Outcomes In Adult Cardiac Surgery Research Articles

24th hour vasoactive inotrope score is associated with poor outcome in adult cardiac surgery.

The aim of this study was to investigate the efficacy of vasoactive inotrope score at the 24th postoperative hour for mortality and morbidity in elective adult cardiac surgery. Consecutive patients who underwent elective adult coronary artery bypass and valve surgery in a single tertiary center for cardiac surgery between December 2021 and March 2022 were prospectively included. The vasoactive inotrope score was calculated with the dosage of inotropes that were continuing at the 24th postoperative hour. Poor outcome was defined as any event of perioperative mortality or morbidity. The study included 287 patients, of whom 69 (24.0%) were on inotropes at the 24th postoperative hour. The vasoactive inotrope score was higher (21.6±22.5 vs. 0.94±2.7, p=0.001) in patients with poor outcome. One unit increase in the vasoactive inotrope score had an odds ratio of 1.24 (95% confidence interval: 1.14-1.35) for poor outcome. The receiver operating characteristic curve of vasoactive inotrope score for poor outcome had an area under the curve of 0.857. Vasoactive inotrope score at the 24th hour can be a very valuable parameter for risk calculation in the early postoperative period.

Impact of pre-operative vitamin D deficiency on post-operative outcomes in adult cardiac surgery

Pleiotropic effects of Vitamin D (Vit D) on various cell types and causative association in the epidemiology of cardiovascular diseases is known for ages. Observational studies have successfully linked Vit D deficient states to critical illness and increased ICU morbidity and mortality. The role of preoperative Vit D deficiency on postoperative outcome in cardiac surgery patients is a new horizon for research. A prospective observational cohort study was planned to assess impact of pre-operative Vit D deficiency on post-operative cardiac outcomes in adult patients undergoing cardiac surgery, Vit D level was assessed in the preoperative period and divided into group I Vit D deficient (<20ng/ml) and group II Vit D sufficient (>20ng/ml). Primary outcome was to study the occurrence of myocardial infarction, arrhythmia, low cardiac output syndrome (LCOS) and inotropic requirement. Secondary outcomes were duration of mechanical ventilation, ICU length of stay, hospital stay and mortality. Vit D deficiency was associated with increased incidence of arrhythmia (p=0.019), LCOS (0.003) and high inotropic requirements (p=0.001) with no relation to occurrence of MI (p=0.422) and mechanical support (p= 0.114) as compared to the sufficient group. Vit D deficiency was also associated with increased duration of mechanical ventilation (p=0.008), ICU (p=0.001) and hospital stay (p=0.00) as compared to other group. Vitamin D deficiency was associated with increased occurrence of arrhythmia, LCOS and high inotropic requirements. ICU morbidity in the form of increased duration of mechanical ventilation, ICU and hospital stay was increased in patients with Vit D deficiency.

Effect of Remote Ischemic Preconditioning on Outcomes in Adult Cardiac Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies.

Remote ischemic preconditioning (RIPC) has been demonstrated to prevent organ dysfunction in cardiac surgery patients. However, recent large, prospective, multicenter, randomized controlled trials (RCTs) had controversial results. Thus, a meta-analysis of RCTs was performed to investigate whether RIPC can reduce the incidence of acute myocardial infarction (AMI), acute kidney injury (AKI), and mortality in adult cardiac surgery patients. Study data were collected from Medline, Elsevier, Cochrane Central Register of Controlled Trials and Web of Science databases. RCTs involving the effect of RIPC on organ protection in cardiac surgery patients, which reported the concentration or total release of creatine kinase-myocardial band, troponin I/troponin T (TNI/TNT) after operation, or the incidence of AMI, AKI, or mortality, were selected. Two reviewers independently extracted data using a standardized data extraction protocol where TNI or TNT concentrations; total TNI released after cardiac surgery; and the incidence of AKI, AMI, and mortality were recorded. Review Manager 5.3 software was used to analyze the data. Thirty trials, including 7036 patients were included in the analyses. RIPC significantly decreased the concentration of TNI/TNT (standard mean difference [SMD], -0.25 ng/mL; 95% confidence interval [CI], -0.41 to -0.048 ng/mL; P = .004), creatine kinase-myocardial band (SMD, -0.22; 95% CI, -0.07-0.35 ng/mL; P = .46), and the total TNI/TNT release (SMD, -0.49 ng/mL; 95% CI, -0.93 to -0.55 ng/mL; P = .03) in cardiac surgery patients after a procedure. However, RIPC could not reduce the incidence of AMI (relative risk, 0.89; 95% CI, 0.70-1.13; P = .34) and AKI (relative risk, 0.88; 95% CI, 0.72-1.06; P = .18), and there was also no effect of RIPC on mortality in adult cardiac surgery patients. Interestingly, subgroup analysis showed that RIPC reduced incidence of AKI and mortality of cardiac surgery patients who received volatile agent anesthesia. Our meta-analysis demonstrated that RIPC reduced TNI/TNT release after cardiac surgery. RIPC did not significantly reduce the incidence of AKI, AMI, and mortality. However, RIPC could reduce mortality in patients receiving volatile inhalational agent anesthesia.

