Nonemergent Cardiac Surgery Research Articles

Performance of the EuroSCORE Models in Emergency Cardiac Surgery

Accurate risk-adjustment models are useful for clinical decision making and are important for minimizing any tendency toward risk-averse clinical practice. In cardiac surgery, emergency patients are potentially at greatest risk of inappropriate risk-averse clinical decisions. UK cardiac surgery outcomes are currently risk-adjusted with EuroSCORE models. The objective of this study was to assess the performance of the EuroSCORE models in emergency cardiac surgery. The National Institute for Cardiovascular Outcomes Research database was used to identify adult cardiac surgery procedures performed in the United Kingdom between April 2008 and March 2011. A subset of procedures (July 2010-March 2011) was used for EuroSCORE II validation. The outcome measure was in-hospital mortality. Model calibration (Hosmer-Lemeshow test, calibration plots, calculation of calibration intercept and slope) and discrimination (area under receiver-operating characteristic curve [area under the curve]) were assessed. In total, 109 988 cardiac procedures at 41 hospitals were included, of which 3342 were defined as emergency procedures. Compared with performance in all cardiac surgery and nonemergency cardiac surgery, the logistic EuroSCORE and EuroSCORE II models had poorer discrimination (area under the curve, 0.703 and 0.690, respectively) and poorer calibration for emergency surgery. The EuroSCORE risk factors of female sex, chronic pulmonary disease, neurological disease, active endocarditis, unstable angina, recent myocardial infarction, and pulmonary hypertension were not identified as important risk factors for emergency cardiac surgery. Both EuroSCORE models demonstrated poor calibration and comparatively poor discrimination for emergency cardiac surgery. This has important implications when these models are used for clinical decision making or to adjust governance analyses.

Does use of cell saver decrease the inflammatory response in cardiac surgery?

The role of a cell-saver device in the inflammatory response to cardiac surgery has not been well documented. We hypothesized that the use of a cell saver may reduce proinflammatory cytokine concentrations in patients undergoing cardiac surgery. 57 patients presenting for first-time nonemergency cardiac surgery were prospectively randomized to control or cell salvage groups. Blood samples for inflammatory marker assays were collected from the arterial line on induction of anesthesia, at the end of cardiopulmonary bypass, 1 h after surgery, and 24 h after surgery. Plasma proinflammatory cytokines were analyzed using a sandwich solid-phase enzyme-linked immunosorbent assay. The highest cytokine levels were observed 1 h after surgery. When comparing serum interleukin levels in both patient groups during the different perioperative periods, we found a higher interleukin-8 concentration 24 h after the procedure, and higher concentrations of the p40 subunit of interleukin-12 at 1 h and 24 h postoperatively. The concentrations of interleukin-6 and p40 were greater in blood stored by the cardiotomy suction system than in blood processed by the cell saver (p = 0.01 in both cases). The interleukin-8 concentration was higher in the blood processed by the cell saver (p = 0.03). No significant differences were observed in interleukin-1 and interferon gamma levels in blood from both systems. Clinical outcomes were similar in both groups. Our results suggest that cell salvage in low-risk patients undergoing their first elective cardiac procedure does not decrease the inflammatory response after surgery.

Prospective clinical trial on dosage optimizing of tranexamic acid in non-emergency cardiac surgery procedures

After withdrawal of aprotinin in 2008 only tranexamic acid (TxA, Cyclocapron, Pfitzer, Germany) remains available as antihyperfibrinolytic agent in Europe. Dosage (from 1 g to 20 g) and application strategy (single shot i.v., infusion i.v., topical) reflect an indiscriminate use of TXA in cardiac surgery. We use data analysis of three registries to evaluate safety issues and sufficiency of different TxA dosages in our center. Registry 1: Single shot ultra-low dose TxA (1 g in priming volume). Registry 2: Single shot medium dose TxA (5 g in priming volume). Registry 3: Single shot medium dose TxA (3 g in priming volume) and continuous, weight-adapted administration during cross clamping. Independence of surgeon's preference was achieved by changing dosage every surgery day regardless of operation schedule. Data analysis was carried out on 1182 consecutive, elective patients (1 g TxA n = 415; 3 g + x g TA n = 367; mean TxA dose 4.4 g ± 1.0 g; 5 g TxA n = 400). Patient characteristics were well matched in all three registries (mean age: 69 ± 9.5y, BMI 28.2 ± 4.7, Creatinin 107.5 ± 52.8 μM), as were performed surgical procedures (excluding organ transplantation). Postoperative data showed no significant differences for blood loss and major adverse events (1 g vs. 3 + g vs. 5 g: blood loss: 894 ± 1479 vs. 903 ± 1282 vs. 1004 ± 1604 ml; stroke: 1.5 vs. 1.6 vs. 1.5%; myocardial infarction 2.7 vs. 3.3 vs. 1.3%; 30d mortality 3.9 vs. 4.2 vs. 4.8%, respectively). Secondary endpoints (de novo dialysis, transfusion requirement, ICU and total treatment time) showed no significant differences between registries. Use of 1 g TxA is safe and sufficient for elective patients with on pump cardiac surgery and thus has been established as strategy of choice in our center.

