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Previous studies have demonstrated superior patency of no-touch as compared to conventional saphenous vein grafts in coronary artery bypass grafting. We aimed to compare mid-term clinical outcomes of both techniques in a large cohort of routine patients. We identified all patients undergoing non-emergent primary coronary artery bypass grafting with either no-touch or conventional saphenous vein grafts at our institution between 2000 and 2020. Propensity score matching was used to create adjusted cohorts based on 5,288 eligible patients. The primary outcome was the combined endpoint of all-cause mortality and repeat revascularization. Secondary outcomes were individual rates of all-cause mortality and repeat revascularization, surgical complications, and short-term mortality. Propensity score matching resulted in cohorts of no-touch (n=923) and conventional (n=923) saphenous vein grafted patients with comparable baseline characteristics. Mean follow-up time was significantly shorter for the no-touch compared to the conventional cohort (4.9 ± 2.3 versus 8.3 ± 2.6 years, p< 0.001). Up to seven-year follow-up, neither the rate of the primary composite endpoint nor death differed significantly between the cohorts. The rate of repeat revascularization was significantly higher in patients in the no-touch cohort (12.9% versus 9.3% at seven-year follow-up, p=0.022. Post-hoc analysis of percutaneous coronary intervention during follow-up revealed comparable rates of saphenous vein graft failure (no-touch 42/923 (4.6%) versus conventional 32/923 (3.5%), p=0.286). In this large propensity score matched registry study, coronary artery bypass with no-touch compared to conventional saphenous vein grafting did neither enhance mid-term survival nor reduce the rate of repeat revascularization.

Background A recent article provided compelling evidence for a cardioprotective effect of afternoon compared with morning operation in patients undergoing aortic valve replacement. The present study sought to investigate any daytime-dependent effect on perioperative myocardial injury or clinical outcomes in a large cohort of patients undergoing elective cardiac surgery. Methods The study identified all patients who underwent nonemergency aortic valve replacement and/or on-pump coronary artery bypass grafting at the Department of Cardiothoracic and Vascular Surgery of Aarhus University Hospital, Aarhus, Denmark between 1999 and 2018. Propensity-score matching was used to create adjusted cohorts for morning and afternoon operation. The primary end point was a composite of 30-day mortality and in-hospital acute myocardial infarction (major adverse cardiac events). Secondary end points were new-onset in-hospital atrial fibrillation, peak creatine kinase-MB levels, and up to 19 years of follow-up for all-cause mortality. Results The study identified 7148 patients who underwent either aortic valve replacement with or without coronary artery bypass grafting (n = 2806) or isolated coronary artery bypass grafting (n = 4342). Propensity-score matching resulted in comparable cohorts of morning and afternoon operation. The morning and afternoon operation cohorts had no differences in the rates of major adverse cardiac events after both procedures. Similarly, no daytime-dependent variation in the rate of new-onset in-hospital atrial fibrillation, long-term all-cause mortality, or peak creatine kinase-MB levels could be identified. Conclusions In this large cohort study of Danish patients, who underwent either aortic valve replacement and/or coronary artery bypass grafting, the study identified no clinically relevant biorhythm for myocardial ischemia-reperfusion tolerance.

OBJECTIVES: Evaluation of 3-year clinical outcome of hybrid myocardial revascularization (HMR) compared to conventional revascularization strategies in patients with multivessel coronary artery disease involving the proximal left anterior descending artery. Design. Retrospective matched cohort study based on a prospective feasibility study including 103 elective patients undergoing staged HMR from October 2010 until February 2012. The Western Denmark Heart Registry was used to identify patients who underwent coronary artery bypass grafting (CABG) and multivessel percutaneous coronary intervention (PCI) by matching on number of diseased vessels, age and comorbidity score. Primary endpoint was the composite rate of major adverse cardiovascular and cerebrovascular events (MACCE) at 3-year follow-up. Secondary endpoints included individual MACCE components, acute kidney injury, and cardiovascular readmissions. Results. There was no difference between MACCE in the three groups (HMR 31.1%; CABG 20.4%; PCI 20.4%, p = .11). Estimates of repeat revascularization were significantly increased with HMR versus CABG. In the CABG group, fewest patients required cardiovascular readmissions though with the highest incidence of acute kidney injury. Conclusions. HMR was not superior with respect to MACCE compared with CABG and PCI. It may, however, represent a safe alternative to conventional revascularization treatment considering the specific procedure-associated morbidity.

