Parsonnet Score Research Articles

Applicability of the commonly used risk scores for coronary bypass surgery in Algeria.

ObjectivesThe applicability of European system for cardiac operative risk evaluation II (EuroSCORE II) and the Society of Thoracic Surgeons Predicted Risk Of Mortality (STS-PROM) as well as the initial logistic Parsonnet risk score, who have been developed from European and American datasets, is questionable outside these regions. We aimed to assess the performance of these three risk scores for patients undergoing isolated coronary artery bypass grafting (CABG) in Algeria.MethodsBetween June 2014 and June 2016, data from 235 consecutive patients, who underwent isolated CABG at a reference center in Algiers, were prospectively collected and scored according to the EuroSCORE II, STS-PROM and the Parsonnet score. Their discriminative power was evaluated by the area under the receiver operating characteristic curve (AUC) while their calibration was tested by the Hosmer–Lemeshow goodness-of-fit test.ResultsThe mean patient age was 59.08 years and 18.3% were female. The mortality at 30 days was 3.40%. The mortality expected by EuroSCORE II, STS-PROM and by Parsonnet risk score was: 1.33%, 0.78% and 3.35%, respectively. Discriminatory ability was fair for the Parsonnet risk score, good for the STS PROM and excellent for EuroSCORE II (AUCs = 0.737, 0.788, and 0.892, respectively). Regarding calibration, EuroSCORE II and STS-PROM under estimated observed mortality (Hosmer–Lemeshow test: P< 0.001 for both scores), while the Parsonnet risk score was well calibrated (Hosmer–Lemeshow test: p = 0.395).ConclusionsEuroSCORE II and STS-PROM had excellent and good discriminating power, respectively, but both underestimated the risk of 30 days mortality following isolated CABG at a reference center in Algiers. The Parsonnet risk score was well calibrated but was moderately discriminating. The development of a local risk score or the recalibration of recent international risk scores is necessary.

Prediction of perioperative mortality in cardiac surgery – Risk scoring systems: In quest of the holy grail

Prediction of perioperative mortality in cardiac surgery – Risk scoring systems: In quest of the holy grail

Assessment of Left Ventricular Diastolic Function by Transesophageal Echocardiography Before Cardiopulmonary Bypass: Clinical Implications of a Restrictive Profile

Left ventricular (LV) diastolic function can be assessed by transesophageal echocardiography before cardiopulmonary bypass in the setting of cardiac surgery. The objective of this study was to determine whether the assessment of LV diastolic dysfunction (LVDD) improves mortality risk prediction. Retrospective single-center cohort study. Single tertiary cardiac surgery center. Data from patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) and for which an evaluation for LVDD was performed before CPB between February 1999 and November 2015. Cases were reviewed retrospectively from a transesophageal echocardiography hemodynamic database. LV diastolic function was graded as normal, impaired relaxation (grade 1), pseudo-normalization (grade 2), or restrictive (grade 3) determined by mitral inflow waves, tissue Doppler imaging of the mitral annulus, and pulmonary venous flow. The main outcome was in-hospital mortality. A total of 760 patients were included, 144 (18.9%) patients with normal diastolic function, 331 (43.6%) patients with grade 1 LVDD, 218 (28.7%) patients with grade 2 LVDD, and 67 (8.8%) patients with grade 3 LVDD. In-hospital mortality occurred in 31 patients (4.1%). The presence of grade 3 LVDD was associated with an increased likelihood of in-hospital mortality (odds ratio [OR]: 19.39, confidence interval [CI]: 2.37-158.48, p = 0.006). In contrast, LV systolic dysfunction was not independently associated with increased mortality. When added to the Parsonnet score, the addition of diastolic function resulted in a net reclassification improvement of in-hospital mortality (NRI: 0.419 CI: 0.049-0.759, p = 0.02), and in integrated discrimination improvement (IDI: 0.0179 CI: 0.0049-0.031, p = 0.007). Difficult separation from CPB was observed more frequently in patients with grade 3 LVDD (62.9% v 36.1%, p = 0.01). In contrast to LV systolic dysfunction, restrictive LVDD is associated with an increased risk of in-hospital mortality in cardiac surgical patients. Further studies should explore how this information may be used by the attending anesthesiologist to tailor perioperative management.

Preoperative Statin Treatment Is Not Associated with Reduced Postoperative Mortality or Morbidity in Patients Undergoing Isolated Valve Surgery.