The correlation between preoperative erythrocyte sedimentation rate and postoperative outcome in adult cardiac surgery.

IntroductionOver the past decades, it has been recommended that preoperative assessment mainly relies on history and physical examination rather than unnecessary laboratory tests. In Iranian hospitals, erythrocyte sedimentation rate (ESR) has been routinely measured in most of the patients awaiting major surgery, which has in turn exacted heavy costs on the health system. Therefore, the aim of the present study was to assess the preoperative routine measurement of ESR in such patients.Materials and methodsThis is a retrospective study, in which we evaluated the medical files of 620 patients. Patients older than 18 years, who had undergone elective heart surgery in our hospital in 2014, were included in the study. The data associated with demography, heart disease diagnosis, type of surgery, significant preoperative tests, delay or postponing of surgery and the reason for it, type and characteristics of the subspecialty consultation, and finally, postoperative complication and mortality rate were collected and analyzed. The patients were categorized into four groups according to ESR value: normal (<15 mm/h in females or <20 mm/h in males), moderately increased (<40 mm/h), severely increased (≥40 mm/h), and not measured.ResultsOf the 620 patients’ files, 402 were of males and 218 were of females. Demographic values and preoperative characteristics were similar in the four groups. A total of 105 consultations were given to 79 patients preoperatively, where only in five cases, the elevation in ESR was the main reason for consultation. In no other cases did the consultations result in new diagnoses. Overall, postoperative complication and mortality rate were the same in all four groups; in severely increased ESR group, on the other hand, the need for long periods of intensive care unit (ICU) and hospital stays was higher than that of other groups.ConclusionIt is concluded that elevated preoperative ESR does not cancel or defer the surgery, nor does it help diagnose a new, previously undiagnosed disease. Furthermore, it does not generally affect postoperative morbidity or mortality rate unless increased to ≥40 mm/h, where it can increase postoperative ICU and hospital stay. Ultimately, routine preoperative ESR measurement in patients is not conducive to elective heart surgery.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2016 Update on Outcomes and Quality

The Society of Thoracic Surgeons Adult Cardiac Database is one of the longest-standing, largest, and most highly regarded clinical data registries in health care. It serves as the foundation for all quality measurement and improvement activities of The Society of Thoracic Surgeons. This report summarizes current aggregate national outcomes in adult cardiac surgery and reviews database-related activities in the areas of quality measurement and performance improvement.

Short-term outcomes in adult cardiac surgery in the use of del Nido cardioplegia solution.