CASE 7—2012 Airway Management and Perioperative Decision Making in the Patient With Severe Pulmonary Hypertension Who Requires Emergency Noncardiac Surgery

ALTHOUGH HEART FAILURE and arrhythmias are the principal causes of death in severe pulmonary hypertension (PH), noncardiac surgery constitutes a high-risk intercurrent event. Optimal perioperative care for patients with severe PH must attend to the physiologic and logistic challenges of critical illness and emergency noncardiac operative intervention superimposed on those with severe PH. The authors present the case of a morbidly obese patient with severe PH who required emergency noncardiac surgery and discuss the strategies of airway management and perioperative intervention as they apply to this high-risk population.

The impact of pre‐operative focused transthoracic echocardiography in emergency non‐cardiac surgery patients with known or risk of cardiac disease

This prospective observational study investigated the effect of focused transthoracic echocardiography in 99 patients who had suspected cardiac disease or were ≥ 65 years old, and were scheduled for emergency non-cardiac surgery. The treating anaesthetist completed a diagnosis and management plan before and after transthoracic echocardiography, which was performed by an independent operator. Clinical examination rated cardiac disease present in 75%; the remainder were asymptomatic. The cardiac diagnosis was changed in 67% and the management plan in 44% of patients after echocardiography. Cardiac disease was identified by echocardiography in 64% of patients, which led to a step-up of treatment in 36% (4% delay for cardiology referral, 2% altered surgery, 4% intensive care and 26% intra-operative haemodynamic management changes). Absence of cardiac disease in 36% resulted in a step-down of treatment in 8% (no referral 3%, intensive care 1% or haemodynamic treatment 4%). Pre-operative focused transthoracic echocardiography in patients admitted for emergency surgery and with known cardiac disease or suspected to be at risk of cardiac disease frequently alters diagnosis and management.

Effects of preoperative aspirin on cardiocerebral and renal complications in non-emergent cardiac surgery patients: a sub-group and cohort study.

Background and ObjectivePostoperative cardiocerebral and renal complications are a major threat for patients undergoing cardiac surgery. This study was aimed to examine the effect of preoperative aspirin use on patients undergoing cardiac surgery.MethodsAn observational cohort study was performed on consecutive patients (n = 1879) receiving cardiac surgery at this institution. The patients excluded from the study were those with preoperative anticoagulants, unknown aspirin use, or underwent emergent cardiac surgery. Outcome events included were 30-day mortality, renal failure, readmission and a composite outcome - major adverse cardiocerebral events (MACE) that include permanent or transient stroke, coma, perioperative myocardial infarction (MI), heart block and cardiac arrest.ResultsOf all patients, 1145 patients met the inclusion criteria and were divided into two groups: those taking (n = 858) or not taking (n = 287) aspirin within 5 days preceding surgery. Patients with aspirin presented significantly more with history of hypertension, diabetes, peripheral arterial disease, previous MI, angina and older age. With propensity scores adjusted and multivariate logistic regression, however, this study showed that preoperative aspirin therapy (vs. no aspirin) significantly reduced the risk of MACE (8.4% vs. 12.5%, odds ratio [OR] 0.585, 95% CI 0.355–0.964, P = 0.035), postoperative renal failure (2.6% vs. 5.2%, OR 0.438, CI 0.203–0.945, P = 0.035) and dialysis required (0.8% vs. 3.1%, OR 0.230, CI 0.071–0.742, P = 0.014), but did not significantly reduce 30-day mortality (4.1% vs. 5.8%, OR 0.744, CI 0.376–1.472, P = 0.396) nor it increased readmissions in the patients undergoing cardiac surgery.ConclusionsPreoperative aspirin therapy is associated with a significant decrease in the risk of MACE and renal failure and did not increase readmissions in patients undergoing non-emergent cardiac surgery.

