Operative Mortality In Group Research Articles

SURGICAL CLOSURE OF SINUS VENOSUS ATRIAL SEPTAL DEFECT: DOES AGE MATTER?

Sinus venosus atrial septal defect (ASD) is defined by its location at the junction of the right atrium and superior vena cava. Diagnosis is often more difficult than other forms of ASD and many patients remain asymptomatic for many years. As a result, the age of presentation of sinus venosus ASD is highly variable. The purpose of this study was to compare the outcomes of patients of two age groups (Group A: < 60 years and Group B: ≥ 60 years) who underwent surgical closure of a sinus venosus atrial septal defect. Between August 2001 and October 2013, 28 consecutive adult patients (>18 years) underwent surgical closure of a sinus venosus ASD at our hospital. All patients had associated partial anomalous pulmonary venous connection. Surgical technique consisted in patch roofing of the sinus venosus ASD and rerouting of the pulmonary veins. Three patients (11%) underwent concomitant tricuspid valve repair. There were 18 patients (64%) in Group A and 10 patients (36%) in Group B. Follow-up was 96% complete (1 loss to follow-up) at a mean of 4 ± 7 months. New York Heart Association (NYHA) functional class, freedom from reoperation and survival rates were used to assess the success of the procedure in both groups. Mean age was 46 ± 17 years for the entire cohort and 50% of patients were female. There was one operative mortality in Group B and none in Group A. Early postoperative conduction disorder was frequent in Group B. Two patients (20%) developed first-degree atrioventricular block, two patients (20%) complete right bundle branch block and two patients (20%) received a permanent pacemaker. No conduction disorder was observed in Group A. New-onset atrial fibrillation occurred in two patients (20%) from Group B and none in Group A. At last follow-up, all patients in Group A (100%) and eight patients in Group B (89%) were in NYHA class I. There were no reoperations or late mortalities in either group. Surgical closure of sinus venosus ASD can be performed safely in patients aged over 60 years of age. However, data from this single-center study suggest that these patients are at higher risk of postoperative rhythm disorder.

The Prognostic Significance of Elevated Troponin Levels in Patients with Normal Coronaries Undergoing Surgery for Aortic Valve Stenosis

The Prognostic Significance of Elevated Troponin Levels in Patients with Normal Coronaries Undergoing Surgery for Aortic Valve Steno Objective: The outcome of aortic valve replacement (AVR) in patients without occlusive coronary artery disease who present with raised pre-operative troponin is not clear. We therefore, investigated the operative mortality and morbidity in this subset of patients undergoing urgent surgery for aortic stenosis. Methods: From a pool of 595 AVR patients in our institution’s database from July 2007 to July 2013, we reviewed the notes of all patients who underwent urgent surgery for aortic stenosis (n=57) and identified those with raised pre-operative troponin (n=16). We compared the observed operative mortality and major morbidity rates between patients with raised preoperative troponin levels (group I) and those with normal troponin levels (group II), and also with their predicted outcomes. Results: The baseline and operative characteristics for the two groups were comparable. There was a trend towards higher operative mortality for group I patients (18.8% versus 7.3% for group II, P=.07). Whereas, the observed operative mortality for group I far exceeded the predicted (18.8% vs 12.5%, p=.05), for group II the observed was slightly lower than the predicted operative mortality (7.3% vs 9.3%, p=.63). On the other hand, the observed mortality was well below the predicted for the elective patients. Conclusion: Patients with aortic stenosis and raised preoperative troponin undergoing urgent AVR may be at risk of higher operative mortality than predicted by the EuroScore. Further studies in this high risk group are warranted.

