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We have reviewed the results of our experience with the use of miniaturized (Mini-CPB) versus conventional (C-CPB) cardiopulmonary bypass in coronary artery bypass surgery (CABG). This study included 365 patients who underwent CABG with C-CPB and 101 patients with Mini-CPB. In-hospital mortality was lower in the C-CPB group (1.4% vs. 3.0%, P = 0.38). A better, but not statistically significant, immediate outcome was observed in the C-CPB group as indicated by a shorter length of stay in the intensive care unit as well as a lower incidence of combined adverse end-point. However, this was probably due to significantly higher operative risk in the Mini-CPB group (logistic EuroSCORE: 8.5 +/- 10.0 vs. 4.6 +/- 7.1, P < 0.0001). Seventy-seven propensity score-matched pairs had similar immediate postoperative results after Mini-CPB and C-CPB (30-day mortality: 1.3% vs. 1.3%; stroke: 0% vs. 0%; intensive care unit stay >/=5 days: 6.5% vs. 9.1%; combined adverse events: 14.3% vs. 11.7%). Mini-CPB achieves similar results to C-CPB in patients undergoing isolated CABG. The potential efficacy of Mini-CPB is expected to be more evident in high-risk patients or in complex cardiac surgery requiring much longer cardiopulmonary perfusion. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to investigate the incidence of permanent working disability (PWD) in young patients after percutaneous or surgical coronary revascularization., Methods and Results: The study included 1035 consecutive patients ≤50 years old who underwent coronary revascularization [910 and 125 patients in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) groups, respectively] between 2002 and 2012 at 4 Finnish hospitals. The median follow-up time was 41 months. The overall incidence of PWD was higher after CABG compared to PCI (at 5 years, 34.8 vs. 14.7%, P < 0.001). Freedom from PWD in the general population aged 45 was 97.2% at 4 years follow-up. Median time to grant disability pension was 11.6 months after CABG and 24.4 months after PCI (P = 0.018). Reasons for PWD were classified as cardiac (35.3 vs. 36.9%), psychiatric (14.7 vs. 14.6%), and musculoskeletal (14.7 vs. 15.5%) in patients undergoing CABG vs. PCI. Overall freedom from PWD was higher in patients without major adverse cardiac and cerebrovascular event (MACCE) (at 5 years, 85.6 vs. 71.9%, P < 0.001). Nevertheless, rate of PWD was high also in patients without MACCE and patients with preserved ejection fraction during follow-up., Conclusions: Although coronary revascularization confers good overall survival in young patients, PWD is common especially after CABG and mostly for cardiac reasons even without occurrence of MACCE. Supportive measures to preserve occupational health are warranted concomitantly with coronary revascularization at all levels of health care., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Objectives: This study aimed to describe the incidence and periprocedural predictors of permanent work disability (PWD) pension among patients ≤50 years old who underwent percutaneous coronary intervention (PCI)., Methods: Patient records of 910 consecutive patients undergoing PCI at four Finnish hospitals in 2002-2012 were reviewed for baseline and procedural data and late adverse events. Data on permanent work disability (PWD) pension allocation were acquired from the Finnish Centre for Pensions, which governs the statutory pension security in Finland., Results: Mean follow-up was 41 [standard deviation (SD) 31] months. Altogether 103/910 (11.3%) of patients were on PWD by the end of follow-up, 60 (58.3%) for cardiac diagnoses (cumulative freedom from PWD 81% at 7 years). Independent predictors of PWD were post procedural stroke [hazard ratio (HR) 4.7, 95% confidence interval (95% CI) 1.8-11.9], post procedural myocardial infarction (MI) (HR 3.3, 95% CI 1.8-6.0), diabetes (HR 2.0, 95% CI 1.1-3.7), discharge diuretics (HR 3.5, 95% CI 2.1-5.9), and increasing age (HR 1.2, 95% CI 1.1-1.3). Predictors of PWD for cardiac diagnoses were post procedural stroke and MI, discharge diuretics, and use of calcium-channel blockers, diabetes and older age., Conclusions: Patients ≤50 years old undergoing PCI are at a high risk for subsequent permanent disability for cardiac diagnoses. This finding underscores the need for reinforcing adherence to secondary prevention by cardiac rehabilitation and early collaboration with occupational health care professionals.

