate the safety and efficacy of deep pericardial sling (DPS) versus lateral pericardial sutures (LPSs) for heart stabilization and adequate coronary artery exposure during off-pump coronary artery bypass surgery (OPCAB)., Methods: One surgeon employed in 101 consecutive patients a series of four to six 2-0 polyglactin sutures placed laterally between the left phrenic nerve and the left pulmonary veins (LPS). Two other surgeons used in 104 consecutive patients a single 0-0 braided silk suture with moistened gauze placed in the oblique sinus of the posterior pericardium, between the inferior vena cava and the right lower pulmonary vein (DPS)., Results: One conversion to beating heart surgery with cardiopulmonary bypass support occurred in each study group. No patient in the LPS group was converted to DPS technique. The use of LPSs allowed a number of distal anastomoses somewhat higher than the DPS technique (4.1+/-1.1 vs. 3.7+/-1.1, P=0.02). Postoperative results were similar in both study groups. A lower incidence of postoperative low-cardiac output syndrome and of prolonged need of inotropes has been observed in the LPS group, but the difference failed to reach statistical significance. One patient in the LPS group had postoperative left phrenic nerve palsy. One patient in the DPS group suffered of intraoperative bleeding secondary to rupture of the inferior vena cava likely related to placement of DPS, which was successfully repaired., Conclusion: LPS technique is as effective as DPS technique and allows complete revascularization with a postoperative outcome similar to the latter technique.

The aim of the present study was to evaluate the changing risk of patients undergoing coronary artery bypass grafting (CABG). Residents of Oulu who underwent coronary angiography and/or revascularization from 1993 to 2006 formed the basis of this community-wide study. One thousand three hundred and forty-nine consecutive patients who underwent CABG have been included in the analysis on changing operative risk and results after CABG. A significant increase in the operative risk occurred in patients who underwent CABG (mean logistic EuroSCORE in 1278 patients: 1993-1997: 3.7%; 1998-2002: 4.6%; 2003-2006: 5.4%; P<0.0001). Thirty-day mortality decreased during the last period (1993-1997: 2.5%; 1998-2002: 3.0%; 2003-2006: 1.6%; P=0.49). The area under the ROC curve of logistic EuroSCORE (1993-1997: 0.86; 1998-2002: 0.78; 2003-2006: 0.99) for prediction of 30-day postoperative mortality markedly improved during the last study period. Despite the increased operative risk, off-pump coronary surgery was associated with lower immediate postoperative mortality rates. Contrary to on-pump surgery, immediate postoperative death occurred after off-pump surgery only in patients with additive EuroSCORE >or=6. The results of this study suggest that improved perioperative care as well as changes in operative strategy are positively faced with the increased burden of comorbidities and operative risk of patients currently undergoing CABG.

Background: We have evaluated the immediate and intermediate outcome after off-pump (OPCAB) and conventional on-pump coronary artery bypass surgery (CCAB) in patients with unstable angina pectoris requiring nitrates infusion until arrival in the operating room., Methods: A consecutive series of 153 and 161 patients with unrelenting angina pectoris underwent CCAB and OPCAB, respectively. Conversion from OPCAB to beating heart surgery with perfusion occurred in 4 patients., Results: The OPCAB patients had a significantly higher operative risk than CCAB patients (logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE]: 13.8 +/- 12.8% vs 10.5 +/- 10.0%, p = 0.005). In the overall series, a lower 30-day postoperative mortality was observed among OPCAB patients (1.9% vs 3.9%, p = 0.33), the difference increased along the logistic EuroSCORE tertiles (upper tertile: 3.2% vs 9.5%, p = 0.14), but failed to reach statistical significance. Similar results have been observed among one-to-one propensity score matched pairs. The results of three surgeons who treated most of their patients (96.9%) with OPCAB were compared with those of three surgeons who used, in most of cases (97.1%), the CCAB technique. When adjusted for logistic EuroSCORE, patients operated on by CCAB surgeons had a significantly higher 30-day postoperative mortality (7.1% vs 2.1%, p = 0.04; odds ratio [OR] 10.143; 95% confidence interval [CI] 1.084 to 94.945) as well as a higher risk of combined adverse events (47.1% vs. 35.1%, p = 0.009; OR 2.586; 95% CI 1.274 to 5.250)., Conclusions: This study provided further evidence on the safety and efficacy of OPCAB in the treatment of high-risk patients. A dedicated approach to OPCAB seems to provide particularly good results. Such findings further support a more confident approach with OPCAB in these patients.