Previous studies have shown that statin use before coronary surgery decreases the mortality and morbidity. This benefit was not clearly detected in isolated valve surgery. The aim of this study was to assess the effect of preoperative statin therapy on postoperative complications and mortality in a large group of patients undergoing valve surgery. The data of consecutive patients undergoing isolated valve replacement during an 8-year period were retrospectively reviewed from a prospective database. Mortality was compared between the patients who received preoperative statin (statin group [SG]) and those who did not receive statin (control group [CG]) after adjustment on EuroSCORE. Main postoperative complications and mortality were compared between the 2 groups by using a propensity score analysis. During the study period, 1115 patients were prospectively included, 796 in the CG group and 319 in the SG. The SG patients were significantly older, had more cardiovascular risk factors (hypertension, diabetes, and weight) than the CG patients, and benefited from more elective surgery or aortic valve replacement. No difference in mortality was found between the groups: 4.4% in the SG and 4.5% in the CG, P = .95. Multivariate analysis also revealed no effect of statin on mortality, according to the type of surgery (aortic valve surgery alone or any kind of valve surgery) (P = .93), or the elective or urgent nature of the surgery (P = .67). Statin did not predict mortality after stratification with the EuroSCORE or the Parsonnet score. No difference was found between the 2 groups for postoperative complications (24-hour bleeding, atrial fibrillation, renal failure, length of mechanical ventilation, or hospital stay) and mortality after adjustment with a propensity score. This study found no difference in mortality or morbidity associated with preoperative statin therapy after isolated valve surgery.

Risk‐adjusted CUSUM charts under model error

In recent years, quality control charts have been increasingly applied in the healthcare environment, for example, to monitor surgical performance. Risk-adjusted cumulative (CUSUM) charts that utilize risk scores like the Parsonnet score to estimate the probability of death of a patient from an operation turn out to be susceptible to misfitted risk models causing deterioration of the charts' properties, in particular, the false alarm behavior. Our approach considers the application of power transformations in the logistic regression model to improve the fit to the binary outcome data. We propose two different approaches of estimating the power exponent δ. The average run length (ARL) to false alarm is calculated with the popular Markov chain approximation in a more efficient way by utilizing the Toeplitz structure of the transition matrix. A sensitivity analysis of the in-control ARL against the true value δ shows potential effects of incorrect choice of δ. Depending on the underlying patient mix, the results vary from robustness to severe impact (doubling of false alarm rate).

Prophylactic amiodarone vs dronedarone for prevention of perioperative arrhythmias in offpump coronary artery bypass grafting: A pilot randomized controlled trial.

The aim of this study was to compare the effects of prophylactic dronedarone and amiodarone in prevention of arrhythmias during and following off-pump coronary artery bypass grafting (OPCAB). This randomized, controlled, double-blinded, parallel-group study was carried out on 36 adult male patients aged 30-70 years, with modified Parsonnet score 0-10 undergoing offpump coronary artery bypass grafting. After obtaining approval from the institutional ethics committee and informed consent, the patients were randomly allocated to two equal groups (n=18). In one group, patients were given inj. amiodarone 3mg/kg in 100ml of normal saline prior to skin incision intravenously over 20 minutes. In the second group patients received tablet dronedarone 400mg orally twice daily, commencing three days prior to the date of surgery. Patients in the amiodarone group received placebo tablet while patients in the dronedarone group received placebo infusion for the sake of blinding. The frequency and profile of arrhythmias intraoperatively and 24 hours postoperatively were studied. Intraoperative arrhythmias occurred in 50% of patients receiving amiodarone and 16.67% of patients receiving dronedarone. Maximum ventricular rate during atrial fibrillation was significantly lower in the dronedarone group (121 beats per min) than in the amiodarone group (168 beats per min). The study concludes that dronedarone appears to be at least as effective as amiodarone in prophylaxis of intraoperative and postoperative arrhythmias in patients undergoing OPCAB, with a better control of ventricular response.

Monitoring patient survival times in surgical systems using a risk-adjusted AFT regression chart

Monitoring surgical processes has gained prominence by accounting for patients’ health condition prior to surgery in recent years. However, most of previous researchers have focused on Phase-II monitoring based on binary outcomes, while very little attention has been paid to Phase-I monitoring procedures, especially when the outcomes are continuous. In this paper, a general Phase-I accelerated failure time-based risk-adjusted control chart is proposed to monitor continuous surgical outcomes based on a likelihood-ratio test derived from a change-point model. Different from the existing models, this paper shows that continuous outcomes depend not only on the patient conditions described by the Parsonnet score, but also is dependent on other categorical operational covariates such as surgeons. The proposed risk-adjustment model is fitted by incorporating dummy variables to reflect different surgeon groups as a categorical covariate. We show that the categorical covariate can effectively reflect the inherent data heterogeneity, thus can improve the estimation of the parameters of the risk-adjustment model and hence can enhance the detection power of the proposed risk-adjusted control chart.

