Risk Factors For Perioperative Mortality Research Articles

Cardiac Surgery in Patients on Dialysis: Decreased 30-Day Mortality, Unchanged Overall Survival

The risk of cardiac surgery in dialysis-dependent patients is high, but little is known about the determinants of survival. We initiated a retrospective multicenter study to overcome this limitation. Nine centers provided data on 522 patients (70% male, aged 61 +/- 11 years) who had chronic dialysis-dependent renal failure. A 14-year period was covered. Most patients had coronary artery bypass grafting, either with (n = 103) or without (n = 326) valve surgery. Multivariable analysis of survival was explored using Cox models. The proportion of patients with diabetes mellitus increased significantly (from 17%, 1989 to 1993, to 32%, 2000 to 2003; p = 0.021) and was independently associated with 30-day mortality (odds ratio = 3.30, p = 0.001) The mean 30-day mortality was 12% (n = 60), but declined significantly during the study period (from 28%, 1989 to 1993, to 7%, 2000 to 2003; p = 0.003). The 5-year survival probability was 42% (95% confidence interval: 36% to 47%). Patients who had renal transplantation during follow-up (n = 17) had the best survival probability (hazard ratio [HR] = 0.14, p = 0.007). Sinus rhythm (HR = 0.48, p < 0.001) and use of internal thoracic artery grafts (HR = 0.67, p = 0.006) proved beneficial for long-term survival. Predictors of death during long-term follow-up were emergency surgery (HR = 2.25, p = 0.001), diabetes mellitus (HR = 1.46, p = 0.020), number of allogenic transfusions (HR = 1.03/unit, p = 0.015), and age (HR = 1.04/year, p < 0.001). In dialysis-dependent patients, cardiac surgery has become significantly safer in recent years, but the overall prognosis of the patients remains poor. The observed improvements in the perioperative survival do not necessarily translate into an improved long-term prognosis. Diabetes mellitus is an important independent risk factor for perioperative mortality and death during follow-up.

Implications of Problematic Access in Transluminal Endografting of Abdominal Aortic Aneurysm

Despite careful preoperative assessment, problematic access to the abdominal aorta for transluminal endografting (TE) of abdominal aortic aneurysm (AAA) is sometimes encountered. This study identifies preoperative risk factors predictive of problematic access and determines the impact of problematic access on outcomes. Three hundred twenty-one consecutive TE procedures for AAA were divided into two groups: group A, which had access problems (n = 74), and group B, which had none (n = 247). Logistic regression analysis of risk factors showed that (i) a pulmonary risk score of 3 (P <.001; odds ratio, 11.2), (ii) a hyperlipidemia score of 3 (P =.004; odds ratio, 2.6), and (iii) a small body (short height with low weight, P =.003; odds ratio, of 4.2) were independent risk factors for problematic access. Outcomes compared included rates of perioperative mortality, aborted procedure, surgical conversion, major complication, limb complication, and endoleak. The perioperative mortality rate was higher in group A (6.8% vs 1.2%; P =.018) and procedures were more likely to be aborted in patients in group A (12.2% vs 0%; P <.001). Rates of surgical conversion, major complication, and limb complication were not different between the two groups. The endoleak rate was higher in group B (10.8% vs 26.7%; P =.004). Logistic regression analysis showed that problematic access was an independent risk factor (P =.004; odds ratio, 12.0) for perioperative mortality. Moderate to severe chronic obstructive pulmonary disease and hyperlipidemia, both risk factors for atherosclerosis, were related to problematic access in this series. Small body size was another factor related to problematic access. Problematic access was an independent risk factor for perioperative mortality.

Epidemiology of acute kidney injury after cardiac surgery: an update

This aim of this review is to highlight recent studies that have furthered our understanding of the epidemiology, risk factors, and prognosis of acute kidney injury (AKI) following cardiac surgery. AKI is an important postoperative complication of cardiac surgery and is an independent risk factor for perioperative mortality. A consensus definition of AKI, the risk, injury, failure, loss, end-stage kidney disease (RIFLE) criteria, has recently been evaluated in the cardiac surgery population. AKI is an independent risk factor for postoperative death and is associated with increased postoperative complications and overall resource utilization. Despite the high early mortality rate, patients with postoperative AKI who survive to hospital discharge have a reasonable long-term prognosis. The identification of risk factors for AKI has allowed the development of preoperative risk stratification strategies. Future studies are necessary to determine if preoperative risk stratification leads to improved outcomes by...