Data on the outcome of young patients after coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are scarce. Data on 2,209 consecutive patients aged≤50 years who underwent CABG or PCI were retrospectively collected from 15 European institutions. PCI and CABG had similar 30-day mortality rates (0.8% vs 1.4%, p=0.27), late survival (at 5 years, 97.8% vs 94.9%, p=0.082), and freedom from stroke (at 5 years, 98.0% and 98.0%, p=0.731). PCI was associated with significantly lower freedom from major adverse cardiac and cerebrovascular events (at 5 years, 73.9% vs 85.0%, p<0.0001), repeat revascularization (at 5 years, 77.6% vs 92.5%, p<0.0001), and myocardial infarction (at 5 years, 89.9% vs 96.6%, p<0.0001) compared with CABG. These findings were confirmed in propensity score-adjusted and matched analyses. Freedom from major adverse cardiac and cerebrovascular events after PCI was particularly low in diabetics (at 5 years, 58.0% vs 75.9%, p<0.0001) and in patients with multivessel disease (at 5 years, 63.6% vs 85.1%, p<0.0001). PCI in patients with ST elevation myocardial infarction was associated with significantly better 5-year survival (97.5% vs 88.8%, p=0.001), which was driven by its lower 30-day mortality rate (1.5% vs 6.0%, p=0.017). In conclusion, patients aged≤50 years have an excellent immediate outcome after either PCI or CABG with similar long-term survival when used according to the current clinical practice. PCI was associated with significantly lower freedom from myocardial infarction and repeat revascularization., (Copyright © 2014 Elsevier Inc. All rights reserved.)

This study was planned to identify the determinants of outcome after coronary artery bypass (CABG) in young patients. Data on 592 patients aged ≤50 years who underwent CABG from 9 European institutions were collected retrospectively. Twenty-eight percent of patients received at least 2 arterial grafts. Clopidogrel was used at discharge in 16.2% and statins in 67.2% of patients. Freedom from major adverse cardiac and cerebrovascular events at 1, 3, and 5 years was 93.8%, 90.1%, and 85.0%; survival rate was 98.3%, 96.3%, and 94.9%; freedom from myocardial infarction was 96.3%, 95.1%, and 92.5%; and freedom from repeat revascularization was 96.3%, 95.1%, and 92.5%, respectively. Neither types of grafts nor medication at discharge had any impact on the late outcome. Age <40 years (relative risk [RR] 2.19, 95% confidence interval [CI] 1.17 to 4.11), diabetes (RR 1.71, 95% CI 1.02 to 2.88), estimated glomerular filtration rate <60 ml/min/1.73 m(2) (RR 2.44, 95% CI 1.26 to 4.72), non-ST-elevation myocardial infarction/ST-elevation myocardial infarction (RR 2.12, 95% CI 1.27 to 3.55), emergency procedure (RR 2.34, 95% CI 1.13 to 4.88), and left ventricular ejection fraction <30% (RR 3.18, 95% CI 1.41 to 7.16) were independent predictors of major adverse cardiac and cerebrovascular events. Patients with left ventricular ejection fraction <30% had a particularly poor survival rate (at 5 years 67.7% vs 96.1%; adjusted analysis RR 14.01, 95% CI 5.16 to 38.03). Poor left ventricular function, myocardial infarction, diabetes, renal failure, and age <40 years are major determinants of late outcome after CABG in young patients. In conclusion, data from this real-world registry indicate that multiple arterial grafts and statin treatment are largely underutilized in these patients., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The impact of blood transfusion on the development of post-operative stroke after coronary artery bypass grafting (CABG) is not well established. We, therefore, investigated this issue., Materials and Methods: Complete data on peri-operative blood transfusion were available for 2,226 patients who underwent CABG in three Finnish hospitals., Results: Stroke occurred post-operatively in 53 patients (2.4%). Logistic regression showed that pre-operative creatinine (OR 1.003, 95% CI 1.000-1.006), extracardiac arteriopathy (OR 2.344, 95% CI 1.133-4.847), pre-operative atrial fibrillation (OR 2.409, 95% CI 1.149-5.052), and the number of packed red blood cell units transfused (OR 1.121, 95% CI 1.065-1.180) were significantly associated with post-operative stroke. When the various blood product transfusions instead of transfused units were included in the multivariable analysis, solvent/detergent treated plasma (Octaplas) transfusion (OR 2.149, 95% CI 1.141-4.047), but not red blood cell transfusion, was significantly associated with postoperative stroke. Use of blood products ranging from no transfusion (stroke rate 1.6%) to combined transfusion of red blood cells, platelets and Octaplas was associated with a significant increase in post-operative stroke incidence (6.6%, adjusted analysis: OR 1.727, 95% 1.350-2.209). Patients who received >2 units of red blood cells, >4 units of Octaplas units and >8 units of platelets had the highest stroke rate of 21%. CART analysis showed that increasing amount of transfused Octaplas, platelets and history of extracardiac arteriopathy were significantly associated with post-operative stroke., Conclusions: Transfusion of blood products after CABG has a strong, dose-dependent association with the risk of stroke. The use of Octaplas and platelet transfusions seem to have an even larger impact on the development of stroke than red blood cell transfusions.