Del Nido cardioplegia in adult cardiac surgery has not been studied although it has been in common use as a "single" dose cardioplegia in pediatric heart surgery. We retrospectively assessed the short-term (in-hospital) clinical outcomes of patients undergoing aortic valve replacement (AVR) using del Nido cardioplegia solution, comparing it to conventional multi-dose whole blood cardioplegia. We switched our cardioplegia protocol from conventional whole blood cardioplegia exclusively to del Nido solution in May 2011. In 2011, 240 consecutive patients underwent isolated AVR. One hundred and seventy-eight of them were operated on with the use of del Nido cardioplegia (del Nido group) and whole blood cardioplegia (conventional group) was used in the other 62 patients. Isolated AVR was chosen as a cohort because of its relative simplicity and the similarity of surgical techniques among surgeons. Propensity-score matching identified 54 matched pairs for analysis. The retrograde cardioplegia technique was used in 19 cases (35.2%) in the del Nido group and 52 cases (96.3%) in the conventional group (p<0.001). Mean cardiopulmonary bypass time and mean aortic cross-clamp time were significantly shorter in the del Nido group compared to the conventional group: 71 ± 16 min vs. 84 ± 28 min (p<0.01), 52 ± 14 min vs. 60 ± 16 min (p<0.01), respectively. Postoperative inotropic support was required in 11 patients (20.4 %) in the del Nido group and 13 patients (24.1 %) in the conventional group (p=0.82) with no statistical difference. No patient required a postoperative intra-aortic balloon pump and in-hospital mortality was 0% in both groups. There was no significant difference in postoperative complications between the two groups. Short-term outcomes in adult cardiac surgery using del Nido solution were acceptable and comparable to conventional multi-dose whole blood cardioplegia. The del Nido cardioplegia technique was associated with shortened cross-clamp times and less frequent utilization of the retrograde cardioplegia delivery technique.

Impact of hepatic cirrhosis on outcome in adult cardiac surgery.

Increasing prevalence of hepatic disease is likely to translate in a growing number of patients with significant hepatic disease requiring cardiac surgery. Available cardiac risk stratification models do not address the risk associated with hepatic disease. However, weighted mean mortality rates based on previous studies of cardiac surgery in patients with hepatic disease demonstrate operative mortality rates that range from 9.88% (standard deviation [SD] 9.69) for patients in Child-Turcotte-Pugh (CTP) class A cirrhosis to 69.23% (SD 28.55) for patients with CTP class C cirrhosis. This review comprehensively appraises the pathophysiology of hepatic disease, reported clinical outcomes and considerations for risk stratification.

Acuity adaptable patient care unit system shortens length of stay and improves outcomes in adult cardiac surgery: University of Wisconsin experience

The Acuity Adaptable Patient Care (AAC) unit system allows all beds within a nursing unit to negate the need for transfer with changes in patient status. The unit is specialty specific to all levels of patient care. This system was implemented in March 2006 for cardiothoracic surgery at our institution. The purpose of this study was to evaluate the impact of the AAC system on the outcomes after adult cardiac surgery. We retrospectively reviewed 2930 consecutive patients who underwent major adult cardiac procedures between January 2003 and December 2010. The cohorts were divided into the pre-AAC group (January 2003 to February 2006, n = 1029) and the AAC group (March 2006 to December 2010, n = 1901). Patient demographics and postoperative outcomes were assessed. The proportion of coronary artery bypass grafting was significantly lower (pre-AAC vs AAC: 43 vs 35%, P < 0.01), while those of aortic procedure (4 vs 11%, P < 0.01) and mechanical assist device insertion (3 vs 5%, P = 0.02) were higher in the AAC group. After the implementation of the AAC system, the incidence of all complications defined by the Society of Thoracic Surgeons (STS) database (49 vs 34%, P < 0.01), the median length of intensive care unit (ICU) stay (49 [interquartile range (IQR), 27-99] vs 26 [19-45] h, P < 0.01), that of hospital stay (6 [4-10] vs 5 [4-7] days, P < 0.01) and the readmission rate of ICU (5 vs 2% P < 0.01) were significantly decreased. Significant reductions in hospital mortality and the rate of hospital readmission <30 days were not observed. The implementation of the AAC system has improved the outcomes after major cardiac procedures. The incidence of postoperative complications and length of stay have all decreased significantly without increasing readmission rate. AAC creates a system of fluid care with specialty-trained nursing and other ancillary support that expedites discharge and improves overall patient outcomes.

EComment. The impact of blood conservation on outcomes in adult cardiac surgery

We read with great interest the study by Vandewiele and associates [1]. Many studies have shown the benefits of retrograde autologous priming (RAP) on preserving the patient's haematocrit to levels that do not require transfusion. Only a study by Murphy et al. failed to reproduce similar results in a large cohort of 545 patients [2]. Since our publication in 1998 on retrograde autologous priming [3], we have developed further strategies for blood conservation that have resulted in improved outcomes. Our strategy is three-fold: retrograde autologous priming, low prime volume in the cardiopulmonary bypass (CPB) circuit, and autologous blood donation immediately in the operating room immediately after incision is made. Our preliminary data in the first 300 patients showed a dramatic reduction in the post-operative blood transfusion requirement, with 70% of our patients requiring no blood transfusion at all. In the same time period, our 30-day mortality for all open heart procedures had decreased in an all-time low of 1.38%, and the respiratory complications had dropped from 7% in 2007, to 3% in the end of 2012. This proves that the above three techniques of blood conservation are safe and desirable, leading to reduced morbidity and hospital cost. Conflict of interest: none declared.