Semi-skeletonized internal mammary grafts and phrenic nerve injury: Cause-and-effect analysis

Phrenic nerve injury after cardiac surgery increases postoperative pulmonary complications. The purpose of this study was to analyze the causes and effects of phrenic nerve injury after cardiac surgery. Prospectively collected data on 2084 consecutive patients who underwent cardiac surgery from Jan. 1995 to Feb. 2002 were analyzed. Twenty-eight preoperative and operation related variables were subjected to logistic analysis with the end point being phrenic nerve injury. Then phrenic nerve injury and 6 perioperative morbidities were included in the analysis as variables to determine their independent predictive value for perioperative pulmonary morbidity. An identical approach was used to identify the independent risk factors for perioperative mortality. There were 53 phrenic nerve injuries (2.5%). There was no phrenic nerve injury in non-coronary surgery or coronary surgery using conduits other than the internal mammary artery. The independent risk factors for phrenic nerve injury were the use of internal mammary artery (Odds ratio (OR) = 14.5) and thepresence of chronic obstructive pulmonary disease (OR = 2.9). Phrenic nerve injury was an independent risk factor (OR = 8.1) for perioperative pulmonary morbidities but not for perioperative mortality. Use of semi-skeletonized internal mammary artery harvesting technique and drawing attention to possible vascular or mechanical causes of phrenic nerve injury may reduce its occurrence. Unilateral phrenic nerve injury, although rarely life-threatening, is an independent risk factor for postoperative respiratory complications. When harvesting internal mammary arteries, it should be kept in mind avoiding stretching, compromising, or inadvertently dissecting phrenic nerve is as important as avoiding damage of internal mammary artery itself.

Identification of Risk Factors for Perioperative Mortality in Acute Mesenteric Ischemia

Acute intestinal ischemia is in most cases a lethal condition with a low survival rate. Risk factors of perioperative mortality are poorly defined. The aim of this study was to define risk factors that predict an adverse outcome of acute mesenteric ischemia (AMI). A total of 132 consecutive patients (73 men, 59 women), mean+/-SD age 71.96+/-13.64 years, who underwent surgery because of AMI in a university tertiary care center were evaluated over a period of 10 years. Clinical features, laboratory findings, etiologic factors, and surgical procedures were recorded and assessed as possible risk factors for perioperative mortality. Of 132 patients, 86 (65.2%) died during the perioperative period as a direct result of AMI. Significant univariate predictors of perioperative mortality were age (P=0.01), cardiopathy (P=0.002), digoxin intake (P=0.015), shock (P=0.01), urea plasma level (P<0.001), creatinine (P<0.001), potassium (P=0.042), low pH (P=0.015) and bicarbonate (P=0.035); hemoglobin>or=2.48 mmol/L (P=0.035); time delay to surgery (P=0.023); colonic involvement (P<0.001); small and large bowel involvement (P<0.001); arterial versus venous ischemia (P=0.007); and intestinal resection (P<0.001). In the multivariate analysis, the variables previous cardiac illness (P=0.045), urea plasma levels (P<0.001), and small and large bowel involvement were identified as independent risk factors of perioperative mortality. Intestinal resection (P<0.001) was a favorable predictor. Age, time delay to surgery, shock, and acidosis significantly increase the risk of mortality due to AMI, whereas intestinal resection has a protective effect. However, only previous cardiac illness, acute renal failure, and large bowel ischemia have a negative effect as independent risk factors of mortality of AMI.