Objective: Whether aspirin should be discontinued before coronary artery bypass grafting is controversial. The potential benefits and harms associated with late use of aspirin (no discontinuation or discontinuation <3 days before surgery) were investigated in this retrospective, multicenter study., Design: Retrospective, multicenter study., Setting: Two university hospitals and one central hospital., Participants: A consecutive series of 859 patients who underwent elective coronary artery bypass grafting from January 2008 through December 2010., Interventions: Aspirin (100 mg/day) was used <3 days before surgery in 240 patients and was discontinued >3 days before surgery in 619 patients., Results: In the overall series, similar in-hospital mortality, amount of postoperative blood loss, rate of re-exploration for excessive bleeding, and use of blood products were observed in the study groups. However, aspirin discontinuation >3 days before surgery tended to be associated with a higher postoperative stroke rate (1.9% v 0.4%, p = 0.13). Such a trend was observed after off-pump (1.9% v 0%, p = 0.58) and on-pump (2.0% v 0.6%, p = 0.46) surgery. Among 153 pairs matched by the propensity score, patients with aspirin discontinued >3 days before surgery had a significantly higher rate of postoperative stroke (5.9% v 0.7%, p = 0.02) and tended to have a higher risk of the composite adverse outcome endpoint (19.6% v 12.4%, p = 0.09). The postoperative release of troponin I was similar in the study groups., Conclusions: Late or no discontinuation of low-dose aspirin before coronary artery bypass grafting may decrease the risk of postoperative stroke without increased postoperative bleeding and need for blood transfusion. These findings and the risk of cardiovascular events possibly occurring at the time of its discontinuation suggest that the use of aspirin until the day of elective coronary surgery may be beneficial., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Aim: The aim of this study was to evaluate whether pulmonary function as assessed by spirometry affects the immediate and late outcome after isolated coronary artery bypass surgery (CABG)., Methods: Data on preoperative percentages of the predicted forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were retrieved from a series of 1848 patients who underwent isolated CABG. Pulmonary disease was defined according to EuroSCORE criteria., Results: Logistic regression showed that percentage of predicted FVC was an independent predictor of in-hospital mortality along with estimated glomerular filtration rate, age and extracardiac arteriopathy. Cox regression analysis showed that pulmonary disease and percentages of predicted FVC were independent predictors of late overall mortality. Percentage of predicted FVC < 70% (at 10-year: 63.8% vs. 74.3%, Cox regression analysis: P = 0.014, RR 1.50, 95%C.I. 1.08-2.08) and pulmonary disease (at 10-year: 58.0% vs. 76%, Cox regression analysis: P < 0.0001, RR 1.75, 95%C.I. 1.29-2.39), but not percentage of predicted FEV1 < 70%, were associated with a marked decrease in late survival., Conclusion: This study confirmed the significant, negative prognostic impact of pulmonary disease on the immediate and long-term survival after isolated CABG.

Background: EuroSCORE is an adult cardiac surgery risk scoring method that is used worldwide, which has been shown to significantly overestimate the operative risk. We derived a new risk scoring method by modifying some of the risk factors included in the EuroSCORE algorithm and we validated it in an external database., Methods: This study included 4,014 patients who underwent adult cardiac surgery at the Heart Centre, Tampere University Hospital, Finland. Operative risk was estimated by EuroSCORE and its modified version., Results: In-hospital postoperative mortality rate was 3.2%. EuroSCORE (AUC for logistic EuroSCORE 0.82; 95% confidence interval (CI), 0.79-0.85) and modified score (AUC for logistic modified score 0.79; 95% CI, 0.75-0.83) performed well in predicting in-hospital mortality in this series. The mean logistic EuroSCORE was 8%, and the mean logistic modified score was 2.2%. Thus, the observed to expected ratio for in-hospital mortality was 0.4 for logistic EuroSCORE and 1.5 for logistic modified score. The difference between observed and predicted mortality rate matched correctly for increasing additive modified score, but not for EuroSCORE. The observed to predicted ratio in high-risk patients (within the 90th percentile of each risk algorithm) was 0.36 (13.2%/36.2% in 402 patients) for logistic EuroSCORE and 0.99 (14.7%/14.9% in 395 patients) for logistic modified score., Conclusions: This modified and simplified score, which includes most of EuroSCORE variables, seems to provide a more realistic estimation of postoperative mortality risk of patients undergoing any adult cardiac surgery.