Invited Commentary

Dr Ranucci and colleagues present a robust and timely analysis on the utility of preoperative severe anemia in modeling mortality after adult cardiac surgery [1Ranucci M. Di Dedda U. Castelvecchio S. Menicanti L. Frigiola A. Pelissero G. Impact of preoperative anemia on outcome in adult cardiac surgery: a propensity-matched analysis.Ann Thorac Surg. 2012; 94: 1134-1142Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar]. The authors recognize a substantial gap in cardiac surgery prediction modeling for mortality in both the United States (Society for Thoracic Surgeons and the Northern New England Cardiovascular Disease Study Group [NNE]) and Europe (EuroScore): severe anemia at the presentation for cardiac surgery. Propensity matching was used to retrospectively balance patients to treatment allocations; in this analysis, patient and operative risk factors were essentially balanced to reduce confounding, including perfusion characteristics (duration of cardiopulmonary bypass and temperature on bypass) and calculated EuroSCORE. With a well-balanced propensity-matched group of patients, a convincing case was made for the addition of severe anemia, defined as a baseline hematocrit below 30%, to standing cardiac surgery preoperative mortality models. Patients with severe anemia had nearly double the operative mortality rate of patients with moderate or no anemia and were more likely to experience other adverse events, including exposure to packed red blood cells, prolonged mechanical ventilation, and intensive care unit days. Most importantly, the authors evaluate the utility of preoperative severe anemia on the standing cardiac surgery models, including the EuroScore and NNE preoperative mortality models. The authors discovered that although the addition of severe anemia to these models did not demonstrate a significant improvement in the model's ability to predict death, it did provide a clinically meaningful improvement in the model performance in estimating mortality. In other words, the absence of severe anemia in the models underestimated the true (observed) death rate, whereas the addition of severe anemia improved each model's performance to more accurately predict mortality. Therefore, the analysis presented here is a call to both the United States and the European societies to evaluate the utility and clinical significance of severe anemia in the existing preoperative mortality models. Meanwhile, efforts should be taken to determine the presence of severe anemia before surgery; improve a patient's baseline hematocrit before surgery (when possible, without the use of transfusion) to reduce the risk of death, adverse events, and transfusions; and better incorporate patient decision-making based on more accurate estimations of the risks and benefits of surgery. In some cases, clinicians may need to consider delayed or deferred surgery for patients with severe anemia (hematocrit below 30%). Impact of Preoperative Anemia on Outcome in Adult Cardiac Surgery: A Propensity-Matched AnalysisThe Annals of Thoracic SurgeryVol. 94Issue 4PreviewPreoperative anemia is not considered an operative mortality risk factor by the majority of the risk stratification tools used in cardiac surgery. However, retrospective studies have found associations between preoperative anemia and morbidity and mortality in cardiac operations. The present study compares the postoperative outcome of a group of moderate-to-severe anemic patients with a propensity-matched group of nonanemic patients undergoing cardiac operations. Full-Text PDF

Impact of Preoperative Anemia on Outcome in Adult Cardiac Surgery: A Propensity-Matched Analysis

Preoperative anemia is not considered an operative mortality risk factor by the majority of the risk stratification tools used in cardiac surgery. However, retrospective studies have found associations between preoperative anemia and morbidity and mortality in cardiac operations. The present study compares the postoperative outcome of a group of moderate-to-severe anemic patients with a propensity-matched group of nonanemic patients undergoing cardiac operations. This is a retrospective study based on 17,056 consecutive patients included in our Institutional Database. A total of 13,843 adult patients with preoperative hematocrit value available were selected for this study; 401 patients had a severe anemia (hematocrit<30%). From the remaining patients, a control group of 401 non-severely anemic patients was selected with a propensity-based matching. Postoperative morbidity and mortality were compared between the 2 groups. The 2 groups were comparable for preoperative comorbidities and operative details. Anemic patients had a significantly (p=0.045) higher rate of stroke (1% vs 0%), major morbidity (27.4% vs 17.5%, p=0.001), and a significantly higher (0.014) operative mortality rate (12.7% vs 7.5%). An additional analysis, inclusive of patients with moderate preoperative anemia, confirmed these results. Moderate-to-severe preoperative anemia is a risk factor for major morbidity and operative mortality in adult cardiac operations. This finding is confirmative of the role of preoperative anemia in determining adverse events in major noncardiac operations. The exclusion of preoperative anemia from the existing risk scores is probably a statistical consequence of the associated comorbid conditions that confound the specific role of anemia as a risk factor.