Computerized prediction of intensive care unit discharge after cardiac surgery: development and validation of a Gaussian processes model

BackgroundThe intensive care unit (ICU) length of stay (LOS) of patients undergoing cardiac surgery may vary considerably, and is often difficult to predict within the first hours after admission. The early clinical evolution of a cardiac surgery patient might be predictive for his LOS. The purpose of the present study was to develop a predictive model for ICU discharge after non-emergency cardiac surgery, by analyzing the first 4 hours of data in the computerized medical record of these patients with Gaussian processes (GP), a machine learning technique.MethodsNon-interventional study. Predictive modeling, separate development (n = 461) and validation (n = 499) cohort. GP models were developed to predict the probability of ICU discharge the day after surgery (classification task), and to predict the day of ICU discharge as a discrete variable (regression task). GP predictions were compared with predictions by EuroSCORE, nurses and physicians. The classification task was evaluated using aROC for discrimination, and Brier Score, Brier Score Scaled, and Hosmer-Lemeshow test for calibration. The regression task was evaluated by comparing median actual and predicted discharge, loss penalty function (LPF) ((actual-predicted)/actual) and calculating root mean squared relative errors (RMSRE).ResultsMedian (P25-P75) ICU length of stay was 3 (2-5) days. For classification, the GP model showed an aROC of 0.758 which was significantly higher than the predictions by nurses, but not better than EuroSCORE and physicians. The GP had the best calibration, with a Brier Score of 0.179 and Hosmer-Lemeshow p-value of 0.382. For regression, GP had the highest proportion of patients with a correctly predicted day of discharge (40%), which was significantly better than the EuroSCORE (p < 0.001) and nurses (p = 0.044) but equivalent to physicians. GP had the lowest RMSRE (0.408) of all predictive models.ConclusionsA GP model that uses PDMS data of the first 4 hours after admission in the ICU of scheduled adult cardiac surgery patients was able to predict discharge from the ICU as a classification as well as a regression task. The GP model demonstrated a significantly better discriminative power than the EuroSCORE and the ICU nurses, and at least as good as predictions done by ICU physicians. The GP model was the only well calibrated model.

Perioperative Mortality Score: Data Collection and Cost

The perioperative mortality score aims to predict mortality in elderly patients undergoing noncardiac surgery using three preoperative risk factors (age, albumin and American Society of Anesthesiologists physical status) and then modify this risk assessment if any of three postoperative complications occur (unplanned intensive care unit admission, systemic inflammation and acute renal failure). In order to determine the cost of routine perioperative mortality score calculation in future research, we audited the incidence of clinician-initiated preoperative albumin, pre- and postoperative creatinine and postoperative white cell count testing in patients aged > or = 70 years presenting for elective and emergency noncardiac surgery requiring at least overnight admission over a three-month period. We recruited 637 noncardiac surgical patients. All laboratory tests required for perioperative mortality score calculation were performed in only 47% of patients and the total cost of testing all untested patients was A$12,057 (A$18,927 per 1000 patients). Preoperative hypoalbuminaemia was present in 11% of tested patients, acute renal impairment in 24% of tested patients and high white cell count in 33% of tested patients. These results may be used to inform future research or clinical use of the score.

Anaesthesia for non-cardiac surgery in a cardiac transplant recipient

Cardiac transplantation has become the standard therapy for idiopathic dilated cardiomyopathy and end-stage ischaemic heart disease. With the introduction of newer immunosuppressants, together with better patient selection, improved perioperative monitoring and care, the overall survival of recipients has improved. An increasing number of patients who received a transplant present for either elective or emergency non-cardiac surgery. We hereby discuss the perioperative management of such a patient who came to our set-up for bipolar haemiarthroplasty.