Frequency of Reoperations in Patients With Marfan Syndrome

We undertook a retrospective study of the pattern of reoperations in surgical patients with Marfan disease. Between 1985 and 2008, 83 Marfan patients (60 males, 23 females) underwent 155 aortic operations in our institution. Twenty-eight patients had acute dissection (22 type A, 6 type B), and two had aortic rupture. Mean age at initial operation was 32±13 years. Operations included valve-sparing or Bentall aortic root repair, and ascending aorta, arch, descending thoracic, thoracoabdominal aorta, and infrarenal aortic replacement. Sixty-one patients whose initial operation was elective (Group I) were compared with 22 patients with initial emergency surgery (Group II). Overall, 81/83 patients ultimately underwent root/ascending repair: 64% initially and 36% at reoperation. Operative mortality in Group I was 1.6% for both initial operations and reoperations vs 9.0% and 0% in Group II. Significant differences between Group I and Group II patients included: total reoperations (1 vs 3, p=0.05); arch operations (0 vs 1, p=0.003); descending thoracic aortic operations (0 vs 0.5, p=0.003); and total aortic segments replaced (1.6±1.0 vs 2.4±1.1, p=0.001). Survival at 5 and 10 years did not differ between Group I and II patients (87% and 71% vs 82% and 56%, p=0.19). Although reoperation occurs in about half of surgical Marfan patients, reoperative mortality is low. Patients with initial elective procedures fare better than those with initial emergency surgery: they have fewer subsequent operations, fewer aortic segments replaced, and trend toward improved survival. Elective root replacement should be seriously considered in any Marfan patient with significant root dilatation.

Is Hypothyroidism Overlooked in Cardiac Surgery Patients?

Objectives: to analyze adequacy of preoperative thyroid screening of cardiac surgery patients (pts) with hypothyroidism (HT) and compare with pts without HT by demographic data, EuroSCORE (ES) scores, early and late outcomes. Patients: From 1000 cardiac surgery pts from Jan 1999 through May 2000 pts with HT were identified (Group 1, n = 80). 920 pts (Group 2) had no HT. Results Group 1 pts were older (p 60 years (p = 0.004), more females (p < 0.0001) and higher number of other than CABG surgery pts (p = 0.01) in Group 1. 47 (58.8%) had adequate laboratory tests. 15 (18.8%) had no tests and 18 (22.5%) inadequate tests. 10 (12.5%) pts had no replacement therapy. There was no operative mortality in Group 1 and 14 (1.5%) in Group 2 (p = 0.70). Hospital mortality was higher in Group 1 (6/7.5% vs 37/4.5%), p = 0.03. Stay in postoperative intensive care unit and hospital were similar (p = 0.66 and 0.53). More pts in Group 1 needed prolonged ICU and LOS (p < 0.0001 for both). Occurrence of postoperative AF was higher in Group 1, p < 0.02. Seventeen pts (23.0%) were not discharged home in Group 1 and 87 (10.2%) in Group 2, (p = 0.002). Follow-up mortality was higher in Group 1 (45/58.1% vs 378/43.5%, p = 0.02). Conclusions HT is overlooked in cardiac surgery patients. Long-term mortality is higher in pts with HT. Resource utilization is higher in pts with HT.

Surgical Management of Pulmonary Atresia With Ventricular Septal Defect: Early Total Correction Versus Shunt

We changed our surgical strategy for pulmonary atresia with ventricular septal defect from shunt operation to early total correction as an initial procedure since 2004. The objective of this study was to compare the surgical outcomes of shunt and early total correction. From 1997 to 2008, 47 patients with pulmonary atresia with ventricular septal defect and no major aortopulmonary collateral arteries who underwent surgical correction were enrolled in this retrospective study. Twenty-nine patients underwent palliative shunt operation (group S) and 18 patients underwent early total correction (group T). The patients in group T were younger than that of group S (23.2±12.6 vs 40.1±23.3 days; p=0.008). There were 3 operative mortalities in group S and 1 operative mortality in group T. Four interstage deaths in group S and 1 late death in group T occurred. There was no difference in the overall survival rate between the 2 groups (p=0.3). The reoperation rate was higher in group S (p<0.0001) and the reintervention rate was higher in group T (p=0.006). The ventilator support time (5.5±5.1 vs 4.2±5.6 days; p=0.016) and intensive care unit stay (20.3±25.5 vs 15.5±16.0 days; p=0.233) were longer in group T. The preoperative age, body weight, and pulmonary artery size were not associated with the prolonged ventilator support time in group T. The patients who had received preoperative ventilator care showed tendency of prolonged postoperative ventilator support time (p=0.004). The midterm results of early total correction for pulmonary atresia with ventricular septal defect are acceptable. Despite a difficult postoperative course, there was no difference in the mortality compared with shunt operation. Although the reintervention rate was higher in the early total correction group, we were able to avoid interstage mortalities that occurred in the shunt group, and we reduced the reoperation rate in the early total correction group.