Does Aortic Valve Replacement Restore Normal Life Expectancy: a Twenty-Year Relative Survival Study

&lt;strong&gt;Background &lt;/strong&gt;This 20-year relative survival study investigates life expectancy in defined age cohorts&lt;strong&gt; &lt;/strong&gt;and evaluates the role of patient, procedural and peri-operative variables on absolute survival after aortic valve replacement.&lt;p&gt; &lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods &lt;/strong&gt;Absolute long-term survival variance was calculated using Cox regression analysis in 585 consecutive aortic valve replacement patients. Relative survival curves in defined age groups were constructed using age- and gender-matched controls.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results&lt;/strong&gt; There were 12 peri-operative deaths (2.1%), and 11 further deaths (1.9%) during the first year. 154 patients (26.3%) died subsequently and 408 patients (69.7%) were alive after 20 years. Relative survival increased with age: in patients over 68 survival was equivalent to an age- and gender-matched population. Patient risk indicators for decreased absolute survival included age, Parsonnet score, additive and logistic EuroSCORE, and for increased absolute survival included weight, body surface area, and stroke volume. Procedural risk indicators for decreased absolute survival included bypass time, use of a tissue valve, and prosthesis-patient mismatch with size 19 valves, and for an increased absolute survival included use of a mechanical valve. Post-operative risk indicators for decreased absolute survival included ITU stay, ventilation time, transfusion, haemorrhage volume and new-onset atrial fibrillation/flutter. Strong risk indicators included intra-aortic balloon pump use, and dialysis.&lt;/p&gt;&lt;p&gt; &lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions&lt;/strong&gt; Patients over 68 years discharged from hospital after aortic valve replacement had a similar 10-year survival as an age- and gender-matched population. In this age cohort surgery restored the patient’s normal life expectancy.&lt;/p&gt;&lt;p&gt; &lt;/p&gt;&lt;p&gt;Key words: aortic valve replacement; absolute survival predictors; relative survival&lt;/p&gt;

Risk Factors Involved in Central-to-Radial Arterial Pressure Gradient During Cardiac Surgery.

A central-to-radial arterial pressure gradient may occur after cardiopulmonary bypass (CPB), which, in some patients, may last for a prolonged time after CPB. Whenever there is a pressure gradient, the radial artery pressure measure may underestimate a more centrally measured systemic pressure, which may result in a misguided therapeutic strategy. It is clinically important to identify the risk factors that may predict the appearance of a central-to-radial pressure gradient, because more central sites of measurements might then be considered to monitor systemic arterial pressure in high-risk patients. The objective of this study was to assess preoperative and intraoperative risk factors for central-to-radial pressure gradient. Seventy-three patients undergoing cardiac surgery using CPB were included in this prospective observational study. A significant central-to-radial arterial pressure gradient was defined as a difference of 25 mm Hg in systolic pressure or 10 mm Hg in mean arterial pressure for a minimum of 5 minutes. Preoperative data included demographics, presence of comorbidities, and medications. Intraoperative data included type of surgery, CPB and aortic clamping time, use of inotropic drugs, and vasodilators or vasopressors agents. The diameter of the radial and femoral artery was measured before the induction of anesthesia using B-mode ultrasonography. Thirty-three patients developed a central-to-radial arterial pressure gradient (45%). Patients with a significant pressure gradient had a smaller weight (71.0 ± 16.9 vs 79.3 ± 17.3 kg, P = 0.041), a smaller height (162.0 ± 9.6 vs 166.3 ± 8.6 cm, P = 0.047), a smaller radial artery diameter (0.24 ± 0.03 vs 0.29 ± 0.05 cm, P < 0.001), and were at a higher risk as determined by the Parsonnet score (30.3 ± 24.9 vs 17.0 ± 10.9, P = 0.007). In addition, a longer aortic clamping time (85.8 ± 51.0 vs 64.2 ± 29.3 minutes, P = 0.036), mitral and complex surgery (P = 0.007 and P = 0.017, respectively), and administration of vasopressin (P = 0.039) were identified as potential independent predictors of a central-to-radial pressure gradient. By using multivariate logistic regression analysis, the following independent risk factors were identified: Parsonnet score (odds ratio [OR], 1.076; 95% confidence interval [CI], 1.027-1.127, P = 0.002), aortic clamping time >90 minutes (OR, 8.521; 95% CI, 1.917-37.870, P = 0.005), and patient height (OR, 0.933, 95% CI, 0.876-0.993, P = 0.029). The relative risk (RR) estimates remained statistically significant for the Parsonnet score and the aortic clamping time ≥90 minutes (RR, 1.010; 95% CI, 1.003-1.018, P = 0.009 and RR, 2.253; 95% CI, 1.475-3.443, P < 0.001 respectively) while showing a trend for patient height (RR, 0.974; 95% CI, 0.948-1.001, P = 0.058). Central-to-radial gradients are common in cardiac surgery. The threshold for using a central site for blood pressure monitoring should be low in small, high-risk patients undergoing longer surgical interventions to avoid inappropriate administration of vasopressors and/or inotropic agents.