Objective: The aim of the present study was to evaluate the impact of estimated glomerular filtration rate (eGFR) on the 15-year outcome after coronary artery bypass surgery (CABG) in a community-wide population study., Methods: Eight hundred and eighty-two patients who underwent CABG were included in this study. eGFR was estimated by the modified Modification of Diet in Renal Disease study equation., Results: Among 30-day operative survivors, patients with eGFR<60 ml/min/1.73 m(2) had significantly poorer overall survival (at 5, 10 and 15 year, 84.7%, 63.5% and 43.8% vs 92.8%, 77.6% and 58.3%, respectively, p<0.0001). eGFR (HR 0.989, 95% CI 0.981-0.997, as well as eGFR<60 ml/min/1.73 m(2): HR 1.470, 95% CI 1.092-1.979) was an independent predictor of late all-cause mortality only when patients' age was excluded from the regression model. This was probably due to strong impact of age on eGFR. eGFR (HR 0.987, 95% CI 0.975-0.998, as well as eGFR<60 ml/min/1.73 m(2); HR 1.612, 95% CI 1.086-2.395) was an independent predictor of cardiovascular mortality secondary to ischemic heart disease or ischemic stroke. eGFR (HR 0.991, 95% CI 0.983-0.999, as well as eGFR<60 ml/min/1.73 m(2): HR 1.396 95% CI 1.031-1.891) was an independent predictor of cardiovascular mortality and morbidity (myocardial infarction, stroke, need for redo CABG or PCI). When both preoperative serum creatinine and eGFR were included in the regression model, only eGFR was predictive of all-cause mortality, cardiovascular mortality and combined cardiovascular mortality and morbidity., Conclusions: This study showed that an eGFR<60 ml/min/1.73 m(2) is an important determinant of long-term outcome after isolated CABG. Since its predictive value seems to be superior to serum creatinine, eGFR may be useful to identify those patients undergoing CABG with subclinical chronic kidney disease.

Aim: In order to investigate the neuroprotective efficacy of off-pump coronary artery bypass surgery (OPCAB) over conventional on-pump coronary artery bypass surgery (CCAB), we have performed a prospective randomized study evaluating retinal circulation changes after OPCAB and CCAB., Methods: Twenty patients were randomized to OPCAB or CCAB. Retinal fluorescein angiography and 60 degrees black-and-white as well as color fundus photographs of both eyes of each patient were taken 1 to 24 h before and 5 to 6 days after the operation., Results: Patients undergoing OPCAB had more severely stenosed carotid arteries (P=0.075), higher incidence of slightly diseased ascending aorta (P=0.087) and higher Northern New England Cardiovascular Study Group stroke risk score (P=0.075). Neither stroke nor transient ischemic attack occurred postoperatively in these patients. Inferotemporal retinal arterial embolization and microinfarction was detected in one patient after CCAB, but in none of the OPCAB group., Conclusion: The risk of retinal embolism can be minimized by the use of OPCAB and, most likely, by adequate epiaortic ultrasound scanning of the ascending aorta and avoiding clamping in case of severely diseased aorta.

Purpose: The Spyder aortic connector (Medtronic, Minneapolis, MN) is a new, promising connector device and its safety and efficacy have been evaluated in this study., Description: Twenty-two patients were randomized to proximal vein graft anastomosis with the Spyder aortic connector (Medtronic) or hand-sewn technique., Evaluation: Twenty patients underwent multi-detector computed tomographic scans of the chest 6 months after surgery to evaluate vein graft patency. We have failed to successfully deploy three Spyder connector devices. Thus in this study we have evaluated the graft patency of 19 hand-sewn grafts and of 19 vein grafts anastomosed with the Spyder anastomotic device. Three vein grafts whose proximal anastomosis was accomplished with the Spyder anastomotic connector were occluded and all hand-sewn vein grafts were patent (16% vs 0%; p = 0.23). Stenosis of the proximal anastomosis was observed in seven vein grafts (37%), accomplished with the Spyder anastomotic connector, and in one (5%) hand-sewn vein graft (p = 0.042)., Conclusions: The results of this study suggest that the use of the Spyder aortic connector device is associated with suboptimal 6-month graft patency.

Background and Aim of the Study: The European system for cardiac operative risk evaluation score (EuroSCORE) has been shown to be a valid tool for predicting immediate and late outcome after coronary artery bypass surgery. As evidence also suggests its value in heart valve surgery, this issue was investigated in a series of patients who underwent surgery for mitral valve regurgitation., Methods: Data obtained from 180 patients who underwent mitral valve repair (MVRep) or mitral valve replacement (MVR) were reviewed, and the patients' additive and logistic EuroSCOREs calculated., Results: The 30-day postoperative mortality rate was 10.0% (n = 18); rates were 7.1% after MVRep and 20.5% after MVR (p = 0.013). The additive EuroSCORE (p <0.0001, area under the ROC curve: 0.804, 95% CI 0.689-0.919, SE 0.059), as well as logistic EuroSCORE (p <0.0001, area under the ROC curve: 0.806, 95% CI 0.695-0.918, SE 0.057) were predictors of 30-day postoperative death. The 10-year overall survival rate from any cause of death was 74.7%. Additive and logistic EuroSCOREs were significantly higher in the MVR group compared to the MVRep group (p <0.0001 in both cases), and also among operative survivors. Patients who underwent MVR had a significantly poorer long-term survival than those with MVRep (p = 0.01). Both the additive EuroSCORE (p <0.0001) and logistic EuroSCORE (p = 0.003) were predictors of late, all-cause mortality. Both scores remained significant predictors of late outcome also when adjusted for type of surgery (MVRep versus MVR). Survival was particularly dismal in patients with an additive EuroSCORE >6 (at 10 years, 54.4% versus 86.6%, p <0.00001) or a logistic EuroSCORE >4% (at 10 years, 58.7% versus 86.6%, p <0.00001)., Conclusion: EuroSCORE is an important predictor of immediate and late outcome after surgery for mitral valve regurgitation.