Risk of Adverse Events After Coronary Artery Bypass Graft and Subsequent Noncardiac Surgery

Coronary artery bypass grafts (CABGs) are increasingly performed in elderly patients. Risk factors and outcomes are poorly described for those undergoing noncardiac surgery within 1 year after CABG. Our objectives were to assess the risk and predictors of major adverse events associated with noncardiac surgery within 1 year after CABG. In a retrospective review of medical records at Mayo Clinic (Rochester, MN, USA), over a period of 5 years, we identified patients who underwent noncardiac procedures within 1 year post-CABG. All events that occurred within 30 days after noncardiac surgery and deaths within 1 year after noncardiac surgery were considered to be related to CABG. We identified 211 patients; of these, 21 patients had 24 adverse events. Within 1 year, 11 died, and within the first 30 days, three myocardial infarctions, six acute congestive heart failure episodes, three cerebrovascular accidents and one deep vein thrombosis episode had occurred. Predictors of an adverse event included emergency operation (odds ratio: 6.8), ejection fraction less than 45% (p < 0.001) and elevated right ventricular systolic pressure by 40 mmHg or more (p = 0.03). After the noncardiac procedure, patients requiring dialysis (p = 0.02), ventilatory support (p = 0.03) and longer hospital stay (p = 0.03) had greater rates of adverse outcomes. Post-CABG, preoperative ejection fraction less than 45%, right ventricular systolic pressure of 40 mmHg or more, as well as emergent noncardiac surgery, were predictors of adverse outcomes after the noncardiac procedure. Longer postoperative hospital stay, dialysis, as well as ventilatory support, were predictors of adverse outcomes after CABG.

Rationalising the treatment of anaemia in cardiac surgery: short and mid-term results from a local quality improvement initiative

BackgroundTransfusion of red blood cells, while often used for treating blood loss or haemodilution, is also associated with higher infection rates and mortality. The authors implemented an initiative to reduce...

Retrograde autologous priming of the cardiopulmonary bypass circuit reduces blood transfusion in small adults: a prospective, randomized trial

Extreme haemodilution occurring with cardiopulmonary bypass imposes a primary risk factor for blood transfusion in small adult cardiac surgical patients. Priming of the cardiopulmonary bypass circuit with patients' own blood [retrograde autologous priming (RAP)] is a technique used to limit haemodilution and reduce transfusion requirements. We designed this study to evaluate the effects of RAP on reducing perioperative blood transfusion in small adults. One hundred and twenty patients with a body surface area of less than 1.5 m undergoing first-time, nonemergency cardiac surgery were randomized to either the standard priming group or the RAP group. All patients followed strict transfusion criteria. Homologous transfusion, haematocrit, plasma colloid osmotic pressure and postoperative clinical outcomes were evaluated perioperatively. Patient characteristics and operative parameters were equal for patients in both groups. With autologous priming, a mean volume of 614.8 +/- 138.8 ml of priming solution was replaced with autologous blood. This allowed a significantly higher haematocrit value during cardiopulmonary bypass (P < 0.05). Red blood cell transfusion was necessary in 83.3% of patients of the standard priming group on pump, whereas only 26.7% of patients of the RAP group required transfusion (P < 0.01). The overall transfusion rate of the RAP group was significantly less than that in the standard priming group during the hospitalization (90.0 vs. 50.0%, P < 0.01). Amongst patients who received transfusion on pump, the number of homologous units of packed red blood cells was less in the RAP group than that in the standard priming group intraoperatively and perioperatively (0.94 +/- 0.32 vs. 1.48 +/- 0.68 units, P = 0.03; 1.24 +/- 0.54 vs. 1.69 +/- 0.69 units, P = 0.15). Ten minutes after aortic cross-clamp, colloid osmotic pressure was reduced by 39.7 +/- 2.8% in the standard priming group and by 28.6 +/- 3.2% in the RAP group (P < 0.05). Clinical outcomes were similar with respect to pulmonary, renal and hepatic function, length of ICU stay and hospital stay. RAP resulted in a significant decrease in intraoperative haemodilution and conserved the use of blood. This technique should be considered for patients with a small body surface area (<1.5 m) undergoing open heart surgery.