Staged below-knee amputations for septic peripheral lesions due to ischaemia

Preservation of the knee joint is of paramount importance in lower limb amputation for ischaemia. Clinical predictors of healing are unreliable in patients with septic peripheral lesions due to ischaemia. Seventy-three patients in whom a below-knee amputation was considered likely to heal, based on the temperature and appearance of the skin and bleeding from skin and muscle flaps, were divided into two groups. Twenty-nine (Group A) had a primary below-knee (BK) amputation at the site of election with delayed primary skin closure, while 44 patients (Group B) initially had a guillotine BK amputation below the site of election, with elective amputation at the appropriate level once infection had been eradicated (4-5 days later). The groups were similarly matched with regard to level of occlusive arterial disease, nature of ischaemic lesions and operative risk factors. There was no significant difference in the overall operative mortality in Group A (6.7 per cent) compared with Group B (11.4 per cent) (P greater than 0.05). There was a significantly higher above-knee revision rate in Group A survivors (33.3 per cent) compared with Group B (7.7 per cent) (P less than 0.01) due to non-viability and uncontrolled sepsis of the BK amputation site. The presence or absence of a palpable femoral or popliteal pulse had no significant influence on healing in either group.

Is the use of cardiopulmonary bypass for multivessel coronary artery bypass surgery an independent predictor of operative mortality in patients with ischemic left ventricular dysfunction?

Background Coronary artery bypass grafting for patients with ischemic left ventricular dysfunction (ILVD) remains superior to medical therapy in terms of long-term survival. Recently, off-pump coronary artery bypass surgery has been shown to be very promising in achieving functional improvements with favorable operative mortality in this challenging group of patients. The aim of this study was to assess the risk factors responsible for operative mortality in this group of patients. Methods The records of 305 consecutive ILVD patients, who underwent primary isolated coronary artery bypass grafting for multivessel disease at The National Heart and Lung Institute, Imperial College, University of London, between January 1999 and January 2002, were reviewed retrospectively. Patients were considered to have ILVD if they had a left ventricular ejection fraction of 0.30 or less on preoperative coronary angiography. One hundred six patients were operated on using the off-pump coronary artery bypass surgery technique, and 199 patients were operated on using the conventional coronary artery bypass grafting technique with cardiopulmonary bypass. Results Seven (6.6%) patients died in the off-pump coronary artery bypass surgery group, whereas 28 (14.1%) patients died in the cardiopulmonary bypass group ( p = 0.05). Univariate analysis of all the preoperative characteristics was performed to identify the potential predictors of mortality in the whole group of ILVD patients. Potential predictors of mortality included symptom status (stable/unstable), chronic obstructive airway disease, dyspnea grade III and IV on the New York Heart Association classification, intravenous nitrates, preoperative use of intraaortic balloon pump, ventricular tachycardia or ventricular fibrillation, body surface area less than 2, and cardiopulmonary bypass. Only ventricular tachycardia or ventricular fibrillation was proved to act as an independent predictor of operative mortality in this group of ILVD patients, with an odds ratio of 29.6 (95% confidence interval, 8.9 to 98). Conclusions This study showed that using cardiopulmonary bypass for multivessel coronary artery bypass grafting in patients with ILVD was not proved to act as an independent predictor of operative mortality.

Borderline hypoplastic left heart malformations: Norwood palliation or two-ventricle repair?

Patients with hypoplastic left heart syndrome (HLHS) and associated malformations undergo Norwood palliation or potentially a two-ventricle repair. Since 8/99, 8 patients with typical HLHS and two with DILV underwent Norwood/Fontan palliation (group I). Three other patients (group II) had two-ventricle repair. Anatomy was: aortic atresia, coarctation, unrestrictive VSD (patient 1), hypoplastic mitral and aortic valve, arch and LV, coarctation (patients 2 and 3). Surgical procedures were Norwood arch reconstruction with either Rastelli operation (patient 1) or ASD-closure (patients 2 and 3). Operative mortality in group I was 1/8 (day 22; RV-failure). Two patients died before Glenn (sepsis, RV-failure). Six patients underwent Glenn procedure successfully. No patient died in group II. Echocardiography after 13 +/- 7.4 months showed mild homograft dysfunction (patient 1) and an LVOT-gradient of 20 mmHg (patient 3). Clinical condition of all survivors in both groups is good. Some anatomical subsets of HLHS with borderline mitral valves and small left ventricles may undergo two-ventricle repair despite severe LVOTO. Mortality and morbidity seem to be lower, but selection criteria are so far not defined.