Objective: The aim of this study was to review the results of off-pump (OPCAB) versus conventional on-pump coronary artery bypass surgery (CCAB) in high-risk patients., Methods: In a cohort of patients with an additive EuroSCORE >/= 6, 67 underwent OPCAB and 112 underwent CCAB., Results: Thirty-day postoperative death and stroke rates were 7.5 % and 6.0 % for the OPCAB group, and 5.4 % ( P = 0.75) and 8.0 % ( P = 0.77) for the CCAB group, respectively. No significant differences were observed for other major outcome endpoints other than cardiac troponin I (OPCAB: 117 +/- 428 ng/ml vs. CCAB: 58 +/- 99 ng/ml, P = 0.028), a result which was probably due to preoperative massive myocardial infarction in two very high-risk patients who underwent OPCAB. A similar outcome was also observed among propensity score-matched pairs. Congestive heart failure ( P = 0.006, OR: 6.366, 95 % CI: 1.682 - 24.093) and baseline cardiac index ( P = 0.018, OR: 0.171, 95 % CI: 0.040 - 0.735) were independent predictors of 30-day postoperative mortality., Conclusions: OPCAB can be safely performed in high-risk patients with results as satisfactory as those achieved with CCAB.

Objective: The value of off-pump over conventional coronary artery bypass surgery in reducing the risk of postoperative stroke is controversial. This issue has been evaluated in light of our recent clinical experience., Methods: Off-pump coronary artery bypass surgery was performed in 557 patients, and conventional coronary artery bypass surgery was performed in 445 patients. Preoperative stroke risk was calculated according to the Northern New England Cardiovascular Disease Study Group stroke risk-scoring method., Results: Off-pump coronary artery bypass surgery was associated with a lower but not significant rate of postoperative stroke in the overall series (1.8% vs 2.5%, P = .45), a difference that slightly increased in the highest tertile of the Northern New England Cardiovascular Disease Study Group score (2.8% vs 4.2%, P = .75). The postoperative stroke rate was significantly lower when the operation was performed by off-pump coronary artery bypass surgeons using routinely epiaortic ultrasonographic scanning compared with conventional coronary artery bypass surgeons not using epiaortic ultrasonographic scanning (0.4% vs 3.9%, P = .015). The Northern New England Cardiovascular Disease Study Group score (mean, 4.6 +/- 2.1 vs 4.9 +/- 2.2; P = .189) was similar in these groups. Logistic regression showed that when adjusted for Northern New England Cardiovascular Disease Study Group stroke risk score and critical preoperative status, the treatment approach (off-pump coronary artery bypass surgery and routine epiaortic ultrasonographic scanning) was an independent predictor of postoperative stroke (P = .012; odds ratio, 34.1; 95% confidence interval, 2.2-533.7)., Conclusions: The neuroprotective efficacy of off-pump coronary artery bypass surgery is marginal compared with that of conventional coronary artery bypass surgery. A decreased risk of postoperative stroke after off-pump coronary artery bypass surgery is expected, mostly in high-risk patients and when epiaortic ultrasonographic examination is routinely used for better planning of operative strategy, aiming to minimize the risk of intraoperative embolism.

Background: The incidence of pulmonary embolism (PE) after coronary artery bypass surgery is ill defined., Methods: Twenty-four patients undergoing off-pump coronary artery bypass surgery were enrolled in a prospective randomized study evaluating a new proximal aortic anastomotic device. Computed tomography was performed postoperatively about 1 week after surgery., Results: Computed tomography showed signs of PE in 6 patients (25%), which were bilateral in 2 cases. None of these patients had symptoms or signs of PE or deep venous thrombosis., Conclusions: The present findings widen the controversial issue of thromboprophylaxis after cardiac surgery and suggest that low-dose heparin may be indicated after coronary artery bypass surgery.

Background: Avoidance of manipulation of diseased ascending aorta has been shown to be associated with a reduced risk of postoperative stroke after off-pump coronary artery bypass surgery (OPCAB). The use of the Heartstring device (Guidant, Indianapolis, USA) to accomplish a proximal aortic anastomosis without aortic clamping has been suggested in such patients., Patients and Methods: From April 2004 to December 2005, proximal aortic anastomoses have been accomplished employing the Heartstring device in 19 patients with calcified ascending aorta who underwent OPCAB. The diagnosis of diseased ascending aorta was made intraoperatively by epiaortic ultrasound scanning., Results: Eighteen vein grafts and three radial artery grafts have been successfully anastomosed to the ascending aorta by employing the Heartstring device. Breaking of eight seals occurred during insertion. One patient (5.2%) had stroke two days after urgent OPCAB., Conclusion: The use of the Heartstring anastomotic device should be considered in high-risk patients with diseased ascending aorta requiring a prompt myocardial revascularization, whenever there is a place to safely insert this device into the ascending aorta.