Invited Commentary

Invited Commentary

Longer Blood Storage Is Associated With Suboptimal Outcomes in High-Risk Pediatric Cardiac Surgery

The negative effects of long-term storage of allogeneic red blood cells (RBCs) on outcomes in adult cardiac surgery have been established, but evidence of a similar effect in pediatric cardiac surgery is limited. The weighted average duration of storage for RBC units used in 1,225 pediatric cardiac operations was determined. Operations were divided into high RBC use (more than 4 units or more than 150 mL/kg) or low RBC use. For both categories, associations between storage duration and surgical outcomes, adjusted for relevant patient characteristics, were evaluated. High RBC use was associated with higher surgical complexity. Storage duration for patients who received low RBC volumes was not associated with surgical outcomes. For patients with high RBC transfusion volumes, longer storage duration (per day) was associated with higher odds of bleeding complications (odds ratio 1.029, p=0.07), renal insufficiency (odds ratio 1.085, p=0.001), higher inotrope score after surgery (12 to 24 hours +0.08, p=0.002; 24 to 48 hours +0.07, p<0.001), greater chest tube drainage (24 hours +1.5 mL/kg, p<0.001), longer postoperative hospitalization (+0.3 days p=0.02), and increased in-hospital mortality (odds ratio 1.054, p=0.03). Effects of RBC transfusions on postoperative bleeding were greatest for storage duration longer than 14 days. The freshest RBC units available should be used for pediatric cardiac operations expected to require more than 4 units or more than 150 mL/kg of allogeneic RBC transfusions, with no units more than 14 days old being transfused whenever possible.

Low preoperative total lymphocyte count as a predictor of poor outcome in adult cardiac surgery

Evaluation of operational risk is an important goal of perioperative management of patients in cardiac surgery. The aim of this study was to investigate the prognostic value of preoperative total lymphocyte count (PTLC) in peripheral blood as a predictor of postoperative complications and mortality in cardiac surgery.

Preoperative Total Lymphocyte Count in Peripheral Blood as a Predictor of Poor Outcome in Adult Cardiac Surgery

The aim of this study was to investigate the prognostic value of the preoperative total lymphocyte count in peripheral blood as a predictor of postoperative complications and mortality in cardiac surgery. A retrospective, observational study. The Novosibirsk State Research Institute of Circulation Pathology (single institution). All adults undergoing primary cardiopulmonary bypass in 2009. None. The cohort size was 1,368 patients operated upon with cardiopulmonary bypass. Patient characteristics, hospital mortality, postoperative complications, ventilation time, intensive care unit, and hospital stay were analyzed. A preoperative total lymphocyte count <1,500 cells/μL was associated with significantly higher mortality by univariate (p < 0.0001) and multivariate (p < 0.044) analyses. A low preoperative total lymphocyte count was associated with more frequent inotropic support (p < 0.001); postoperative heart arrhythmia (p < 0.001); dialysis-dependent acute renal failure (p < 0.001); and a prolonged ventilation time (p = 0.001), intensive care unit stay (p < 0.001), and hospital stay (p = 0.007). A low preoperative total lymphocyte count in peripheral blood is a useful prognostic criterion for the evaluation of a complicated postoperative period in cardiac patients operated under cardiopulmonary bypass.

Low preoperative total lymphocyte count as a predictor of poor outcome in adult cardiac surgery

Evaluation of operational risk is an important goal of perioperative management of patients in cardiac surgery. The aim of this study was to investigate the prognostic value of preoperative total lymphocyte count (PTLC) in peripheral blood as a predictor of postoperative complications and mortality in cardiac surgery.