Diabetes Mellitus is no Independent Risk Factor for Perioperative Mortality Following Hepatic Resection

For patients with concomitant diabetes mellitus an increased perioperative mortality and morbidity in hepatic resections has repeatedly been described. Other studies, however, demonstrated equal outcome data in diabetic and non-diabetic patients. As patient populations were selected for underlying disease, conflicting results may reflect patient selection criteria rather than impact of diabetes mellitus on outcome measures. Therefore, a multivariate analysis in a largely unselected patient population has been performed to determine the independent prognostic value of diabetes mellitus in liver surgery. From a prospective database 633 adult patients undergoing hepatic resection without preceding major abdominal surgery or chemotherapy have been identified. Besides diabetes mellitus, demographic data, variables expressing the functional reserve of the liver, and parameters of surgical technique were analyzed for their impact on mortality and morbidity. 75 patients were diabetic (11.8 %) and 96 hepatic resections (15.2 %) were performed in cirrhotic patients. In the univariate analysis, concomitant diabetes was associated with an increased mortality compared to all non-diabetic patients (10.7 % vs. 5.3 %, p = 0.047). Diabetic patients, however, were also significantly older and presented a higher prevalence of liver cirrhosis. Multivariate modeling finally identified only age, albumin, cirrhosis, extent of surgery, and era of surgery as independent variables with an impact on perioperative mortality. Overall, complications were detected in diabetic and non-diabetic patients with a comparable frequency (44 % vs. 36 %, p = 0.179). Also, the length of in-hospital stay did not significantly differ between both groups (18.5 +/- 1.7 vs. 17.7 +/- 1.0 days, p = 0.119). Rates of postoperative renal impairment, prolonged ascites or pneumonia, however, were higher in diabetics than in other patients. Following established cardiopulmonary and surgical selection criteria, diabetes mellitus is not an independent risk-factor for perioperative mortality in hepatic resections. Although the overall postoperative morbidity was not different in diabetic and non-diabetic patients, a specific pattern of complications has been identified, mandating particular attention in the postoperative course of diabetic patients.

Pancreaticoduodenectomy in the Very Elderly

It is estimated that by 2050, there will be a 300% increase in the elderly population (> or =65 years) and a corresponding increase in elderly patients presenting for surgical evaluation. Surgical decision-making in this population can be difficult because outcomes in the elderly are poorly defined. We reviewed 2698 consecutive pancreaticoduodenectomies (PDs) at our institution over a 35-year period (April 1970 through March 2005), with the last 1000 resections being done in the last 4 years. Data collected included surgical indication, mortality (defined as 30-day or in-hospital mortality), complications, and survival. Patients were divided by age into three groups (<80, 80-89, and > or =90 years) and evaluated using multiple logistic regression. Two hundred seven patients > or =80 years old underwent a PD (7.7% of 2698). Patients 80-89 years of age had a mortality rate of 4.1% (8 of 197) and a complication rate of 52.8% (99 of 197), whereas patients < or =79 years of age had a mortality of 1.7% and a complication rate of 41.6% (P < 0.05). There were no perioperative deaths among the 10 patients > or =90 years of age, and their complication rate was 50% (5 of 10). One-year survival for patients 80-89 years of age was 59.1%, and that for patients > or =90 years was 60%. Age was not an independent risk factor for perioperative mortality and morbidity following PD after adjusting for preoperative comorbidities. We demonstrate that PD can be safely performed in patients over 80 years of age and conclude that age alone should not be a contraindication to pancreatic resection. The advent of improved surgical outcomes and an aging population will likely result in a significant increase in the number of PDs performed in the next few decades.

Correction of Tetralogy of Fallot and of Pulmonary Atresia with Ventricular Septal Defect in Adults