Objective: To identify the preoperative risk factors associated with increased prevalence of atherosclerotic lesions of the ascending aorta among patients undergoing off-pump coronary artery bypass surgery (OPCAB)., Material and Methods: OPCAB was performed in 241 patients who were intraoperatively investigated by epiaortic ultrasound for the presence of atherosclerotic lesions of the ascending aorta. The Northern New England Cardiovascular Disease Study Group (NNECVDSG) and the Multicenter Study of Perioperative Ischemia (McSPI) stroke risk scores were retrospectively calculated., Results: A diseased ascending aorta was detected by intraoperative epiaortic ultrasound in 74 patients (30.7%). Patient's age (P = .002, odds ratio [OR] 1.067, 95% confidence interval [CI] 1.025-1.110), diabetes (P = .023; OR, 2.211; 95% CI, 1.117-4.378), extracardiac arteriopathy (P = .014; OR, 2.567; 95% CI, 1.214-5.428) and urgent/emergency operation (P < .0001; OR, 3.066; 95% CI, 1.685-5.580) were independent preoperative predictors of a diseased ascending aorta. The area under the ROC curve of the NNECVDSG score in predicting a diseased ascending aorta was 0.710 (95% CI, 0.642-0.778), and that of the McSPI score was 0.722 (95% CI, 0.655-0.788). The prevalence of a diseased ascending aorta was 11.2%, 34.7%, and 49.4% among the NNECVDSG score tertiles (P < .0001), and 11.3%, 31.7%, and 49.4% among the McSPI score tertiles (P < .0001)., Conclusions: These findings confirm the reported high incidence of a diseased ascending aorta in patients undergoing coronary artery bypass surgery. Current stroke risk scores, particularly the simple NNECVDSG score, are valuable predictors of increased prevalence of a diseased ascending aorta.

Background: The use of aortic connector devices for proximal vein graft anastomosis has been shown to be associated with a relevant rate of early graft complications. Cardica PAS-Port is a new aortic connector whose preliminary clinical results seem promising. The safety and efficacy of this aortic connector device have been evaluated in this prospective, randomized study., Material and Methods: Twenty-four patients were randomized to receive proximal aorta-vein graft anastomosis with either the Cardica PAS-port aortic connector or by the hand-sewn technique. Twenty-three patients underwent multidetector computed tomographic scan (MDCT) of the chest 6 months after surgery to evaluate graft patency., Results: All aortic connector devices (18) were successfully deployed and 31 proximal anastomoses were performed by the hand-sewn technique. MDCT showed that 6-month freedom from vein graft complication was 22.2% in the PAS-Port group and 58.1% in the hand-sewn group (P = .04). Four vein grafts (22.2%) anastomosed with the PAS-Port and 2 hand-sewn vein grafts (6.5%) were occluded (P = .10). The use of the PAS-Port aortic connector was also predictive of any vein graft complication when adjusted for vein graft flow (P = .01; OR 8.64, 95% CI 1.66-45.00) and for peripheral resistance units (P = .02; OR 6.14, 95% CI 1.33-28.43)., Conclusions: The results of this prematurely stopped, prospective, randomized study suggest that the use of PAS-Port aortic connector device is associated with a higher rate of early vein graft complications than the hand-sewn technique.

Background and Aim of the Study: Mitral valve repair for degenerative and ischemic mitral valve regurgitation has been shown to be a durable procedure. The study aim was to evaluate the quality of life of patients who had undergone mitral valve repair, and to compare it to that of an age- and gender-adjusted Finnish general population., Methods: Among 130 late survivors after mitral valve repair, 109 (83.8%) answered the RAND-36 Health Survey questionnaire; these patients form the basis of the present study., Results: The Wilcoxon test showed significantly higher mental health (p = 0.04) and pain scores (p = 0.015) and a lower role functioning/physical score (p = 0.008) in the study group. The scores of the other RAND-36 Health Survey variables of the study group were similar to those of the age- and gender-adjusted general population. The mean total score for the study group was 512 (median 532, IQR 360-678), compared to 522 (median 538, IQR 468-549) in the general population (p = 0.72) (only 95 patients were included in the analysis due to isolated missing scores)., Conclusion: The quality of life of long-term survivors after mitral valve repair, as assessed by the RAND-36 Health Survey, is similar to that of an age- and gender-adjusted general Finnish population.

Background: Several studies reported excellent long-term results after mitral valve repair for regurgitation, however a number of patients still experience recurrent mitral valve regurgitation which requires reoperation. We have evaluated the long-term outcome of a consecutive series of patients who underwent mitral valve repair for regurgitation in an attempt to identify the risk factors associated with late failures., Patients and Methods: One-hundred and sixty-four patients underwent mitral valve repair for ischemic and degenerative mitral valve regurgitation. Seventy-two patients underwent echocardiographic evaluation a median of 5.6 years after surgery., Results: Ten-year survival freedom from any fatal cardiac event was 75.9% and survival freedom from redo mitral valve surgery was 93.8%. Multivariable analysis showed that residual mitral valve regurgitation grade>1 as assessed during the immediate postoperative period (at 10-year, 60.6% vs. 95.7%, p=0.001, RR 20.7, 95%C.I. 3.4-125.3) and chronic obstructive pulmonary disease/asthma (at 10-year 66.8% vs. 95.2%, p=0.013, RR 12.0, 95%C.I. 1.7-85.2) were predictors of redo mitral valve surgery. The same findings were observed also among patients with myxomatous degenerative disease. At echocardiographic follow-up, no significant improvement was detected in terms of left ventricular ejection fraction, whilst mitral valve regurgitation grade (median, 3 to 1), New York Heart Association class (median, 2 to 1) and left atrium diameter (median, 50 to 44 mm) decreased significantly., Conclusions: This study confirms the excellent clinical long-term results after mitral valve repair. An adequate repair technique is advocated in order to decrease the immediate postoperative rate of residual regurgitation>1 as this is a main determinant of late failures requiring redo mitral valve surgery. Further studies are required to better define the possible causative role of chronic obstructive pulmonary disease and any underlying connective tissue metabolic disorder in late failures after mitral valve repair.