Intraaortic balloon pump therapy facilitates posterior vessel off-pump coronary artery bypass grafting in high-risk patients

Background. Displacement of the heart to expose posterior vessels during coronary artery bypass grafting (CABG) without cardiopulmonary bypass (off-pump CABG, or OPCAB) may impair cardiac function. We used the intraaortic balloon pump (IABP) preoperatively to reduce operative risk and to facilitate posterior vessel OPCAB in high-risk patients with left main coronary artery disease (> 75% stenosis), intractable resting angina, postinfarction angina, left ventricular dysfunction (ejection fraction < 35%), or unstable angina.Methods. One hundred and forty-two consecutive patients who underwent multivessel OPCAB including posterior vessel revascularization were studied prospectively. The patients were divided into group I (n = 57), which received preoperative or intraoperative IABP, and group II (n = 85), which did not receive IABP. In group I, there were 34 patients with left main coronary artery disease, 24 patients with intractable resting angina, 8 patients with left ventricular dysfunction, 5 patients with postinfarction angina, and 40 patients with unstable angina. Seven patients received intraoperative IABP support owing to hemodynamic instability during OPCAB.Results. There was no operative mortality in group I and 1 death in group II. The average number of distal anastomoses was not different between group I and group II (3.4 ± 0.9 versus 3.5 ± 0.9, p = not significant). There were no significant differences in the number of posterior vessel anastomoses per patient. There were no differences in ventilator support time, length of stay in the intensive care unit, hospital stay, and morbidity between the two groups. There was one IABP-related complication in group I.Conclusions. IABP therapy facilitates posterior vessel OPCAB in high-risk patients, and surgical results are comparable with those in lower-risk patients.

Mitral Valve Reconstruction and Mitral Valve Replacement for Ischemic Mitral Insufficiency

Patients with ischemic mitral incompetence have a high operative risk whether the valve is repaired or replaced. The advantage of repair over replacement is unclear in this group of patients. Between April 1986 and December 1994, 232 patients underwent surgery for ischemic mitral valve insufficiency; mitral valve replacement was performed in 98 of them. Operative mortality was 13.3%. The actuarial survival rate after 5 years was 73.3%. The surgical risk in patients whose left ventricular ejection fraction (LVEF) was 10%-30% (operative mortality 50.0%) was higher than in those whose LVEF was greater than 30%. Valve reconstruction was performed in 102 patients. Operative mortality in this patient group was 14.7%. The surgical risk in patients whose LVEF was < or = 30% was higher (operative mortality 42.9%). The total actuarial survival rate of all patients was 64.4% after 5 years. Mortality during follow-up was higher in patients with residual mitral valve insufficiency greater than grade I after mitral valve reconstruction. Twenty-four patients with severely impaired left ventricular function underwent heart transplantation. Operative mortality in this group was 12.5%. Eight patients received left ventricular aneurysmectomy in addition to valve surgery, three of them died early. We conclude that patients with highly impaired left ventricular function and ischemic mitral insufficiency are at too great a risk for either valve reconstruction or replacement. Cardiac transplantation should be considered for this patient group. However, patients with ischemic mitral insufficiency and moderately impaired left ventricular function can undergo valve reconstruction or replacement with an acceptable prognosis. The goal of mitral valve reconstruction should be reducing mitral valve insufficiency to at least grade I. If this is not achieved, the prognosis after repair is worse than after valve replacement, therefore, the surgeon should replace the valve without delay.