The use of “LAST” operation in high risk patient

The LAST operation, in spite of few drawbacks, represents a good option for single Left Anterior Descending (LAD) revascularization. This procedure does not allow multivessel revascularization, where hybrid procedure have been previous described. We report preliminary experience with the LAST operation performed in high risk patients. From October 2004 to February 2005, 11 male high risk patients (mean age 74 +/- 8 years) underwent the LAST operation. Mean predicted death with EUROSCORE and Parsonnet score were 29% and 31% respectively. All patients had a proximal LAD lesion either not suitable for PTCA and multivessel coronary artery disease. The mean preoperative Ejection Fraction was 42 +/- 5% (27-55%). Four patients (36.4%) had previous surgical myocardial revascularization. An incision of about 6 cm was made in the appropriate intercostal space and the LIMA (Left Internal Mammary Artery) was harvested using a special costal retractor. After heparin administration the LIMA is distally divided to check the adequacy of the blood flow. Following the insertion of a temporary intracoronary shunt, the LIMA was LAD anastomosis was carried out with a continuous 8-0 polypropylene suture. No hospital or late mortality was observed. Uneventful conversion to midline sternotomy was necessary in one patient with low value of mammary flow. All patients were discharged within the first postoperative week. The use of the LAST operation enhances the role of minimally invasive surgery also in high risk patients who need coronary revascularization.

Dialysis-requiring Acute Kidney Injury after Coronary Artery Bypass Grafting: Performance of Six Risk Models

(TAVI) is considered in patients with severe aortic valve disease at high risk for surgical aortic valve replacement. Risk stratification plays a critical role in selecting the appropriate treatment modality. We compared the prognostic utility of surgical risk scores at predictingmortality after TAVI in this meta-analysis. Methods: MEDLINE, Embase, Cochrane and Web of Science databases from 1 January 1980 to 31 December 2015 were searched. Studies were systematically reviewed for inclusion, then data extracted for pooled analyses. Results: Amongst 1688 articles searched, 47 full-text articles were screened and 23 studies (11,936 TAVI cases) included for analyses. Areas under curve (95% confidence interval) for operative mortality were EuroSCORE 0.61 (0.560.66) in 20 studies, EuroSCORE II 0.62 (0.59-0.66) in 15 studies, STS Score 0.62 (0.59-0.65) in 20 studies, Ambler Score 0.54 (0.49-0.58) in 4 studies and Parsonnet Score 0.51 (0.44-0.58) in 2 studies. Respective Peto’s odds ratios (95% confidence interval) were EuroSCORE 0.32 (0.30-0.35), EuroSCORE II 1.31 (1.14-1.50), STS 0.84 (0.76-0.94), Ambler Score 1.46 (1.091.96) and Parsonnet Score 0.38 (0.29-0.50). Areas under curve (95% confidence interval) for 1-year mortality were EuroSCORE 0.62 (0.57-0.67), EuroSCORE II 0.66 (0.61-0.71) and STS Score 0.58 (0.53-0.64). Conclusion: Only the widely used EuroSCORE, EuroSCORE II and STS Scores moderately discriminated operative and 1-year mortality. EuroSCORE and Parsonnet score grossly over-estimated operative mortality, while EuroSCORE II/Ambler Score and STS Score marginally under-estimated and over-estimated operative mortality respectively, but this varied by the level of estimated surgical risk.

The current role of total intravenous anesthesia in cardiac surgery: total intravenous anesthesia and cardiopulmonary bypass.