Background: Mitral valve repair (MVR) has been shown to achieve good long-term results. However, this procedure is associated with relevant immediate postoperative mortality. The aim of this study is to identify those preoperative variables associated with an increased risk of 30-d postoperative death., Methods: One hundred and sixty-four patients underwent MVR at our institution from January 1993 to December 2000., Results: Eleven patients (6.7%) died during the immediate postoperative outcome, a median of 14 d after surgery (range, 1-29 d). One patient (1.3%) out of 80 who underwent MVR as lone procedure died on postoperative day 14 of cardiac tamponade. The mortality rate in those who underwent MVR associated with other procedures was 11.9%. Multivariable analysis (154 patients included in the analysis) showed that patients' age (p = 0.006, for an increase of 10 units: OR 4.33, 95% CI 1.53-12.27), history of prior cardiac surgery (p = 0.006, OR 118.56, 95% CI 4.03-3491.14) and NYHA functional class (p = 0.011, OR 5.66, 95% CI 1.49-21.49) were significantly associated with an increased risk of postoperative death. The receiver operating characteristics (ROC) curve showed that patients' age had an area under the curve of 0.762 (95% CI 0.622-0.901, p = 0.004), its best cut-off value being 65 years (mortality, 13.4% vs 2.1%, p = 0.008, sensitivity 81.8%, specificity 62.1%, accuracy 63.4%). None of the patients older than 65 and with a history of prior cardiac surgery survived the operation., Conclusions: MVR is associated with a relevant 30-d mortality risk in patients older than 65 years, with advanced NYHA functional class and a history of prior cardiac surgery.

Objective: To evaluate whether pulmonary artery blood (PA) temperature on admission to the intensive care unit (ICU) is predictive of postoperative outcome after isolated on-pump coronary artery bypass grafting (CABG)., Design: A retrospective study on 1639 patients who underwent isolated on-pump CABG in whom PA temperature at admission to the ICU was available for review., Results: Thirty-three patients (2.0%) died during the in-hospital stay and 87 patients (5.3%) developed low cardiac output syndrome. PA temperature at admission to the ICU was significantly associated with an increased risk of overall postoperative death (p = 0.002), cardiac death (p = 0.03), and low cardiac output syndrome (p < 0.0001), and was significantly correlated with prolonged length of ICU stay (p < 0.0001) and postoperative bleeding (p = 0.001). Patients with high PA temperature had significantly more severe comorbidities, and longer aortic cross-clamping and cardiopulmonary bypass time. The receiver operating characteristic curve showed that PA temperature at admission to the ICU in predicting postoperative death had an area under the curve of 0.660 (p = 0.002) and its best cut-off value was 36.4 degrees C (sensitivity: 63.6%, specificity: 65.2%). When the PA temperature at admission to the ICU was > or = 36.4 degrees C, the postoperative mortality and low cardiac output syndrome rates were 3.6 and 8.3%, whereas they were 1.1 and 3.7% when the PA temperature at admission to the ICU was < 36.4 degrees C (p = 0.001, p < 0.0001), respectively., Conclusion: Patients having a PA temperature > or =36.4 degrees C at admission to the ICU after CABG seem to be at higher risk of poor postoperative outcome.

During the last 2 years, 103 aortic saphenous vein graft anastomoses were performed in 68 patients undergoing off-pump coronary artery bypass by using the Symmetry Bypass System Aortic Connector. Of these patients, 2 died during the early postoperative period. In the first patient, after an episode of ventricular fibrillation and closed-chest cardiac massage, the sternum was opened and hemopericardium secondary to leakage of the proximal anastomotic device was found. The second patient died of ascending aortic dissection, the tear of which was likely to have originated from the proximal anastomotic site.

Background: Atrial fibrillation, occurring after coronary artery bypass grafting (CABG), has been suggested to be associated with the development of postoperative stroke. However, it is not clear what is the incidence of atrial fibrillation-related postoperative stroke, the timing of its occurrence, and the outcome. These issues have been investigated in a consecutive series of patients who have undergone on-pump coronary artery bypass grafting (ONCAB)., Methods: Among 2,630 patients who underwent ONCAB, 52 patients (2.0%) experienced postoperative stroke and form the basis of the present study., Results: Twelve patients (23.1%) died postoperatively. The ischemic cerebral event occurred after a mean of 3.7 days (range, 0 to 33). In 19 patients (36.5%), atrial fibrillation preceded the occurrence of neurologic complication. These patients experienced a mean of 2.5 episodes of atrial fibrillation before the occurrence of neurologic complication. The cerebrovascular event occurred after a mean of 6.0 days in patients in whom atrial fibrillation preceded it, after a mean of 1.2 days in those with calcified ascending aorta, and after a mean of 3.1 days in those without calcified ascending aorta or in whom atrial fibrillation did not precede the cerebrovascular complication (p < 0.0001). Stroke occurred a mean of 21.3 hours after atrial fibrillation., Conclusions: This study confirmed that atrial fibrillation, occurring after CABG, is a major determinant of postoperative stroke. Prevention of postoperative atrial fibrillation, and of formation of clots into the left atrium, may dramatically reduce the risk of postoperative stroke.