Surgery for Gastric Cancer Patients Aged 75 and Over

To analyze the clinicopathological characteristics and surgical results in very elderly gastric cancer patients, we reviewed 129 patients aged 75 years and over (group 1) and 708 patients younger than 60 years (group 2) as controls. There were significant differences between group 1 and group 2 with regard to the preoperative impairment of cardiac, respiratory, liver and renal function. The maximum dimension of the tumor in group 1 was greater than that in group 2, and lymph node metastases were more common in group 1. Although reduced lymph node dissection was performed more frequently in group 1 than in group 2, the operative mortality in group 1 (8.5%) was significantly higher than that in group 2 (2.5%, p = 0.002). Among the causes of operative mortality, anastomotic leakage was the most common in the both groups (group 1 36.3%; group 2 44.4%). With regard to the long-term results, although a significant difference in the cumulative 5 -year survival rate was detected in stage I or II patients (group 1 52.2%; group 2 91.1%; p < 0.001), there was no significant difference in survival in stage III or IV patients (group 1 23.3%; group 2 38.7%). In conclusion, diligent preoperative and postoperative care combined with rational surgical procedures are indispensable to prevent postoperative complications in very elderly patients. However, as satisfactory long-term results can be expected, even in very elderly patients, the option of surgery for gastric cancer should not be abandoned solely because of age.

Effect of advancing age on cost and outcome of coronary artery bypass grafting

The clinical and billing records of 250 patients (173 men and 77 women) undergoing isolated coronary artery bypass grafting between 1987 and mid-1990 were retrospectively reviewed to determine charges and clinical results as related to age. Patients were stratified by age into five groups of 50 consecutive patients each: group 1, less than 50 years of age; group 2, 50 to 59 years; group 3, 60 to 69 years; group 4, 70 to 79 years; and group 5, 80 years or older. The groups were compared in regard to perioperative clinical variables, long-term follow-up, and total charges. Group 5 had significantly more postoperative complications than the other four groups ( p < 0.05). In addition, length of postoperative hospitalization was significantly longer in group 5 compared with groups 1, 2, and 3 ( p < 0.05), and operative mortality in group 5 (20%) was significantly higher than that in the other four groups. The mean total charges for group 5 were $73,399, which was significantly higher than the totals in the other four groups ( p < 0.05). Actuarial 3-year survival for the hospital survivors was 87%, 89%, 78%, 82%, and 60% for groups 1, 2, 3, 4, and 5, respectively ( p < 0.001). Postoperative performance as measured by the Karnofsky scale was significantly lower in group 5 than in groups 1 and 2 ( p < 0.05). These data support the premise that elderly patients undergoing coronary artery bypass grafting have more complications, longer hospitalizations, and higher operative mortality than younger patients. With increasing age, coronary artery bypass grafting entails a greater expenditure of resources with inferior benefit as measured by long-term survival and function.

Heart transplantation in patients with previous cardiac operations:: Excellent clinical results

A significant proportion of potential transplant recipients have undergone previous cardiac procedures and may be subject to an increased risk because of technical and other factors inherent in a reoperation. Between December 1985 and June 1991, 155 orthotopic heart transplantations were carried out in 146 patients. Eighty-five transplantations (54.8%) were carried out as the initial cardiac operation (group I); 61 operations (45.2%) were performed in patients who had previous nontransplant cardiac operations (group II). Preoperative variables including hemodynamic indexes, renal function, and status on the waiting list were similar between these groups; however, group II patients tended to be older than group I patients (51.9 ± 10.7 versus 47.7 ± 11.6 years, respectively; p < 0.05) and were more likely to have ischemic heart disease (80.3% versus 34.1%) than were those in group I. Significantly longer cardiopulmonary bypass time (127.6 ± 44.7 minutes versus 108.2 ± 18.8 minutes, p < 0.01) and duration of operation (448.1 ± 120.9 minutes versus 353.2 ± 85.1 minutes, p < 0.01) was found in group II. Operative mortality in group I was 4.7% and in group II was 6.6% ( p > 0.9). Group I actuarial survival at 1 year and 5 years was 87.1% ± 3.6% and 72.9% ± 6.2%, respectively. Group II actuarial survival was 85.3% ± 4.5% and 76.0% ± 6.6%, respectively, for the same time periods. In spite of the greater technical challenge implied by previous cardiac operations, no significant survival differences occurred between these groups ( p > 0.9). However, patients undergoing a second cardiac transplantation ( n = 9) were identified as a high-risk subset with operative mortality of 22.8% and 1-year survival of only 33.3% ± 15.7% ( p < 0.0003). Cardiac transplantation in patients who have undergone previous nontransplant cardiac operations can be carried out without compromising immediate or long-term outcome. (J THORACCARDIOVASCSURG1994;107:203-9)

Coronary artery disease in patients requiring abdominal aortic aneurysm repair. Selective use of a combined operation.