Early correction is regarded as the treatment of choice for patients with tetralogy of Fallot or pulmonary atresia with ventricular septal defect. Nevertheless, some of these patients reach adulthood without early correction. This study sought to assess risk factors for operative mortality and determine the benefit of total correction in adolescent and adult patients. A retrospective analysis of 52 patients (>16 years at the time of corrective surgery) for tetralogy of Fallot (n = 42) or pulmonary atresia with ventricular septal defect (n = 10) between 1974 and 2003 was performed. Age at correction was 28.9 +/- 9.9 (16 to 57 years). There were 8 early deaths (15.4%). Preoperative hemoglobin concentration (p = 0.002) and reconstruction of the right ventricular outflow tract with a patch (p = 0.002) were correlated with a significantly higher early mortality. Mean follow-up time was 12.3 +/- 10.4 years. Late deaths (n = 6; 11.5%) were cardiac-related in 2 of 6 cases. At follow-up, 28 patients (87.5%) were assigned to the New York Heart Association functional class I. Twenty-four patients led a normal life with full-time work, 6 patients were able to do part-time work, and only 2 patients experienced noticeable limitation on activities. Repair of tetralogy of Fallot and of pulmonary atresia with ventricular septal defect in this patient group is associated with a high early mortality. Preoperative chronic cyanosis, expressed by elevated hemoglobin concentration, is predictive for early mortality. Because cyanosis has been shown to lead to multiorgan dysfunction, we conclude that preoperative multiorgan dysfunction may be the intrinsic risk factor for perioperative mortality. Surgical correction in this patient group should still be recommended because the functional status considerably improves.

Perioperative Risk Factors for Mortality in Non-infected Abdominal Aortic Aneurysm

Background: This study assesses the surgical outcome of non-infected nonruptured abdominal aortic aneurysm (AAA) and ruptured AAA, and defines the risk factors of death. Methods: We studied 115 consecutive patients who underwent conventional operations for non-infective abdominal aortic aneurysm between July 1989 and December 2003. The 115 patients were divided into two groups according to the preoperative findings of the computed tomography (CT) scan. In group I (n=91), the patients had AAA without CT evidence of preoperative rupture of the abdominal aorta. In group Ⅱ (n=24), the patients had AAA with CT evidence of preoperative rupture of the abdominal aorta. Rupture was defined as free blood in the retroperitoneal or peritoneal space. Data were collected by retrospective chart review. Both univariate and multivariate analyses were used as risk factors for death. Results: From 1989 to 2003, 115 patients underwent operations for abdominal aortic aneurysm. The average patients age was 71.4±7.1 years (range, 40 to 87 years), and 99(86%) were male. Twenty-four patients were operated upon in ruptured state. The overall hospital mortality was 16.5%(19/115): 66.7%(16/24) in patients with ruptured abdominal aortic aneurysm and 3.3%(3/91) in patients with nonruptured abdominal aortic aneurysm. Risk factors for death were presence of rupture, preoperative shock and necessity for emergency operation. Conclusions: Mortality rates after AAA repair in our hospital were comparable with those previously reported in other series. Major determinants of surgical mortality in patients with abdominal aortic aneurysm were preoperative complications. Early diagnosis and operation before aneurysm rupture were essential for survival.

Radical surgery for esophageal cancer: our experience and analysis of risk factors for perioperative mortality

Radical operative therapy for esophageal cancer is usually connected with a significant mortality and morbidity. Purpose of this study is analysis of potential risk factors for mortality after radical surgery for esophageal cancer and presentation of our experience with this kind of surgery. There were 65 patients undergone radical surgery for esophageal cancer from the June 2003 to the April 2004 in our University Hospital for Chest Diseases. We analyzed as mortality risk factors: sex, age, albumin, aspartate transaminase, alanine transaminase, gamma glutamyl transferase, creatinine, hemoglobin, leucocytes, fibrinogene, prothrombine time, activated partial thromboplastine time, forced expiratory volume in the first second, vital pulmonary capacity, diffusion capacity for carbon monoxide (all preoperative), duration of surgery, perioperative infused fluid volume, perioperative transfusion, duration and stay in ICU. In our study perioperative mortality was 15.38%. Incidence of complications: pulmonary 44.61%, cardiac 6.15%, and surgical 27.69%. There were no statistically significant differences between groups of patients connected with most of analyzed factors. The most important finding is positive correlation of level of gamma glutamyl transpherase with perioperative mortality (p=0.012 for gamma glutamyl transferase >38 U/L, and p=0.017 for gamma glutamyl transferase >76 U/L-Fishers 2x2 test). Among the analyzed factors, only factor of potential prognostic importance for patients undergoing radical surgery for esophageal cancer could be the level of gamma glutamyl transferase. Reference: 1. Liu JF, Watson DI, Devitt PG, et al. Risk factor analysis of post-operative mortality in oesophagectomy. Dis Esophagus 2000 ; 13(2): 130-135.