Background: The pathogenesis of anastomotic femoral pseudoaneurysms (AFPs) is still unclear. We have performed this long-term retrospective study of patients who underwent aortobifemoral reconstruction for abdominal aortic aneurysm (AAA) in order to better establish the long-term rate of AFP and to identify the predictors of its late occurrence., Methods: The long-term outcome of 178 patients who underwent and survived aortobifemoral reconstruction for infrarenal AAA was reviewed., Results: During a median follow-up of 5.2 years, 28 AFPs developed in 19 patients. Six AFPs were recurrent. The mean linearized rate of AFPs was 1.88% per year. At 15 years, the survival-freedom rate from AFPs was 60%, and from repair of AFPs it was 62%. The survival-freedom rate from AFP was significantly poorer in patients with chronic obstructive pulmonary disease (P = 0.017; at 10 years: 64.3% versus 92.3%), hyperlipidemia (P = 0.0056; at 10 years: 59.2% versus 87.5%), current smoking (P <0.0001; at 10 years: 65.8% versus 94.5%), and postoperative inguinal wound infection (P <0.0001; at 10 years: 42.8% versus 86.8%). Multivariate analysis showed that chronic obstructive pulmonary disease (relative risk [RR]: 3.05, 95% confidence interval [CI]: 1.04 to 8.95), current smoking (RR: 5.38, 95% CI: 1.62 to 17.90), and postoperative inguinal wound infection (RR: 9.04, 95% CI: 2.76 to 29.96) were significantly associated with the development of AFPs. The linearized rate of AFPs was significantly higher only among current smokers (P <0.0001, 4.4% versus 0.8% per year) and among those who had inguinal wound infection (P = 0.001, 9.2% versus 1.5% per year)., Conclusions: Current smoking and inguinal wound infection may contribute to the development of AFP after aortobifemoral reconstruction for AAA, likely by affecting reparative connective tissue mechanisms at the anastomotic site.

Background: C-reactive protein (CRP) is a predictor of early and late outcome after coronary angioplasty, but there is scant data on its impact on the outcome after coronary artery bypass grafting (CABG)., Methods: The predictive value of preoperative CRP was evaluated in a series of 764 patients who underwent on-pump CABG., Results: During the in-hospital stay, 13 patients (1.7%) died, 45 (4.5%) developed low cardiac output syndrome, and 28 (3.7%) suffered minor or major cerebrovascular complications. Patients with a preoperative serum concentration of CRP>/=1.0 mg/dL had a higher risk of overall postoperative death (5.3% vs 1.1%, p = 0.001), cardiac death (4.4% vs 0.8%, p = 0.002), low cardiac output syndrome (8.8% vs 3.7%, p = 0.01), and any cerebrovascular complication (4.4% vs 3.5%, p = 0.66). Preoperative serum concentration of CRP>/=1.0 mg/dL was significantly more frequent among patients with history of myocardial infarction, diabetes, lower limb ischemia, low left ventricular ejection fraction, NYHA class IV, and in those undergoing urgent or emergency operation. At multivariate analysis, preoperative serum concentration of CRP >/= 1.0 mg/dL (p = 0.01, O.R.: 6.97) and left ventricular ejection fraction (p = 0.01, O.R.: 0.95) were independent predictors of postoperative death. Postoperative mortality rate was 0.3% among patients with preoperative CRP < 1.0 mg/dL and an ejection fraction >/=50%, whereas it was 21.4% among those with a preoperative CRP >/= 1.0 mg/dL and an ejection fraction less than 50% (p < 0.0001)., Conclusions: Preoperative serum concentration of CRP in patients undergoing on-pump coronary artery bypass surgery is an important determinant of postoperative outcome.

Objective: It is not clear whether the severity of coronary artery disease as assessed on angiography has an impact on the postoperative outcome after coronary artery bypass surgery (CABG)., Design: The angiographic status of 15 coronary arteries/segments of 2,233 patients who underwent isolated on-pump CABG was graded according to the following criteria: 1 = no stenosis; 2 = stenosis <50%; 3 = stenosis of 50-69%; 4 = stenosis of 70-89%; 5 = stenosis of 90-99%; 6 = vessel occlusion; and 7 = vessel is not visualized., Results: Thirty-seven patients (1.7%) died during the in-hospital stay and 108 (4.8%) developed postoperatively low cardiac output syndrome. Multivariate analysis showed that along with other risk factors the overall coronary angiographic score was predictive of postoperative death (p = 0.03; OR: 1.027, 95% CI: 1.003-1.052) and of low cardiac output syndrome (p = 0.04; OR: 1.172, 95% CI: 1.010-1.218). The status of the proximal segment of the left circumflex coronary artery, the diagonal arteries and the left obtuse marginal arteries was most closely associated with adverse postoperative outcome., Conclusion: The angiographic status of coronary arteries has an impact on the immediate outcome after CABG.