Background: We have reviewed our experience with octogenarians undergoing coronary artery bypass grafting., Methods: A consecutive series of 274 patients age 80 years or greater out of 3,474 patients who underwent isolated coronary artery bypass grafting. We have assessed the intrinsic risk aged 80 years or greater by comparing them with a propensity score-matched cohort of younger patients with similar operative risk (other than age)., Results: Thirty-day mortality (4.7% vs 1.3%, p<0.0001), combined adverse event rates (13.1% vs 6.6%, p<0.0001), and five-year survival (76.6% vs 90.4%, p<0.0001) were significantly poorer among patients aged 80 years or greater as compared with younger patients. These figures were, however, better than estimates of a recent systematic review by McKellar and colleagues (McKellar SH, Brown ML, Frye RL, Schaff HV, Sundt TM III. Comparison of coronary revascularization procedures in octogenarians: a systematic review and meta-analysis. Nat Clin Pract Cardiovasc Med 2008;5:738-46) (30-day mortality 7.2%, and five-year survival, 68%). When octogenarians were compared with 273 propensity score-matched patients aged less than 80 years, the 30-day mortality (4.8% vs 2.6%, p=0.17) and combined adverse event rates (13.2% vs 10.6%, p=0.36) did not significantly differ. Five-year survival, despite statistical significance, was not remarkably lower than that of propensity-matched patients aged less than 80 years (77.0% vs 81.3%, p=0.009). The decrease in survival of octogenarians was evident only during the first few months after surgery, but not later on., Conclusions: The results of this study suggest that immediate and five-year survival of octogenarians undergoing coronary artery bypass grafting may be even better than previously estimated. Survival of octogenarians may be suboptimal only during the first few months after surgery, whereas at five years may not differ remarkably from younger patients with otherwise similar operative risk., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To review our results with the use of miniaturized cardiopulmonary bypass (Mini-CPB) versus conventional cardiopulmonary bypass (C-CPB) in high-risk patients (additive EuroSCORE>or=6) who have undergone coronary artery bypass graft surgery (CABG)., Patients and Methods: This study includes a consecutive series of 236 patients with an additive EuroSCORE>or=6 who underwent CABG, employing either C-CPB or Mini-CPB. Propensity score analysis was performed., Results: The study groups had similar EuroSCOREs. Stroke rate was significantly higher among C-CPB patients (5.4% vs. 0%, p=0.026). In-hospital mortality (4.8% vs. 3.4%, p=0.75) and combined adverse end-point rate were higher in C-CPB patients (20.4% vs. 13.5%, p=0.18). Postoperative bleeding and need for transfusion were similar in the study groups, but re-sternotomy for bleeding was more frequent among C-CPB patients (4.8% vs. 1.1%, p=0.26). Seventy-four propensity matched pairs had similar immediate postoperative results: C-CPB patients had higher mortality (6.8% vs. 4.1%, p=0.72), stroke (5.4% vs. 0%, p=0.12) and combined adverse end-point rates (27.0% vs. 16.2%, p=0.11), but such differences failed to reach statistical significance., Conclusions: Mini-CPB achieved somewhat better results than C-CPB in these high-risk patients undergoing isolated CABG. This study confirmed that cerebral protection could be the main benefit associated with the use of Mini-CPB.

Objective: We derived a new risk-scoring method by modifying some of the risk factors included in the EuroSCORE algorithm., Methods: This study includes 3613 patients who underwent cardiac surgery at the Vaasa Central Hospital, Finland. The EuroSCORE variables, along with modified age classes (< 60 years, 60-69.9 years, 70-79.9 years and > or = 80 years), eGFR-based chronic kidney disease classes (classes 1-2, class 3 and classes 4-5) and the number of cardiac procedures, were entered into the regression analysis., Results: An additive risk score was calculated according to the results of logistic regression by adding the risk of the following variables: patients' age classes (0, 2, 4 and 6 points), female (2 points), pulmonary disease (3 points), extracardiac arteriopathy (2 points), neurological dysfunction (4 points), redo surgery (3 points), critical preoperative status (8 points), left ventricular ejection fraction (> 50%: 0; 30-50%: 2 and < 30%: 3 points), thoracic aortic surgery (8 points), postinfarct septal rupture (9 points), chronic kidney disease classes (0, 3 and 6 points), number of procedures (1: 0; 2: 2 and 3 or more: 7 points). The modified score had a better area under the receiver operating characteristic curve (additive: 0.867; logistic: 0.873) than the EuroSCORE (additive: 0.835; logistic: 0.840) in predicting 30-day postoperative mortality. The modified score, but not EuroSCORE, correctly estimated the 30-day postoperative mortality., Conclusion: EuroSCORE still performs well in identifying high-risk patients, but significantly overestimates the immediate postoperative mortality. This study shows that the score's accuracy and clinical relevance can be significantly improved by modifying a few of its variables. This institutionally derived risk-scoring method represents a modification and simplification of the EuroSCORE and, likely, it would provide a more realistic estimation of the mortality risk after adult cardiac surgery.