LTHOUGH OVERALL mortality after cardiac surgery has decreased in recent decades, this process has been partially offset by changes in the patient population involving more complex disease and significant comorbidity. 1 Perioperative morbidity has stayed roughly the same and remains a relevant burden to health care providers. Attempts to identify independent risk factors for cardiac surgery are complex and include patient factors as expressed in the EuroSCORE or Parsonnet score, surgical technique, and the presence or absence of systematic goal-directed protocols. 2 However, the contribution of anesthesia is largely unknown. With the availability of newer and shorter acting intravenous (IV) and volatile anesthetic agents, cardiac anesthesia fundamentally has shifted from a high-dose opioid/narcotic technique in recent years to a more balanced, synergistic approach. This shifted paradigm also has led to an emphasis on early tracheal extubation with application of multimodal analgesia including local anesthetic techniques resulting in the establishment of safe and effective fast-track protocols. 3,4 Modern anesthesia techniques for cardiac surgery need to offer qualities that go beyond safety alone.

Does Parsonnet scoring model predict mortality following adult cardiac surgery in India?

Aims and Objectives:To validate the Parsonnet scoring model to predict mortality following adult cardiac surgery in Indian scenario.Materials and Methods:A total of 889 consecutive patients undergoing adult cardiac surgery between January 2010 and April 2011 were included in the study. The Parsonnet score was determined for each patient and its predictive ability for in-hospital mortality was evaluated. The validation of Parsonnet score was performed for the total data and separately for the sub-groups coronary artery bypass grafting (CABG), valve surgery and combined procedures (CABG with valve surgery). The model calibration was performed using Hosmer–Lemeshow goodness of fit test and receiver operating characteristics (ROC) analysis for discrimination. Independent predictors of mortality were assessed from the variables used in the Parsonnet score by multivariate regression analysis.Results:The overall mortality was 6.3% (56 patients), 7.1% (34 patients) for CABG, 4.3% (16 patients) for valve surgery and 16.2% (6 patients) for combined procedures. The Hosmer–Lemeshow statistic was <0.05 for the total data and also within the sub-groups suggesting that the predicted outcome using Parsonnet score did not match the observed outcome. The area under the ROC curve for the total data was 0.699 (95% confidence interval 0.62–0.77) and when tested separately, it was 0.73 (0.64–0.81) for CABG, 0.79 (0.63–0.92) for valve surgery (good discriminatory ability) and only 0.55 (0.26–0.83) for combined procedures. The independent predictors of mortality determined for the total data were low ejection fraction (odds ratio [OR] - 1.7), preoperative intra-aortic balloon pump (OR - 10.7), combined procedures (OR - 5.1), dialysis dependency (OR - 23.4), and re-operation (OR - 9.4).Conclusions:The Parsonnet score yielded a good predictive value for valve surgeries, moderate predictive value for the total data and for CABG and poor predictive value for combined procedures.

Pilot Randomized Controlled Trial of Inhaled Milrinone in High-Risk Cardiac Surgical Patients

Background: Pulmonary hypertension is a major cause of mortality and morbidity in patients undergoing valvular and complex heart surgery. Inhaled milrinone has been used for the treatment of pulmonary hypertension, but its safety and effects compared with a placebo on hemodynamics and ventricular function have not been studied in patients undergoing high-risk valvular surgery. Methods: Twenty-one high-risk cardiac surgical patients with preoperative pulmonary hypertension were randomized in a double-blind study to receive inhaled milrinone or placebo. The inhalation occurred after the induction of anesthesia and before the surgical incision and cardiopulmonary bypass. The effects on ventricular function were evaluated by means of pulmonary artery catheterization and transesophageal echocardiography. The primary outcome variable was the systemic mean arterial pressure. Results: There were 8 men and 13 women (mean age 71 ± 6 years) with a mean Parsonnet score of 32 ± 9 who underwent a total of 17 complex procedures and 6 reoperations. There were no significant changes in mean arterial pressure throughout the study. A reduction in pulmonary vascular resistance (p = 0.0458) was observed in the inhaled milrinone group, but the change in mean pulmonary artery pressure was not significant (p = 0.1655). Right ventricular end-diastolic area (p = 0.0363) and right atrial transverse diameter (p < 0.0001) increased in the control group, but not with inhaled milrinone. No significant side effects occurred in the inhaled milrinone group. Conclusion: In this high-risk cardiac surgery cohort, the use of inhaled milrinone was not associated with systemic hypotension but with a reduced pulmonary vascular resistance and prevention of the increase in right-sided cavity dimensions.