Objective: The purpose of the present study was to evaluate the usefulness of the myoglobin/carboanhydrase III (Myo/CAIII) ratio in the diagnosis of perioperative myocardial infarction during coronary artery bypass surgery., Design: Thirty patients undergoing elective coronary artery bypass grafting (CABG) were included in the series. The patients were randomized in two groups: one received conventional normothermic retrograde blood cardioplegia, while the other was subjected to a 5-min period of ischemic preconditioning before cardioplegia. Biochemical markers for myocardial and skeletal muscle injury were measured in serial blood samples taken postoperatively from 4 h after aortic declamp., Results: Three patients were diagnosed to have suffered from perioperative myocardial infarction on the basis of significant elevations of troponin T and creatine kinase MB-isoenzyme (CK-MB) concentrations. In these particular patients the Myo/CAIII ratio increased rapidly after aortic declamping. In uncomplicated patients, the median value of the Myo/CAIII ratio remained within normal limits. There was a positive correlation between the net output of lactate during the aortic cross-clamping period and postoperative Myo/CAIII ratio. The Myo/CAIII ratio proved to be a more specific indicator for myocardial damage than myoglobin alone. The Myo/CAIII ratio was higher in the preconditioning group than in the control group., Conclusion: Myo/CAIII ratio is a sensitive and specific marker for perioperative myocardial infarction increasing rapidly after aortic declamping. This ratio could also be used when assessing the extent of ischemic myocardial injury and comparing different surgical and cardioprotective techniques.

Objective: To compare the long-term clinical outcome of patients who underwent aortic valve replacement with St. Jude Medical and Medtronic-Hall mechanical prostheses., Design: From June 1978 to June 1982, 43 Medtronic-Hall and 48 St. Jude Medical mechanical valves were implanted in 90 consecutive patients with aortic valve disease, and their clinical outcome was retrospectively assessed., Results: At 20 years in the St. Jude Medical group and in the Medtronic-Hall group the actuarial rates of overall survival were 50 and 49% (p = NS), of cardiovascular survival 66 and 63% (p = NS), of valve-related survival 95 and 91% (p = NS), of freedom from major valve-related complications 83 and 45% (p = 0.005), from major cerebrovascular events 93 and 71% (p =0.06), from valve thrombosis 97 and 89% (p = NS), from aortic valve reoperation 93 and 88% (p = NS), from major bleeding 96 and 82% (p = 0.04), and from endocarditis 93 and 82% (p = NS), respectively. The linearized rate of overall major aortic valve prosthesis-related complications was 3.47%/year in the Medtronic-Hall valve group and 1.53%/year in the St. Jude Medical valve group (p = 0.003). Multivariate analysis showed that the type of prosthesis was predictive of freedom from valve-related complications (p = 0.01; 2.849; C.I. 95%: 1.246-6.516)., Conclusion: The aortic St. Jude Medical mechanical valve seems to be associated with a slightly lower rate of long-term valve-related morbidity than the aortic Medtronic-Hall mechanical valve. Because of the small patient population and the retrospective nature of the study, the choice between these two prostheses should not be made only on the basis of these findings. However, these results suggest a reappraisal for further comparative studies with such an extended follow-up.

The physiological role of F(1)F(0)-ATPase inhibition in ischemia may be to retard ATP depletion although views of the significance of IF(1) are at variance. We corroborate here a method for measuring the ex vivo activity of F(1)F(0)-ATPase in perfused rat heart and show that observation of ischemic F(1)F(0)-ATPase inhibition in rat heart is critically dependent on the sample preparation and assay conditions, and that the methods can be applied to assay the ischemic and reperfused human heart during coronary by-pass surgery. A 5-min period of ischemia inhibited F(1)F(0)-ATPase by 20% in both rat and human myocardium. After a 15-min reperfusion a subsequent 5-min period of ischemia doubled the inhibition in the rat heart but this potentiation was lost after 120 min of reperfusion. Experiments with isolated rat heart mitochondria showed that ATP hydrolysis is required for effective inhibition by uncoupling. The concentration of oligomycin for 50% inhibition (I(50)) for oxygen consumption was five times higher than its I(50) for F(1)F(0)-ATPase. Because of the different control strengths of F(1)F(0)-ATPase in oxidative phosphorylation and ATP hydrolysis an inhibition of the F(1)F(0)-ATPase activity in ischemia with the resultant ATP-sparing has an advantage even in an ischemia/reperfusion situation.