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We defined factors affecting the postoperative outcome in adult cardiac surgery with cardiopulmonary bypass (CPB). Thirty-two adult patients scheduled for elective cardiac surgery participated in this study. Levels of leukocyte, glutamic oxaloacetic transaminase (GOT), troponin-I (cTNI), interleukin-6 (IL-6), D-dimer and neuron-specific enolase (NSE) were significantly elevated, whereas platelet count declined in cardiac surgery with CPB. GOT and D-dimer levels at CPB-off each had a positive significant correlation significantly with 24 hrs-bleeding, total bleeding, mechanical ventilatory assist time, ICU stay time and length of hospitalization. BUN levels at CPB-off were directly related to total bleeding, mechanical ventilatory assist time, ICU stay time and length of hospitalization. Platelet count at CPB-off was inversely related to mechanical ventilatory assist time, ICU stay time and length of hospitalization. Creatinine concentration at CPB-off interrelated positively with mechanical ventilatory assist time and ICU stay time. NSE levels at CPB-off had a positive relationship with postoperative 24 hrs-bleeding. The length of hospitalization was prolonged proportionally to the elevation of cTNI levels in cardiac surgery. Aortic cross-clamping and total CPB times also related with increase of 24 hrs and total bleeding volumes and the length of hospitalization. IL-6 and ET-1 had no mutual relation with any postoperative outcome. These data suggest that GOT, BUN, creatinine, D-dimer and platelet levels are the most important factors affecting postoperative outcomes and patient's recovery in adult cardiac surgery with CPB.

Computer tools to assist the monitoring of outcomes in surgery

In recent years, there has been increasing use of analytical and graphical methods to assist the monitoring of outcomes in adult cardiac surgery. In this paper, we present extensions to the basic VLAD methodology that add flexibility and assist in its interpretation. Using techniques from probability theory, we have devised graphical tools whereby deviations from expected outcomes can be monitored to see how likely they are to have occurred by chance. The methods are based upon pre-operative assessments of risk and use exact analytical techniques. These tools allow deviations from expected outcomes to be readily assessed and compared with the distribution of chance outcomes. Appropriate colour coding allows interpretation in terms of a temperature gradient. Exact analysis methods based on the use of pre-operative risk assessment provide a useful means for assisting the interpretation of VLAD charts. Such analysis has the advantage that it is applicable even for relatively short series of operations. Also, it takes specific account of the heterogeneity of case mix when quantifying the variability that is expected. By displaying the overall history of outcomes in a visually intuitive manner, it complements the more formal tools for detecting isolated good and bad runs that are available.

Isoflurane may not influence postoperative cardiac troponin I release and clinical outcome in adult cardiac surgery

Isoflurane has been shown experimentally to protect the myocardium against infarction but the clinical relevance of these findings is not yet well established. We therefore evaluated the effects of isoflurane administration before cardiopulmonary bypass (CPB) on postoperative cardiac troponin I (cTnI) release and clinical outcome in a large group of adult patients scheduled for cardiac surgery. Three hundred and fifty-nine consecutive patients were included prospectively in an open observational study and divided into two groups according to whether or not isoflurane was administered before CPB. Postoperative cTnI release, in-hospital mortality, time to discharge from hospital, time to extubation and non-fatal postoperative cardiac events (number of internal cardioversions, need for inotropic support, ischaemic events, dysrhythmias and/or conduction abnormalities) were recorded. Two hundred and twenty-one (62%) patients did not receive isoflurane and 138 (38%) received isoflurane (1.3% [1.0-1.8%] minimum alveolar concentration over 22 [15-331 min). Postoperative cTnI release was not significantly different between the control and isoflurane groups (5.9 [1.0-336.8] vs. 6.0 [1.5-392.0] ng mL(-1), P = 0.88). No significant differences were found in non-fatal cardiac events (63% vs. 57%, P = 0.22) and in-hospital mortality (1.8% vs. 1.4%, P = 0.79) between the control and isoflurane groups. No significant effect was observed on postoperative cTnI release and in-hospital outcome when isoflurane was added to standardized intravenous anaesthesia before CPB in adult patients undergoing cardiac surgery.

Isoflurane may not influence postoperative cardiac troponin I release and clinical outcome in adult cardiac surgery

Isoflurane may not influence postoperative cardiac troponin I release and clinical outcome in adult cardiac surgery