Mid-Term Outcome and Angiographic Follow-Up of Endarterectomy of the Left Anterior Descending Artery in Patients Undergoing Coronary Artery Bypass Surgery

With the advancement of percutaneous coronary interventions (PCIs), more patients with diffuse coronary artery disease are referred for coronary artery bypass graft (CABG) surgery. The use of coronary endarterectomy may be useful in such cases. We reviewed our experience with left anterior descending artery endarterectomy as an adjunct to conventional CABG. Between June 2005 and 2011, 58 consecutive patients underwent left anterior descending artery endarterectomy as an adjunct to CABG. These were matched to 58 cases based on age, gender, and Parsonnet score. All data were collected prospectively in a departmental database. Postoperative complications and in-hospital mortality were analyzed. Survival curves were produced. There was one death in the endarterectomy group (1.7%) from liver failure. There was no significant difference in postoperative complications (especially perioperative myocardial infarction) between the two groups with similar hospital mortality. Computed tomography (CT) angiography was performed in 24 patients with endarterectomy (41%), which showed 100% patency of the left internal mammary artery graft to the left anterior descending artery. Survival and freedom from intervention at a mean follow-up of 4.2 years were similar. In patients with diffuse disease, the use of endarterectomy is a safe technique with no increase in short-term morbidity or mortality. Mid-term results are similar to nonendarterectomized patients. This technique is useful in patients with diffuse coronary artery disease.

OPTIMAL EUROSCORES FOR PREDICTING INPATIENT DEATHS IN PATIENTS WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION UNDERGOING CARDIAC SURGERY

The utility of surgery revascularization in patients (pts) with a low LVEF and operable coronary disease is unclear, highlighting the importance of risk stratification. Whilst the EuroSCORE and Parsonnet score (PS) are established prognosticators, their relative utility and optimal cut-offs in pts

700 Reassessment of Open Isolated Aortic Valve Replacement Outcomes in the Era of Transaortic Valve Implantation

BackgroundTransaortic aortic valve implantation (TAVI) has been shown to be superior to medical therapy in non-surgical candidates with aortic stenosis and comparable to surgery in high-risk surgical patients. Trials to evaluate TAVI in moderate surgical risk patients are ongoing. The current study aims to assess outcomes of isolated aortic valve replacement (AVR) in the pre and post TAVI era.MethodsSince May 2007, 190 pts underwent TAVI while 619 pts were operated for a conventional AVR using cardiopulmonary bypass (post-TAVI). Results of post-TAVI pts were compared to a similar time-frame period (Jan 2003-May 2007) where 529 pts were submitted to conventional AVR (pre-TAVI).ResultsPatient risk profile was higher in the pre-TAVI period in terms of preoperative renal failure (p<0.0001) and ejection fraction < 40% (p=0.005). Preoperative Parsonnet score was significantly higher in the pre-TAVI group (p=0.01) while the logistic Euroscore was similar (p=0.6). Postoperative outcome showed a similar rate of stroke (pre-TAVI: 2.5%, post-TAVI:2.6%). Postoperative renal failure was more frequent in the pre-TAVI patients (p=0.03) while reoperation for bleeding (p=0.03) and transfusion requirements (p<0.0001) were less frequent in the post-TAVI cohort. Mean duration of ICU stay was significantly less in the post-TAVI period (p=0.04); while overall hospital stay was comparable (p=0.2). Hospital mortality was significantly decreased in the post-TAVI period (pre-TAVI=3.2%, post-TAVI=1.3%; p=0.04).ConclusionThe advent of TAVI decreased the risk profile of patients submitted to isolated AVR. Perioperative mortality was significantly reduced in the post-TAVI period and perioperative morbidity in terms of transfusion requirements and ICU stay were lessened. For future comparison, results of open AVR should be based on post-TAVI outcomes. BackgroundTransaortic aortic valve implantation (TAVI) has been shown to be superior to medical therapy in non-surgical candidates with aortic stenosis and comparable to surgery in high-risk surgical patients. Trials to evaluate TAVI in moderate surgical risk patients are ongoing. The current study aims to assess outcomes of isolated aortic valve replacement (AVR) in the pre and post TAVI era. Transaortic aortic valve implantation (TAVI) has been shown to be superior to medical therapy in non-surgical candidates with aortic stenosis and comparable to surgery in high-risk surgical patients. Trials to evaluate TAVI in moderate surgical risk patients are ongoing. The current study aims to assess outcomes of isolated aortic valve replacement (AVR) in the pre and post TAVI era. MethodsSince May 2007, 190 pts underwent TAVI while 619 pts were operated for a conventional AVR using cardiopulmonary bypass (post-TAVI). Results of post-TAVI pts were compared to a similar time-frame period (Jan 2003-May 2007) where 529 pts were submitted to conventional AVR (pre-TAVI). Since May 2007, 190 pts underwent TAVI while 619 pts were operated for a conventional AVR using cardiopulmonary bypass (post-TAVI). Results of post-TAVI pts were compared to a similar time-frame period (Jan 2003-May 2007) where 529 pts were submitted to conventional AVR (pre-TAVI). ResultsPatient risk profile was higher in the pre-TAVI period in terms of preoperative renal failure (p<0.0001) and ejection fraction < 40% (p=0.005). Preoperative Parsonnet score was significantly higher in the pre-TAVI group (p=0.01) while the logistic Euroscore was similar (p=0.6). Postoperative outcome showed a similar rate of stroke (pre-TAVI: 2.5%, post-TAVI:2.6%). Postoperative renal failure was more frequent in the pre-TAVI patients (p=0.03) while reoperation for bleeding (p=0.03) and transfusion requirements (p<0.0001) were less frequent in the post-TAVI cohort. Mean duration of ICU stay was significantly less in the post-TAVI period (p=0.04); while overall hospital stay was comparable (p=0.2). Hospital mortality was significantly decreased in the post-TAVI period (pre-TAVI=3.2%, post-TAVI=1.3%; p=0.04). Patient risk profile was higher in the pre-TAVI period in terms of preoperative renal failure (p<0.0001) and ejection fraction < 40% (p=0.005). Preoperative Parsonnet score was significantly higher in the pre-TAVI group (p=0.01) while the logistic Euroscore was similar (p=0.6). Postoperative outcome showed a similar rate of stroke (pre-TAVI: 2.5%, post-TAVI:2.6%). Postoperative renal failure was more frequent in the pre-TAVI patients (p=0.03) while reoperation for bleeding (p=0.03) and transfusion requirements (p<0.0001) were less frequent in the post-TAVI cohort. Mean duration of ICU stay was significantly less in the post-TAVI period (p=0.04); while overall hospital stay was comparable (p=0.2). Hospital mortality was significantly decreased in the post-TAVI period (pre-TAVI=3.2%, post-TAVI=1.3%; p=0.04). ConclusionThe advent of TAVI decreased the risk profile of patients submitted to isolated AVR. Perioperative mortality was significantly reduced in the post-TAVI period and perioperative morbidity in terms of transfusion requirements and ICU stay were lessened. For future comparison, results of open AVR should be based on post-TAVI outcomes. The advent of TAVI decreased the risk profile of patients submitted to isolated AVR. Perioperative mortality was significantly reduced in the post-TAVI period and perioperative morbidity in terms of transfusion requirements and ICU stay were lessened. For future comparison, results of open AVR should be based on post-TAVI outcomes.