Objectives: We evaluated the impact of aortic cross-clamping time (XCT) and cardiopulmonary bypass time (CPBT) on the immediate and late outcome after adult cardiac surgery and attempted to identify their safe time limits., Methods: This study includes 3280 patients who underwent adult cardiac surgery of various complexities. Myocardial protection was achieved with tepid continuous antegrade/retrograde blood cardioplegia., Results: Receiver operating characteristics (ROC) curve analysis showed that XCT (area under the curve, AUC: 0.66), CPBT (AUC: 0.73) and CPBT with unclamped aorta (AUC: 0.77) were significantly associated with 30-day postoperative mortality. XCT of increasing 30-minute intervals (Odds Ratio (OR) 1.21, 95%C.I. 1.01-1.52) and CPBT of increasing 30-minute intervals (OR 1.47, 95%C.I. 1.27-1.71) were independent predictors of 30-day mortality. The best cutoff value for XCT was 150 min (30-day death: 1.8% vs. 12.2%, adjusted OR 3.07, 95%C.I. 1.48-6.39, accuracy 91.5%) and for CPBT 240 min (30-day death: 1.9% vs. 31.5%, adjusted OR 8.78, 95%C.I. 4.64-16.61, accuracy 96.0%). These parameters were significantly associated also with postoperative morbidity, particularly with postoperative stroke., Conclusions: XCT and CPBT are predictors of immediate postoperative morbidity and mortality. In our experience, cardiac procedures with CPBT<240 min and XCT<150 min were associated with a rather low risk of immediate postoperative adverse events independently of the complexity of surgery patient's operative risk.

Aim: The aim of this study was to evaluate the impact of preoperative cardiac function and haemodynamic parameters on the immediate outcome after repair of ruptured abdominal aortic aneurysm (RAAA)., Methods: This is a retrospective review of 68 consecutive patients who underwent emergency repair of RAAA. Baseline pulmonary artery pressure, cardiac index, oxygen saturation and pulse rate were measured and recorded immediately after insertion of a pulmonary artery thermodilution catheter and before anaesthesia induction., Results: The in-hospital mortality rate was 39.7%. The area under the receiver operating characteristic (ROC) curve of cardiac index was 0.74 (95% CI 0.61-0.86), of stroke volume index was 0.78 (95% CI 0.67-0.89) and for oxygen delivery 0.72 (95% CI 0.60-0.84) for prediction of in-hospital death. The best cut-off values of cardiac index was 2.7 l/min/m(2) (18.8% vs. 58.3%, OR 6.07, 95% CI 2.00-18.37), of stroke volume index was 27 ml/m(2) (23.1% vs. 62.1%, OR 5.46, 95% CI 1.90-15.70) and of oxygen delivery was 370 ml/min/m(2) (17.9% vs. 56.4%, OR 5.05, 95% CI 1.87-18.91). Multivariate analysis showed that patient's age (P=0.01, OR 1.23, 95% CI 1.05-1.44), stroke volume index (P=0.018, OR 0.89, 95% CI 0.81-0.98), and shock (P=0.007, OR 14.20, 95% CI 2.09-96.67) were independent predictors of in-hospital death., Conclusions: This study suggests that impaired cardiac function and suboptimal oxyhaemodynamic parameters are important determinants of death after repair of RAAA.

Background and Aim of the Study: The study aim was to evaluate whether pulmonary function, as assessed by spirometry, affects immediate outcome after aortic valve replacement (AVR)., Methods: Data relating to the preoperative percentages of predicted forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) were retrieved from a series of 453 patients who underwent AVR, with or without coronary artery bypass surgery., Results: The percentage of predictive FVC (odds ratio (OR) 0.952; 95% CI 0.914-0.990; AUC 0.749; p = 0.019), but not of predicted FEV1, nor any history of pulmonary disease, proved to be independent predictors of in-hospital mortality, even when adjusted for the logistic EuroSCORE. A percentage predictive FVC of < 80% proved to be the best cut-off (in-hospital mortality 6.3% versus 1.3%; p = 0.005; OR 5.100; 95% CI 1.544-16.849; specificity 69%, sensitivity 69%). The percentage of predictive FVC was found to be an independent predictor of stroke (OR 0.956; 95% CI 0.923-0.989; p = 0.009). Patients with a percentage of predictive FVC < 80% had a risk of postoperative stroke of 6.9% versus 1.9% among those patients with better FVC values (OR 3.769; 95% CI 1.342-10.581; p = 0.012). Patients with a percentage of predictive FVC < 80% (10.4% versus 4.2%; OR 2.648; 95% CI 1.225-5.724; p = 0.011) and a history of pulmonary disease (13.1% versus 5.1%; OR 2.808; 95% CI 1.117-6.694; p = 0.016) had a significantly higher risk of an intensive care unit stay of five or more days. Postoperative pneumonia was not associated with either spirometric parameters, nor with any history of pulmonary disease., Conclusion: Pulmonary disease, as indicated by decreased preoperative values of FVC and FEV1, is an important comorbidity factor in patients undergoing AVR surgery. Further studies are required to demonstrate whether the identification and treatment of these patients could improve their outcome after AVR.

Objectives: To assess the health related quality of life (HRQoL) and the change in the NYHA class after coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in the management of stable coronary artery disease (CAD). The study was non-randomized. CABG group consisted of 240 patients and 229 patients were treated with PCI. HRQoL was measured prospectively by the 15D instrument., Results: Three-year survival was 95.0 and 95.6% (NS). The HRQoL improved statistically in both groups until 6 months after treatment but deteriorated towards the end of the follow-up of 36 months. Clinically evident improvement of the HRQoL and decrease of the NYHA class took place more frequently among CABG patients., Conclusions: Despite initially more serious preoperative state and more demanding procedure CABG patients achieve equal level of HRQoL when compared with PCI patients. CABG patients may also obtain better relief from symptoms in mid-term follow-up. HRQoL cannot be the only factor to determine outcome after invasive treatment of CAD but it has to be placed in the context of the overall situation.