Risk factors for perioperative mortality and nosocomial infections in lung transplantation

Risk factors for perioperative mortality and nosocomial infections in lung transplantation

An analysis of the risk factors for perioperative mortality in patients with end-stage renal failure undergoing cardiac surgery: a multicenter study

Objectives: Patients with end-stage renal disease face a significantly increased perioperative risk if they have to undergo cardiac surgery. The factors determining the perioperative risk, however, are poorly understood. We therefore initiated a multicenter study to determine the perioperative risk and its predictors among patients on dialysis who underwent cardiac surgery.

Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery

Purpose To determine the incidence of perioperative events in patients with aortic stenosis undergoing noncardiac surgery. Methods We studied 108 patients with moderate (mean gradient, 25 to 49 mm Hg) or severe (mean gradient, ≥50 mm Hg) aortic stenosis and 216 controls who underwent noncardiac surgery between 1991 and 2000 at Erasmus Medical Center. Controls were selected based on calendar year and type of surgery. Details of clinical risk factors, type of surgery, and perioperative management were retrieved from medical records. The main outcome measure was the composite of perioperative mortality and nonfatal myocardial infarction. Results There was a significantly higher incidence of the composite endpoint in patients with aortic stenosis than in patients without aortic stenosis (14% [15/108] vs. 2% [4/216], P <0.001). This rate of perioperative complications was also substantially higher in patients with severe aortic stenosis compared with patients with moderate aortic stenosis (31% [5/16] vs. 11% [10/92], P = 0.04). After adjusting for cardiac risk factors, aortic stenosis remained a strong predictor of the composite endpoint (odds ratio = 5.2; 95% confidence interval: 1.6 to 17.0). Conclusion Aortic stenosis is a risk factor for perioperative mortality and nonfatal myocardial infarction, and the severity of aortic stenosis is highly predictive of these complications.

Predictors of readmission for complications of coronary artery bypass graft surgery.

Risk factors for perioperative mortality after coronary artery bypass graft (CABG) surgery have been extensively studied. However, which factors are associated with early readmissions following CABG surgery are less clear. To identify significant predictors of readmission within 30 days following CABG surgery. Causes for readmission within 30 days were investigated for all patients discharged after CABG surgery in the state of New York from January 1, 1999, through December 31, 1999. A variety of patient demographics, preoperative risk factors, complications, operative and postoperative factors, and provider characteristics were considered as potential predictors of readmissions. Hospital readmissions within 30 days of discharge following CABG surgery. Of 16 325 total patients, 2111 (12.9%) were readmitted within 30 days for reasons related to CABG surgery. The most common causes of readmission were postsurgical infection (n = 598 [28%]) and heart failure (n = 331 [16%]). Eleven risk factors were found to be independently associated with higher readmission rates: older age, female sex, African American race, greater body surface area, previous myocardial infarction within 1 week, and 6 comorbidities. After controlling for these preoperative patient-level risk factors, 2 provider characteristics (annual surgeon CABG volume <100, hospital risk-adjusted mortality rate in the highest decile) and 2 postoperative factors (discharge to nursing home or rehabilitation/acute care facility, length of stay during index CABG admission of > or =5 days) were also related to higher readmission rates. Readmission within 30 days following discharge is an important adverse outcome of CABG surgery. Continued attempts should be made to explore the potential of readmission as a supplement to mortality in assessing provider quality.

Surgical treatment of acute arch dissection.