In-Hospital Nonvariceal Upper Gastrointestinal Bleeding following Cardiac Surgery: Patient Characteristics, Endoscopic Lesions and Prognosis

Background. Nonvariceal upper gastrointestinal bleeding (NVUGIB) can occur following cardiac surgery, with sparse contemporary data on patient characteristics and predictors of outcome in this setting. Aim. To describe the clinical and endoscopic characteristics of patients with NVUGIB following cardiac surgery and characterize predictors of outcome. Methods. Retrospective review of 131 consecutive patients with NVUGIB following cardiac surgery from 2002 to 2005. Demographic characteristics, therapeutic management, and predictors of outcomes were determined. Results. 69.5% were male, mean age: 68.8 ± 10.2 yrs, mean Parsonnet score: 24.6 ± 14.2. Commonest symptoms included melena (59.4%) or coffee ground emesis (25.8%). In-hospital medications included ASA (88.5%), heparin (95.4%, low molecular weight 6.9%), coumadin (48.1%), clopidogrel (22.9%), and NSAIDS (42%). Initial hemodynamic instability was noted in 47.1%. Associated laboratory results included hematocrit 26 ± 6, platelets 243 ± 133 109/L, INR 1.7 ± 1.6, and PTT 53.3 ± 35.6 s. Endoscopic evaluation (122 patients) yielded ulcers (85.5%) with high-risk lesions in 45.5%. Ulcers were located principally in the stomach (22.5%) or duodenum (45.9%). Many patients had more than one lesion, including esophagitis (28.7%) or erosions (26.8%). 48.8% received endoscopic therapy. Mean lengths of intensive care unit and overall stays were 10.4 ± 18.4 and 39.4 ± 46.9 days, respectively. Overall mortality was 19.1%. Only mechanical ventilation under 48 hours predicted mortality (O.R = 0.11; 95% CI = 0.04−0.34). Conclusions. This contemporary cohort of consecutive patients with NVUGIB following cardiac surgery bled most often from ulcers or esophagitis; many had multiple lesions. ICU and total hospital stays as well as mortality were significant. Mechanical ventilation for under 48 hours was associated with improved survival.