The chief cause of operative mortality after abdominal aortic aneurysm (AAA) repair is myocardial infarction. For this reason, routine coronary angiography followed by prophylactic coronary artery bypass grafting (CABG) prior to AAA repair has been recommended by some surgeons. We report here the results of the selective use of a combined operation. Two hundred twenty-seven patients had elective or emergency repair of nonruptured AAA on our service from 1972 to 1983. Prior to surgery, all patients underwent careful clinical evaluation for the presence of coronary artery disease (CAD) and were classified into the following: group I (n = 121), no clinical evidence of CAD, 53%; group II (n = 96), clinical evidence of stable CAD, symptomatic or asymptomatic, 42%; group III (n = 10), unstable CAD, five per cent; Group IIIa (n = 4), asymptomatic AAA; and group IIIb (n = 6), symptomatic AAA. Seven patients ultimately assigned to group II underwent stress electrocardiogram (ECG) and eight group II patients had coronary angiography before surgery. All patients in groups I and II underwent elective or urgent repair of their AAA without CABG. Prior to surgery, these patients were managed with placement of a pulmonary artery catheter and incremental volume loading to construct a left ventricular performance curve as a guide to surgical fluid replacement. All were carefully monitored for at least 48 hours after surgery in an intensive care unit. Four patients (group IIIa) with unstable CAD and asymptomatic AAA underwent CABG followed by elective AAA repair within six months. Six patients (group IIIb) with unstable CAD and symptomatic AAA underwent combined open heart surgery (CABG and, in one patient, valve replacement) and AAA repair as a single operation. There was no operative mortality in group III patients. Thirty-day operative mortality for the entire group of 227 patients was 1.3% (three deaths), with only one death from a myocardial infarction (0.4%). While there is clearly a high incidence of CAD in patients with AAA, the present results indicate that these individuals can be managed with low risk by a selective approach based upon clinical assessment of their CAD. Our experience further demonstrates that patients with unstable CAD and symptomatic AAA may have both lesions safely repaired as a single operative procedure.

Changes in Coronary Bypass Surgery Leading to Improved Survival

Coronary bypass surgery was performed on 439 patients between the years 1969 and 1973 (group A) and on 1,760 patients between the years 1974 and 1979 (group B). The operative mortality for group A was 3.9%; for group B, 1.3%; four-year survival for group A patients was 88.9% +/- 1.5% (mean +/- SE); for group B patients, 92.5% +/- 0.9%. The difference between the relative four-year survival rates (based on age- and sex-matched Oregon population) between group B and A was 6.2%; the lower operative mortality would account for only 2.6%. We conclude that the results of coronary bypass surgery have improved because of (1) a lower operative mortality, and (2) other factors that cannot be precisely defined at the present time but probably are the long-term result of better and more complete operative and perioperative techniques.

Hemorrhage due to diffuse erosive gastritis.

Of 796 patients admitted with upper gastrointestinal bleeding during a five-year period, 156 (20%) had erosive gastritis. Vigorous nonoperative treatment stopped bleeding in 117 (75%); emergency operation was required in 39 (25%). In 24 of these 39 patients (group A), subtotal gastric resection with truncal vagotomy was performed. In the remaining 15 patients (group B), the operation was limited to pyloroplasty, truncal vagotomy, and multiple suture ligation. These patients were, on the average, 20 years older than the patients in group A, and 12 had life-threatening preoperative problems. (Only four of the group A patients had life-threatening preoperative problems.) The operative mortality in group A was 42%, with rebleeding occurring 33%. In group B, only 17% rebled and the operative mortality was 45%. Survival in the two groups was similar, even though those patients in group B were more critically ill. The less radical procedure may often be the best choice in the high-risk and elderly patients who bleed massively and in whom immediate salvage of life is the main issue.

Some clinical notes on patients with mitral valvular disease who have had mitral valvuloplasty. Part II

Some clinical notes on patients with mitral valvular disease who have had mitral valvuloplasty. Part II