Acute type A arch dissections are rare and no consensus has been reached on their surgical treatment. We studied perioperative risk factors for mortality in arch dissection patients. Between October 1995 and October 2001, 108 patients with acute type A dissection were operated on, of whom 16 had acute arch dissections. Their mean age was 58 +/- 9 (44-77). Surgery involved total arch replacement in 4, hemiarch replacement in 10, and intimal tear repair with pledgeted sutures and ascending aortic replacement in 2. One patient who underwent total arch replacement died intraoperatively due to bleeding. Both patients who underwent ascending aortic replacement and primary repair of arch tears died 2 days postoperatively, 1 due to bleeding, and the other due to multiorgan failure. In-hospital mortality was thus 18.75%, or 3 of 16. All 3 had cardiac tamponade preoperatively. The 13 survivors were discharged after a mean hospital stay of 11 +/- 6 days. Mean follow-up was 38 +/- 25 months, from 3 months to 6 years. One patient died due to graft infection 3 months postoperatively, but the remaining 12 remain in good condition. Univariate predictors of in-hospital mortality were the type of surgery (primary intimal tear repair) (p = 0.027) and preoperative cardiac tamponade (p = 0.007). Surgical treatment of acute type A-arch dissections can be done with reasonable mortality and mid-term survival comparable with those of other subgroups with acute type A dissection. As with series of arch dissections, our patient population is too small to draw specific conclusions, but our experience leads us to conclude that the sites of intimal tears should be resected in acute type A arch dissection.

Risk factors for perioperative morbidity and mortality after extended hepatectomy for hepatocellular carcinoma.

Extended hepatectomy with resection of more than four segments is a high-risk operation, especially in patients with hepatocellular carcinoma (HCC) associated with chronic liver disease. This study evaluated the risk factors for morbidity and mortality following extended hepatectomy for HCC. Preoperative and intraoperative variables of 155 patients who underwent extended hepatectomy for HCC were analysed to identify risk factors for postoperative morbidity and mortality. The overall morbidity rate was 55.5 per cent (n = 86). Most morbidity was due to ascites or pleural effusion. Significant life-threatening complications occurred in 20.0 per cent (n = 31). The perioperative mortality rate was 8.4 per cent (n = 13). Multivariate analysis found that portal clamping (P = 0.023) and perioperative blood transfusion (P < 0.001) were risk factors for morbidity, whereas perioperative blood transfusion (P < 0.001) was the only risk factor for significant morbidity. Co-morbid illness (P = 0.019) and perioperative blood transfusion (P = 0.004) were risk factors for perioperative mortality. Meticulous operative techniques to minimize blood loss and transfusion, while avoiding a prolonged Pringle manoeuvre, may help reduce postoperative morbidity. Avoidance of perioperative blood transfusion and careful preoperative selection of patients in terms of overall physiological status are important measures to reduce the postoperative mortality rate.

Perioperative risk factors for mortality in patients with acute type a aortic dissection

Background This study was undertaken to identify the perioperative risk factors for death in patients with acute type A aortic dissection (AADA). Methods Between 1993 and 2001, 108 consecutive patients (86 men; mean age, 53 years) underwent emergent operations for AADA. All patients but 2 underwent replacement of the ascending aorta with an open distal anastomosis during a period of hypothermic circulatory arrest. In addition, 22 patients had hemiarch and 5 had total arch replacement. Aortic root was replaced in 20 and repaired with gelatin-resorcinol-formaldehyde glue in 39 patients; aortic valve was separately replaced in 3, resuspended in 24, and remained untouched in 22 patients. Results Overall in-hospital mortality was 25%. Mortality rate was significantly higher in patients with preoperative dissection complications than in those without (21/36 [58%] vs 6/72 [8%], p < 0.001). In multivariate analysis, predictors of mortality were presence of rupture, renal failure, and intestinal malperfusion, duration of cardiopulmonary bypass ≥200 minutes, blood loss ≥500 mL, and transfusion of blood ≥4 units. Location of the intimal tear, extent of the replacement, type of the aortic root repair, and duration of hypothermic circulatory arrest did not emerge as predictors of mortality. Conclusions Major determinants of surgical mortality in patients with AADA are preoperative complications. Earlier diagnosis remains essential to improve the survival rate.