Objectives: We wanted to identify determinants for postoperative delirium and its influence on health related quality of life (HRQoL) during 36-month follow-up of coronary artery bypass (CABG) patients., Design: A total of 302 patients were retrospectively analyzed. HRQoL was assessed prospectively by the 15D instrument. Delirium was diagnosed clinically., Results: The incidence of delirium was 6.0%. The cumulative survival (all-cause death) in 36 months was 96.1% in patients without delirium and 77.8% in patients with delirium. Age, cerebral disease, chronic heart failure, male gender, postoperative pneumonia and low output syndrome were predictors for delirium. Delirium patients needed more resources i.e. intensive care or total duration of hospitalization and experienced no positive change in HRQoL. Moreover patients with high preoperative 15D score tended to suffer fairly severe but reversible impairment during the first 6 months after the operation., Conclusions: Preoperatively older and sicker patients with complicated postoperative course are at higher risk of developing delirium after CABG. Preoperative status and operative complications together with delirium may exert negative influence on forthcoming HRQoL, which is seen especially in patients with a relatively high preoperative level of HRQoL.

Three hundred and two patients were evaluated for the EuroSCORE risk and health-related quality of life (HRQoL) during three years after CABG as assessed by the 15D instrument. Both additive and logistic EuroSCORE correlated significantly with the 15D score at 6, 18 and 36 months. A clinically important increase > or =0.03 in the 15D score was achieved by 50.6% of patients at 6 months, 40.0% at 18 months and 35.9% at 36 months. The rates were similar among patients with increasing EuroSCORE at 6 and 18 months, but tended to decrease at 36 months in the highest EuroSCORE group (EuroSCORE 0-2: 46.8%; 3-5: 34.8%; and 6-14: 33.3%, respectively, P=0.13). Both additive (area under the receiver operating characteristic curve, AUC: 0.582, P=0.024) and logistic EuroSCORE (AUC: 0.575, P=0.039) were predictors of a significant increase of the 15D score. The best cut-off value of the additive EuroSCORE for prediction of a clinically important improvement of the 15D score during 3-year follow-up was 3, as 46.7% of patients with EuroSCORE 0-3 and 30.1% of patients with a score >3 (P=0.006) improved clinically. The present study showed that the EuroSCORE also predicts long-term HRQoL after CABG.

Objective: The aim of the present study was to evaluate the change in health related quality of life (HRQoL) among elective coronary artery bypass grafting (CABG) patients., Methods: A total of 302 CABG patients were included in the study. Complete pre-, peri- and postoperative data were collected comprehensively in a database. HRQoL was measured by the 15D instrument. The 15D is a non-disease-specific, 15-dimensional, standardized and self-administered measure of HRQoL that can be used both as a profile and single index score measure. Baseline assessment was carried out before coronary angiography and assessment was repeated 6 and 18 months after surgery. Data were analysed by gender and in three age groups, i.e. patients <65 years, 65-74 years and > or = 75 years., Results: Thirty day mortality was 1.0%, and the survival rate at 6 and 18 months was 99.0% and 96.7%, respectively. Preoperative HRQoL of CABG patients was lower in comparison to age- and gender-standardized Finnish population (P<0.001). HRQoL of the patients improved significantly after CABG and the positive change lasted over the whole observation period, despite a slight decrease of 15D scores until 18 months. Although male patients had a higher preoperative HRQoL than women (P=0.005), both genders benefited similarly from the operation. In the patients > or = 75 years, the initial improvement of HRQoL returned to the preoperative level 18 months after the surgery., Conclusions: CABG patients experience a significant improvement in their HRQoL within 6 months after the operation and the effect remains through a mid-term observation time. However, expectations of improved HRQoL may have a limited value in decision making for surgery of coronary artery disease (CAD) for patients more than 75 years old.

Background and Aims: Stroke has remained one of the most frustrating complications in coronary artery bypass surgery (CABG). The purpose of this study was to describe the incidence and correlates of stroke in CABG patients operated on in a hospital with low annual volume of open-heart surgery procedures. The aim was moreover to clarify subsequent outcome and self-reported satisfaction-based quality of life of patients who had experienced a stroke., Material and Methods: The material was a cohort of 1318 consecutive CABG patients operated on over a 6-year period. Data was collected prospectively but the final analysis was retrospective. Questionnaires supplemented the estimation of survival and subsequent functional status., Results: The incidence of stroke was 2.6 %. Age > 70 years, chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), cerebral vascular disease (CVD), number of aortic anastomoses and significant atherosclerosis of the ascending aorta were univariate predictors of stroke. Postoperative stroke was experienced in 55.9% of cases delayed appearing from 2nd postoperative day on. Stroke patients had a higher rate of mortality (14.7% vs. 1.0%, p = 0.001) and poorer survival than no-stroke patients (82.4% and 97.4% at one year and 61.2% and 89.7% at six years, p < 0.001)., Conclusions: The incidence of stroke seems to be on the same level in CABG patients from a low volume hospital as in reports from centres with a high volume of annual procedures. Stroke predicts higher mortality, longer intensive care unit (ICU) stay, longer hospitalisation and poorer survival. A relatively high number of stroke patients need permanent institutional care. Satisfaction-based quality of life in CABG patients also remains on a lower level in comparison to patients without neurological complications.