Background: There is increased interest in coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB), although the preservation of the myocardium under such circumstances has not been properly investigated. The aim of this randomized study was to compare the changes in myocardial metabolism during CABG with and without CPB., Methods: Myocardial energy metabolism and tissue injury during CABG was monitored in a series of 22 patients (11 with and 11 without CPB)., Results: The maximum myocardial lactate production was significantly higher (p = 0.02) in the group operated with CPB (0.56 mmol/L) than without it (0.17 mmol/L). A similar phenomenon was seen in the transcardiac pH differences (0.085 and 0.034 with and without CPB, p = 0.007). The postoperative peak values of creatine kinase-MB mass (15.1 vs 6.3 microg/L) and troponin I (13.8 vs 5.2 microg/L) were significantly higher (p < 0.001 and p = 0.008) with than without CPB., Conclusions: CABG on a beating heart is associated with better myocardial energy preservation and less myocardial damage compared with conventional CABG with CPB and intermittent antegrade mild hypothermic blood cardioplegia.

Background: Although renewed interest has recently been shown in coronary artery bypass grafting without cardiopulmonary bypass, no reports are available on myocardial metabolism and hemodynamics during temporary coronary occlusion and rotation of the contracting heart., Methods: Changes in myocardial energy metabolism and hemodynamics were monitored in 12 patients undergoing elective coronary artery bypass grafting without cardiopulmonary bypass, and the postoperative efflux of creatine kinase-MB mass and troponin T were also determined., Results: There was a significant increase in myocardial production of ATP degradation products (p = 0.026) and lactate (p = 0.004) during the operation. Myocardial oxygen extraction decreased (p = 0.012) in correlation with use of the short-acting beta-blocker, esmolol (r = -0.71). Apart from a decrease in mean arterial blood pressure (p = 0.002), there were no significant hemodynamic changes during the operation. The overall postoperative troponin T and creatine kinase-MB mass changes remained nonsignificant during the first two postoperative days. One patient had a myocardial infarction, diagnosed by electrocardiography, on the second postoperative day, but otherwise there were no major complications., Conclusions: Coronary artery bypass grafting without cardiopulmonary bypass seems to be well tolerated as only minor changes in myocardial energy metabolism and hemodynamics are observed during the operation.

Background: It has been suggested that the right ventricular myocardium is suboptimally protected during retrograde blood cardioplegia., Methods: Twenty patients undergoing an elective coronary bypass procedure were randomized to receive antegrade or retrograde mild hypothermic blood cardioplegia. Transventricular differences in oxygen extraction, lactate production, and pH were monitored during aortic cross-clamping, and myocardial biopsy specimens were taken from both ventricles before cannulation and 15 minutes after aortic declamping for analysis of adenine nucleotides and their breakdown products. The extent of myocardial injury was estimated by monitoring postoperative leakage of troponin T and the MB isoenzyme of creatine kinase. Hemodynamic recovery and postoperative complications were noted., Results: The preoperative characteristics of the two groups were similar. Oxygen extraction and lactate production in the right ventricular myocardium were higher in the retrograde group. In this group, the right ventricle also extracted more oxygen and produced more lactate and acid than did the left ventricle. Tissue levels of adenine nucleotides tended to decrease in both ventricles during operation, with no differences between them. The level of adenosine catabolites did increase somewhat in the right ventricular myocardium of the retrograde cardioplegia group after aortic declamping. There was a tendency for more prominent efflux of troponin T and the MB isoenzyme of creatine kinase in the retrograde group. Nevertheless, the postoperative course was uneventful in both groups., Conclusions: Retrograde mild hypothermic blood cardioplegia leads to metabolic changes compatible with right ventricular ischemia. Nevertheless, tissue levels of high-energy phosphates are well preserved, and the postoperative course seems to be unproblematic. Care should be taken when retrograde normothermic blood cardioplegia is provided for patients with right ventricular hypertrophy, poor right ventricular function, or severe preoperative myocardial ischemia.

Background: Preconditioning has been suggested as the most powerful mechanism of myocardial protection against prolonged ischemia. However, whether preconditioning offers additional benefits over cardioplegia during coronary artery bypass grafting is not known., Methods: Thirty patients undergoing coronary artery bypass grafting were randomized into two groups. After aortic cross-clamping, group 1 received antegrade blood and blood cardioplegia followed by normothermic retrograde blood cardioplegia (controls), whereas group 2 patients were subjected to 5 minutes of global ischemia followed by reperfusion with antegrade and retrograde blood cardioplegia (preconditioned). The transcardiac differences in oxygen saturation, pH, and lactate were measured during cardiopulmonary bypass. Myocardial biopsy specimens were taken from half of the patients for adenosine triphosphate determination. The extent of myocardial injury was estimated by monitoring the postoperative leakage of creatine kinase-MB and troponin T. Immediate hemodynamic recovery and postoperative complications were also observed., Results: The 5-minute preconditioning induced marked lactate and acid production, and myocardial adenosine triphosphate levels tended to decrease. The heart continued to produce lactate and acid during retrograde cardioplegia, but the transcardiac pH and lactate differences were similar in both groups. Adenosine triphosphate level measured at the end of the cross-clamp period was decreased to a half and one third of the preclamp values in the control and preconditioned groups, respectively. The postoperative creatine kinase-MB and troponin T effluxes tended to be more elevated in the preconditioned group, yet hemodynamic recovery and the number of postoperative complications were similar in both groups., Conclusions: The results show that a 5-minute preconditioning ischemia does not offer any additional benefits over normothermic retrograde blood cardioplegia during coronary artery bypass grafting.