Extended hepatic resection: a 6-year retrospective study of risk factors for perioperative mortality

Background: Extended hepatic resection (more than four liver segments) is a major operative procedure that is associated with significant risk. The purpose of this study was to assess the impact of perioperative variables on in-hospital mortality after extended hepatectomy. Study Design: Consecutive patients who underwent extended hepatic resection were studied. The prognostic value of 29 perioperative variables was evaluated using in-hospital mortality as the endpoint. For each variable, the odds ratio (95% confidence interval) for in-hospital mortality was calculated. Those variables with a lower confidence limit > 1 were considered important risk factors. The population was stratified into categories of patients having the same number of risk factors, and mortality was estimated for each group. These data were used to develop a risk assessment algorithm. Results: There were 14 deaths (6%) in 226 patients. Three preoperative variables (cholangitis, creatinine > 1.3 mg/dL, and total bilirubin > 6 mg/dL) and two operative variables (blood loss > 3 L and vena caval resection) appear to be important factors for in-hospital mortality. The mortality associated with the presence of any two of the five factors was 100% (5 of 5), and the mortality associated with the absence of these factors was 3% (6 of 191). Conclusions: Perioperative evaluation of patients undergoing extended hepatic resection should include the quantitation of mortality risk factors. The combination of any two factors among preoperative cholangitis, elevated serum creatinine, elevated serum bilirubin, high operative blood loss, and vena cava resection may carry a high mortality risk. These results require prospective validation.

Partial left ventriculectomy:: Preoperative risk factors for perioperative mortality

This study aimed at determining risk factors for perioperative mortality for patients undergoing partial left ventriculectomy. Fourteen patients with end-stage congestive heart failure underwent partial ventriculectomy at our institution from February, 1995 to October, 1997. Mean age was 48±11 years, symptoms duration 44±34 months, New York Heart Association symptoms score 4±0, systolic blood pressure 97.69±20.06 mmHg, diastolic blood pressure 65.38±13.91 mmHg, heart rate 91±15 beats/min, furosemide daily dose 121.66±96.65 mg and captopril daily dose 68.75±76.76 mg. Seven (50%) patients needed inotropic support for hemodynamic stabilization. On echocardiography, left ventricular diastolic dimension was 81.71±11.92 mm. Left ventricular ejection fraction determined by radionuclide ventriculography or echocardiography was 16.71±5.13. At heart catheterization, mean right atrial pressure was 12.50±7.72 mmHg, mean pulmonary capillary wedge pressure 23.60±7.79 mmHg, and mean pulmonary artery pressure 34.10±12.81 mmHg. Twelve patients had idiopathic dilated cardiomyopathy and two patients had a globally dilated heart with single vessel coronary artery disease. Aneurysmectomy, mitral valve surgery or coronary artery bypass surgery were not performed in any patient. Four (28%) patients died: three in the operating theatre and one from low output syndrome 2 days after surgery. The proportion of patients operated on with cardiogenic shock was four (100%) in nonsurvivors and 0% in survivors ( P=0.001). Inotropic support was necessary in three (30%) survivors and in four (100%) nonsurvivors ( P=0.06). Thus, preoperative hemodynamic instability may be associated with perioperative mortality after partial left ventriculectomy.

Operation for Infective Endocarditis: Results After Implantation of Mechanical Valves

Background. Operation for acute endocarditis during the active phase violates a basic surgical rule not to implant a foreign body into an infective process, resulting in a high operative mortality and the risk of early recurrent endocarditis. Several investigators analyzing risk factors for perioperative mortality and morbidity presented strategies for more favorable outcomes, but most studies suffer from the drawback of heterogeneous populations observed over a long period of time. Methods. We present a prospective study on 138 patients operated on from March 1988 to March 1996. Patients were only included if the activity of the infection was proved by positive culture of the valve leaflets or by histologic staining. During the observation period, indication for operation, surgical approach, and postoperative antibiotic therapy were standardized as much as possible. After radical debridement of all parts of infected tissue, valve replacement was carried out with mechanical prostheses. Results. The early mortality was 11.5% overall. High New York Heart Association functional classification, advanced age, and staphylococcal disease were significant risk factors for early mortality. The site of infection, multiple valve involvement, and prosthetic valve endocarditis did not affect the outcome. Early recurrent endocarditis was recorded in only 3 patients of the entire series. Conclusions. In case of acute infective endocarditis, valve replacement with mechanical prostheses is a safe procedure, if radical operation and aggressive postoperative antibiotic therapy are performed. For further improvements of the results, earlier operation is advisable in patients with rapidly progressive cardiac deterioration and in most cases of staphylococcal endocarditis.