N-terminal pro-B-type natriuretic peptide levels and early outcome after cardiac surgery: a prospective cohort study

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a powerful predictor of cardiovascular outcome in many circumstances. There are, however, limited data regarding the utility of NT-proBNP or BNP levels in patients undergoing cardiac surgery. The current study assesses the ability of NT-proBNP to predict early outcome in this setting. One thousand and ten patients undergoing non-emergent cardiac surgery were recruited prospectively. Baseline clinical details were obtained and the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Parsonnet score were calculated. Preoperative NT-proBNP levels were measured using the Roche Elecsys assay. The primary endpoint was 30 day mortality. Median NT-proBNP levels were 624 ng litre(-1) among patients who died within 30 days of surgery (n=29), compared with 279 ng litre(-1) in survivors [odds ratio (OR) 1.03 per 250 ng litre(-1), 95% confidence interval 1.01-1.05, P=0.001). NT-proBNP levels remained predictors of 30 day mortality in models including either the additive EuroSCORE (OR 1.03 per 250 ng litre(-1), P=0.01), the logistic EuroSCORE (OR 1.03 per 250 ng litre(-1), P=0.004), or the Parsonnet score (OR 1.02 per 250 ng litre(-1), P=0.04). Levels of NT-proBNP were also predictors of prolonged (>1 day) stay in the intensive care unit (OR 1.03 per 250 ng litre(-1), P<0.001) and of a hospital stay >1 week (OR 1.07 per 250 ng litre(-1), P<0.001). They remained predictive of these outcomes in regression models that included either the EuroSCORE or the Parsonnet score and in a model that included all study variables. NT-proBNP levels predict early outcome after cardiac surgery. Their prognostic utility is modest-but is independent of traditional indicators and conventional risk prediction scores.

Prophylactic Intravenous Magnesium Sulphate in Addition to Oral β-Blockade Does Not Prevent Atrial Arrhythmias After Coronary Artery or Valvular Heart Surgery

Atrial arrhythmias (AA) are an important cause of morbidity after cardiac surgery. Efforts at prevention of postoperative AA have been suboptimal. Perioperative beta-blocker administration is the standard of care at many centers. Although prophylactic administration of magnesium sulfate (MgSO(4)) has been recommended, review of all previously published trials of MgSO(4) reveals conflicting results. This study was designed to address methodological shortcomings from previous studies and is the largest randomized, placebo-controlled trial of intravenous (IV) MgSO(4) for the prevention of AA after coronary artery bypass grafting or cardiac valvular surgery. A total of 927 nonemergent cardiac surgery patients were stratified into 2 groups: isolated coronary artery bypass grafting (n=694), or valve surgery with or without coronary artery bypass grafting (n=233), and randomized to receive either 5g IV MgSO(4) or placebo on removal of the cross-clamp, followed by daily 4-hour infusions, from postoperative day 1 until postoperative day 4. All patients were treated according to an established oral beta-blocker protocol. Postoperative serum Mg levels were checked and standard of care was to administer IV MgSO(4) for low serum levels. The primary end point was AA lasting > or =30 minutes or requiring treatment for hemodynamic compromise. There were no differences in the incidence of AA between patients who received IV MgSO(4) or placebo (26.4% versus 24.3%, respectively). The results were similar when broken down according to stratified groups. In patients treated with a protocol for postoperative oral beta-blocker after nonemergent cardiac surgery, the addition of prophylactic IV MgSO(4) did not reduce the incidence of AA.

Second-day discharge from the ICU after non-emergency cardiac surgery

To develop models that are discriminative for second-day discharge (SDD) after non-emergency cardiac surgery [1].

An Evaluation of a Full-Access Underbody Forced-Air Warming System During Near-Normothermic, On-pump Cardiac Surgery

A new underbody forced-air warming system is available for use during cardiac surgery. We tested the hypothesis combining underbody forced-air warming with standard thermal management would maintain intraoperative core temperature and reduce core temperature after-drop (largest decrease in core temperature in the 60 min after bypass) in patients undergoing near-normothermic cardiopulmonary bypass (CPB). Patients undergoing routine, nonemergent cardiac surgery were randomly assigned to routine thermal management (fluid warming and passive insulation, n = 30) or routine management supplemented by an active underbody forced-air system (n = 30; Arizant Healthcare Model 635, Eden Prairie, MN). Core body temperature was measured by bladder catheter at 15-min intervals during the perioperative period. Comparisons were made between groups for temperature before, during, and after CPB. Data from four patients were excluded for cause, leaving 29 patients in the routine management group and 27 patients in the forced-air group. Initial temperatures were similar, but temperatures in the forced-air group were higher than in the routine group at the start of CPB (36.3 degrees C +/- 0.6 degrees C vs 35.7 degrees C +/- 0.7 degrees C, P = 0.002). There were no differences between groups in the lowest temperatures during CPB (forced air, 35.5 degrees C +/- 1.5 degrees C vs routine, 35.3 degrees C +/- 1.3 degrees C, P = 0.67); the end of CPB (36.7 degrees C +/- 0.4 degrees C vs 36.6 degrees C +/- 0.4 degrees C, P > 0.99); or the temperature at departure from the operating room (36.5 degrees C +/- 0.4 degrees C vs 36.2 degrees C +/- 0.5 degrees C, P = 0.36). After-drop was 0.03 degrees C +/- 0.54 degrees C in patients randomized to underbody forced-air warming and 0.21 degrees C +/- 0.51 degrees C in those assigned to routine management (P = 0.20). Adding an underbody forced-air warming system to the near-normothermic thermal management protocol significantly increased pre-bypass temperature; however, it had no further clinically important effect on core temperature.