Background and Aims: Understanding and objective assessment of risks is crucial in cardiac surgery. The aim of this study was to assess the influence of peripheral vascular disease (PVD) on morbidity, mortality and outcome in coronary artery bypass grafting (CABG) patients., Material and Methods: The ankle-brachial pressure index (ABPI) was used as indicator of PVD and was measured in 178 CABG patients. Two groups were established: 1. normal ABPI (0.9-1.3) (n = 136) and 2. lowered ABPI (< 0.9) (n = 35). The mean follow-up was 26 months., Results: The presence of PVD was 20.5 %. Patients with PVD were older (p < 0.05), more often of female sex (p < 0.05), had higher Higgins's risk score (p = 0.001) and more often intermittent claudication (IC) (p < 0.001). PVD significantly predicted atrial fibrillation (FA) (p < 0.05) and relatively postoperative myocardial infarction (MI) (p = 0.058)., Conclusions: The presence of PVD is relatively high in CABG patients and increases with age. PVD predicts some morbidity but seems to have fairly little influence on short-term or middle-term outcome of CABG patients. ABPI may be of only limited value in identifying patients with high operative risk in CABG.

Objective: The goal of this study was to assess the effects of a combination of glucose-insulin-potassium (GIK) and the amino acids aspartate and glutamate upon perioperative hemodynamics in coronary surgery patients with unstable angina and/or compromised left ventricular function., Design: Prospective, randomized, and double-blind clinical study., Setting: Operating theatre and intensive care unit (ICU) of a university hospital., Patients: 44 coronary artery bypass graft (CABG) patients with unstable angina and/or compromised left ventricular function., Interventions: 22 patients (group A) were given 1l of an infusion with 250g glucose, 100 I.U. fast-acting human insulin, 72 mmol potassium, 32 mmol magnesium, 20 mmol phosphate, 65 mmol aspartate, and 65 mmol glutamate, while another 22 patients (group C) were given 1l of an infusion with 50 g glucose, 72 mmol potassium, 32 mmol magnesium, and 8 mmol phosphate. The infusion rate was 1.2 ml/kg/h from the anesthesia induction onward to the commencement of cardiopulmonary bypass, when it was reduced to 0.8 ml/kg/h. When 11 had been infused, but not later than 4 a.m., the infusion was continued by giving 10% glucose at the same rate to both groups. Additional insulin (median: 14.2 I.U., range: 0-41.5) or saline was given during bypass to the A and C patients, respectively. A blood cardioplegia technique containing aspartate and glutamate was used in both groups., Results: At aortic cannulation, the cardiac index (CI) had increased from the pre-anesthetic level by 15.3% (mean) (SD: 31.7%) in group A and decreased by 7.7% (15.1%) in C patients, p = 0.0069. Also the changes in stroke index (SI; p = 0.022), left (LVSWI; p = 0.0037) and right ventricular stroke work index (RVSWI; p = 0.0097) were more favorable in group A. Despite longer aortic cross-clamp, p = 0.031, and perfusion times, p = 0.042, in A patients, the change in cardiac index was also better in this group after bypass: At decannulation, the difference between mean values was 31.8%, p = 0.0001, and at arrival in the ICU it was 16.1%, p = 0.028. The same was also seen 8 h postoperatively and on the 1st and 2nd postoperative mornings; p = 0.034, 0.040, and 0.037, respectively (Wilcoxon test). Favorable changes were seen for the A patients also regarding SI at decannulation (p = 0.0002) and after 8 h (p = 0.017); LVSWI at decannulation (p = 0.0002), at arrival in the ICU (p = 0.0023), and after 8 h (p = 0.0011); and RVSWI at decannulation (p = 0.0027), at the ICU (p = 0.021), after 8 h (p = 0.014), and on the 1st postoperative morning (p = 0.039). However, the response to a hemodynamic loading test (6% hydroxyethyl starch 5 ml/kg) was similar in the 2 groups, and there was no difference in the need for inotropic support., Conclusions: Amino acid-enriched GIK infusion improves hemodynamic function in CABG patients with unstable angina and/or compromised left ventricular function.