Addition of Frailty and Disability to Cardiac Surgery Risk Scores Identifies Elderly Patients at High Risk of Mortality or Major Morbidity

Background- Cardiac surgery risk scores perform poorly in elderly patients, in part because they do not take into account frailty and disability which are critical determinants of health status with advanced age. There is an unmet need to combine established cardiac surgery risk scores with measures of frailty and disability to provide a more complete model for risk prediction in elderly patients undergoing cardiac surgery. Methods and Results- This was a prospective, multicenter cohort study of elderly patients (≥70 years) undergoing coronary artery bypass and/or valve surgery in the United States and Canada. Four different frailty scales, 3 disability scales, and 5 cardiac surgery risk scores were measured in all patients. The primary outcome was the STS composite end point of in-hospital postoperative mortality or major morbidity. A total of 152 patients were enrolled, with a mean age of 75.9±4.4 years and 34% women. Depending on the scale used, 20-46% of patients were found to be frail, and 5-76% were found to have at least 1 disability. The most predictive scale in each domain was: 5-meter gait speed ≥6 seconds as a measure of frailty (odds ratio [OR], 2.63; 95% confidence interval [CI], 1.17-5.90), ≥3 impairments in the Nagi scale as a measure of disability (OR, 2.98; 95% CI, 1.35-6.56) and either the Parsonnet score (OR, 1.08; 95% CI, 1.04-1.13) or Society of Thoracic Surgeons Predicted Risk of Mortality or Major Morbidity (STS-PROMM) (OR, 1.05; 95% CI, 1.01-1.09) as a cardiac surgery risk score. Compared with the Parsonnet score or STS-PROMM alone, (area under the curve, 0.68-0.72), addition of frailty and disability provided incremental value and improved model discrimination (area under the curve, 0.73-0.76). Conclusions- Clinicians should use an integrative approach combining frailty, disability, and risk scores to better characterize elderly patients referred for cardiac surgery and identify those that are at increased risk.

Prediction and prevention of upper gastrointestinal bleeding after cardiac surgery: a case control study.

Gastrointestinal (GI) complications of cardiovascular surgery, particularly bleeding, occur frequently. To determine factors that predict upper GI bleeding (UGIB) after cardiac surgery to improve prognostication and, thus, outcomes. The present case-control study reviewed institutional records spanning 2002 to 2005 for consecutive patients who developed in-hospital UGIB following cardiovascular surgery. Each case was matched to two to three controls for age, sex and date of hospital admission. Demographics, pharmacotherapy (including use of in-hospital acid suppression), endoscopic findings and outcomes were recorded. After adjustment for possible confounders, including Parsonnet score and demographic parameters, conditional logistic regression analysis identified independent significant predictors of the subsequent development of UGIB. The study population consisted of 131 cases (mean [± SD] age 68.8±10.2 years, 69.5% male, mean Parsonnet score 24.6±14.2) and 387 matched controls (mean age 68.8±10.8 years, 70.0% male, mean Parsonnet score 20.9±14.2). UGIB events occurred a mean of 10.3±7.7 days after cardiac surgery. Duration of mechanical ventilation (OR 3.01 [95% CI 1.44 to 6.28]), elevation of international normalized ratio (OR 1.91 [95% CI 1.31 to 2.78]) and occurrence of Clostridium difficile colitis before bleeding (OR 3.15 [95% CI 1.19 to 8.36]) were independent risk factors. Use of histamine type 2 receptor antagonists (H2RAs) (OR 0.65 [95% CI 0.38 to 1.12]) or proton pump inhibitors (PPIs) (OR 0.60 [95% CI 0.27 to 1.32]) demonstrated trends toward protecting against UGIB after cardiac surgery. GI bleeding events occurred approximately 10 days after cardiac surgery in patients with a complicated postoperative course. Significant predictors of subsequent bleeding included increased duration of mechanical ventilation and elevation of international normalized ratio; routine acid suppression with PPIs should be considered in such patients. C difficile colitis also significantly predicted UGIB, and H2RAs should be considered for acid suppression. Neither H2RAs nor PPIs were effective in preventing UGIB, although the small number of patients limits definitive conclusions regarding the role of acid suppression.