Perioperative Renal Outcome in Cardiac Surgical Patients With Preoperative Renal Dysfunction: Aprotinin Versus Epsilon Aminocaproic Acid

The administration of aprotinin to patients with pre-existing renal dysfunction who are undergoing cardiac surgery is controversial. Therefore, the authors present their experience with the use of aprotinin for patients with preoperative renal dysfunction who underwent elective cardiac surgery requiring cardiopulmonary bypass (CPB). Retrospective analysis. University hospital. Consecutive cardiac surgical patients with preoperative serum creatinine (SCr) > or =1.8 mg/dL undergoing nonemergent cardiac surgery requiring CPB. None. One hundred twenty-three patients either received epsilon aminocaproic acid (EACA, n = 82) or aprotinin (n = 41) as decided by the attending anesthesiologist and surgeon. Data were collected from the Society of Thoracic Surgeons database and from automated intraoperative anesthesia records. Renal function was assessed from measured serum creatinine (SCr) and calculated creatinine clearances (CrCls). Acute perioperative renal dysfunction was defined as a worsening of perioperative renal function by > or =25% and/or the need for hemodialysis (HD). Data were recorded as mean and standard deviation or percentage of population depending on whether the data were continuous or not. Data were compared by using an analysis of variance, chi-square analysis, Student paired and unpaired t tests, Fisher exact test, Wilcoxon rank sum test, and Mann-Whitney U test. A p value <0.05 was considered significant. Overall, 32% and 41% of patients had acute perioperative renal dysfunction measured by CrCl and SCr, respectively. Seven patients required HD (5.7%). Six of these 7 had complicated postoperative courses. Of all the variables measured, only the duration of the aortic crossclamp (AoXCl) and CPB were significantly associated with acute perioperative renal dysfunction. Acute perioperative renal dysfunction was associated with increased intensive care unit and hospital stays, postoperative blood transfusion, dialysis, and major infection. Aprotinin patients were significantly older (75.2 v 70.2 years, p < 0.05), had lower left ventricular ejection fraction (44.4% v 49.2%, p < 0.05), a greater preoperative history of congestive heart failure (63 v 44%, p < 0.05), a greater renal risk score (5.8 v 4.9, p < 0.05), and underwent more nonisolated coronary artery bypass graft surgeries (77% v 29%, p < 0.0001). CPB time (126.0 v 96.5 minutes, p < 0.001) and AoXCl duration (100.9 v 78.0 minutes, p < 0.005) were longer in the aprotinin group. Diabetes (60.5% v 41.5%, p < 0.05) and hypertension (90.1% v 73.2%, p < 0.05) were more prevalent in the EACA group. Baseline renal function and renal outcomes were not significantly different between the aprotinin and EACA groups. Six of the 7 patients who required HD received EACA (p = 0.1). The earliest SCr recorded > or =3 months after surgery was significantly lower in the aprotinin group compared with the EACA group (1.8 v 2.2 mg/dL, p < 0.05). Acute perioperative renal dysfunction was associated with worse patient outcome and longer CPB and AoXCl times. Demographic and surgical variables indicated that the sicker patients undergoing more complex surgeries were more likely to be treated with aprotinin. Although aprotinin patients had a higher renal risk score, the administration of aprotinin did not negatively impact renal outcome.