Magnesium may be beneficial in the control of ventricular ectopy and supraventricular tachyarrhythmias after coronary artery bypass graft (CABG) surgery, but it is not known whether a high-dose magnesium regimen is superior to a regimen keeping the patient normomagnesemic. A prospective randomized and double-blind clinical comparison was performed in 81 elective CABG patients in order to assess the effects of two different magnesium infusion regimens on electrolyte balance and postoperative arrhythmias. Forty-one patients (high-dose group, H) received 4.2 +/- 0.7 g (mean +/- SD), of magnesium sulfate before cardiopulmonary bypass, followed by an infusion of 11.9 +/- 2.8 g of magnesium chloride until the first postoperative (PO) morning, and a further 5.5 +/- 1.0 g until the second PO morning. Forty patients (low-dose group, L) received magnesium sulfate only after bypass to a total of 2.9 +/- 0.5 g at the first, and 1.4 +/- 0.1 g at the second PO morning. A blood cardioplegia technique was used in both groups, including bolus doses of magnesium chloride to a total of 2.4 +/- 0.6 g and 2.3 +/- 0.6 g to H and L patients, respectively. Continuous Holter tape-recording was used for 12 to 15 hours preoperatively, and for 48 hours postoperatively. Serum magnesium peaked in H patients on the first PO morning at 1.60 +/- 0.25 mmol/L, whereafter it declined to the normal level on the third PO morning. Patients in the L group were normomagnesemic, except after the start of bypass.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: The goal of this study was to examine the metabolic and hemodynamic effects of a glucose-insulin-potassium infusion in elective coronary surgery, when blood cardioplegia was used for cardiac protection., Design and Patients: A prospective, randomized, open, clinical comparison was performed between 2 perioperative infusion regimens in 40 elective nondiabetic coronary artery bypass graft (CABG) surgery patients., Setting and Interventions: 20 patients (glucose-insulin-potassium-GIK-group) received glucose 0.2 g/kg/h, insulin 0.12 U/kg/h, potassium 0.15, magnesium 0.032 and phosphate 0.024 mmol/kg/h from anesthesia induction to the start of bypass, when infusion rate was reduced to 30%, and after bypass increased to 50% of the initial rate. The infusion was continued until the first postoperative morning. Another 20 patients (control-R-group) received glucose 0.05 g/kg/h, potassium 0.075, magnesium 0.016 and phosphate 0.008 mmol/kg/h from the end of bypass to the next morning. Pump prime was glucose-free and a blood cardioplegia technique was used for cardiac protection., Results: The GIK patients needed less dopamine support in the intensive care unit (ICU) (p < 0.05). No difference was found between the groups with regard to myocardial injury, the MB-fractions of serum creatine kinase (CK-MB) being elevated to a similar degree in both groups. Likewise there were no significant differences in hemodynamic changes or duration of ICU stay. Although the glucose infusion was continued during bypass in the GIK patients, there was a considerable risk of hypoglycemia (due to insulin and hemodilution) after the onset of bypass: in 5 GIK patients (25%; 95% confidence interval 8.7 to 49.1%) blood glucose was less than 2 mmol/l. However, the hypoglycemia was of short duration and no detrimental effects were seen., Conclusions: Perioperative GIK infusion entailed a slight decrease in the postoperative need for dopamine support, but was connected with a considerable risk of hypoglycemia.

Perioperative GIK therapy has been advocated to ensure adequate energy substrate levels during cardiac surgery. However, hyperglycemia should be avoided because it may worsen neurologic outcome after cerebral ischemia. A prospective, randomized, clinical comparison was performed between two prebypass infusion regimens in 32 elective nondiabetic CABG patients. Sixteen patients (GIK group) received glucose, 0.6 g/kg/h, insulin, 0.12 U/kg/h, and KCl, 0.12 mmol/kg/h, from the induction of anesthesia to the start of CPB; while the remaining 16 patients (R group) received only Ringer's acetate. The pump prime was glucose free and a blood cardioplegia technique was used in both groups. No differences were found between the groups with regard to myocardial injury; the CK-MB enzyme fractions were elevated to a similar degree and the frequency of postoperative ECG changes were similar in both groups. Likewise, there were no differences in hemodynamic changes, need for inotropic support, arrhythmia frequency, or duration of ICU stay. The GIK patients had higher blood glucose (P < 0.05) and insulin levels (P < 0.01); blood glucose increased to 12.4 +/- 5.4 mmol/L (mean +/- SD) at cannulation, with a drop after starting bypass. Interindividual variation in GIK patients was great, with glucose values ranging between 20.1 mmol/L at cannulation to 2.0 mmol/L after starting CPB. A hyperglycemic response was seen in both groups during rewarming: 15.0 +/- 4.2 and 15.0 +/- 3.1 mmol/L in GIK and R patients, respectively. It is concluded that prebypass GIK infusion had no clinical benefits for elective CABG patients as compared to Ringer's acetate.(ABSTRACT TRUNCATED AT 250 WORDS)