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery WRITING COMMITTEE MEMBERS Lee A. Fleisher, MD, FACC, FAHA, Chair; Joshua A. Beckman, MD, FACC; Kenneth A. Brown, MD, FACC, FAHA; Hugh Calkins, MD, FACC, FAHA; Elliott Chaikof, MD; Kirsten E. Fleischmann, MD, MPH, FACC; William K. Freeman, MD, FACC; James B. Froehlich, MD, MPH, FACC; Edward K. Kasper, MD, FACC; Judy R. Kersten, MD, FACC§; Barbara Riegel, DNSc, RN, FAHA; John F. Robb, MD, FACC ACC/AHA TASK FORCE MEMBERS Sidney C. Smith, Jr, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Vice Chair; Cynthia D. Adams, MSN, PhD, FAHA; Jeffrey L. Anderson, MD, FACC, FAHA; Elliott M. Antman, MD, FACC, FAHA; Christopher E. Buller, MD, FACC; Mark A. Creager, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC; David P. Faxon, MD, FACC, FAHA; Valentin Fuster, MD, PhD, FACC, FAHA; Jonathan L. Halperin, MD, FACC, FAHA; Loren F. Hiratzka, MD, FACC, FAHA; Sharon A. Hunt, MD, FACC, FAHA; Bruce W. Lytle, MD, FACC, FAHA; Rick Nishimura, MD, FACC, FAHA; Joseph P. Ornato, MD, FACC; Richard L. Page, MD, FACC, FAHA; Barbara Riegel, DNSc, RN, FAHA; Lynn G. Tarkington, RN; Clyde W. Yancy, MD, FACC

Abstract 2883: Long-term Survival and Cardiac Troponin T Elevation in On- and Off-pump Coronary Artery Bypass Surgery

Introduction: The long-term clinical usefulness of conventional coronary artery bypass graft surgery (CCAB) and off-pump surgery (OPCAB) remains controversial. Long-term survival and cardiac troponin T (cTnT) elevation following CCAB and OPCAB has not been assessed. We tested the hypothesis that long-term survival was similar for CCAB and OPCAB patients when stratified by the presence or absence of cTnT elevation. Methods: In this prospective cohort, we followed 1511 non-emergent patients with 2 or 3 vessel disease (778 CCAB and 733 OPCAB) from a single hospital in Northern New England by surgeons using both procedures between 2000–2004 to determine if 6-year survival was similar for CCAB and OPCAB patients. Postoperative cTnT elevation was defined at ≥1 (ng/μL). Data was linked to the Social Security Administration Death Master File. Kaplan-Meier and log-rank techniques were used. Cox’s proportional hazard models were used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (95%CI), adjusting baseline patient and disease characteristics. Results: Patients were similar with regard to baseline disease characteristics, comorbidities, cardiac history, function and anatomy. CCAB was associated with higher 6-year survival compared with OPCAB regardless of troponin elevation (Figure , p&lt;0.0001). Adjusted HR (CCAB cTnT &lt;1 as referent) were 1.57 (1.05–2.36) for OPCAB cTnT&lt;1, 1.52 (0.95–2.43) for CCAB cTnT ≥1, and 2.50 (1.37–4.58) for OPCAB cTnT≥1. Conclusion: In summary, CCAB results in better survival over OPCAB in patients presenting with two or three vessel disease undergoing non-emergent cardiac surgery.

The utility of B‐type natriuretic peptide in predicting postoperative cardiac events and mortality in patients undergoing major emergency non‐cardiac surgery

B-type natriuretic peptide (BNP) levels predict cardiovascular risk in several settings. We hypothesised that they would identify individuals at increased risk of complications and mortality following major emergency non-cardiac surgery. Forty patients were studied with a primary end-point of a new postoperative cardiac event, and/or development of significant ECG changes, and/or cardiac death. The main secondary outcome was all-cause mortality at 6 months. Pre-operative BNP levels were higher in 11 patients who suffered a new postoperative cardiac event (p = 0.001) and predicted this outcome with an area under the receiver operating characteristic curve of 0.85 (CI = 0.72-0.98, p = 0.001). A pre-operative BNP value > 170 pg x ml(-1) has a sensitivity of 82% and a specificity of 79% for the primary end-point. In this small study, pre-operative BNP levels identify patients undergoing major emergency non-cardiac surgery who are at increased risk of early postoperative cardiac events. Larger studies are required to confirm these data.