Introduction: Acute kidney injury following cardiac surgery is a frequent complication associated with increased mortality and morbidity. Minimal invasive extracorporeal circulation is suggested to preserve postoperative renal function. The aim of this study was to assess the impact of minimal invasive versus conventional extracorporeal circulation on early postoperative kidney function. Methods: Randomized controlled trail including 60 patients undergoing elective stand-alone coronary artery bypass graft surgery and allocated in a 1:1 ratio to either minimal invasive (n = 30) or conventional extracorporeal circulation (n = 30). Postoperative kidney injury was assessed by elevation of plasma neutrophil gelatinase-associated lipocalin (NGAL), a sensitive tubular injury biomarker. In addition, we assessed changes in estimated glomerular filtration rate (eGFR), and the incidence of acute kidney injury according to the Acute Kidney Injury Network (AKIN) classification. Results: We observed no differences between groups regarding increase of plasma NGAL (p = 0.31) or decline of eGFR (p = 0.82). In both groups, 6/30 patients developed acute kidney injury according to the AKIN classification, all regaining preoperative renal function within 30 days. Conclusion: Our findings challenge the superiority of minimal invasive compared to conventional extracorporeal circulation in terms of preservation of renal function following low-risk coronary surgery.

INTRODUCTION: Anaemia is common after cardiac surgery and has a negative impact on rehabilitation and patient well-being. We aim to compare the efficacy of single, high-dose intravenous iron therapy versus oral iron supplementation to correct anaemia following open cardiac surgery.METHODS: We present a randomised, active-control superiority trial. Adult patients with moderate anaemia (haemoglobin 5.0-6.8 mmol/l) on the first post-operative day after first-time, non-emergent cardiac surgery are eligible. After stratification by gender, 110 patients are randomised 1:1 to either single, high-dose intravenous iron therapy (20 mg/kg ferric derisomaltose) or oral iron supplementation (100 mg ferrous sulphate orally twice daily). The primary outcome measure at the four-week follow-up is the proportion of participants who are neither anaemic (haemoglobin less-than 8.1 mmol/l in men and less-than 7.5 mmol/l in women) nor have received allogeneic red blood cells since randomisation. Secondary outcome measures include changes in haemoglobin and iron biomarkers, exercise capacity, patient-reported outcome measures and cost of care at the four-week follow-up.CONCLUSION: The results of the PICS trial may fundamentally alter future management of anaemia following cardiac surgery.FUNDING: The study is supported by Aarhus University Hospital, an unrestricted research grant by Pharmacosmos A/S (Holbæk, Denmark) and an independent grant from the Health Research Foundation of the Central Denmark Region (ISM).TRIAL REGISTRATION: EudraCT number: 2020-001389-12; Clinical Trials ID: NCT04608539.

OBJECTIVES Isolated tricuspid valve (TV) surgery is rarely performed and has been associated with high mortality and morbidity. The aim of this study was to describe the clinical outcome and functional capacity following isolated TV surgery in contemporary practice. METHODS We conducted a retrospective cohort study including all patients who underwent isolated TV surgery at our institution from 2013 to 2019. Our cohort was identified using the Western Denmark Heart Registry. Postoperative outcomes were evaluated using patients’ medical records. The clinical and echocardiographic status was reported for patients who survived beyond 1 year. RESULTS We included 43 patients [mean age 65.2 ± 13.8, median European System for Cardiac Operative Risk Evaluation II 1.8 (interquartile range 2.0)]. Twelve (27.9%) had prior cardiac surgery. Up to 90-day follow-up, no patient died and major morbidity was limited to 4 patients (9.3%) requiring pacemaker implantation and 1 patient requiring 2 reoperations. Within 1 year, 4 patients (9.3%) died. Nine patients (20.1%) required single readmission for cardiac reasons during the median follow-up of 38.4 months (interquartile range 30.9 months). All patients who survived beyond 1 year (n = 39) completed clinical follow-up. At follow-up, 38/39 (97.4%) patients were New York Heart Association I or II compared to 12/39 (30.8%) preoperatively (P = 0.001). The presence of oedema and intensity of diuretic treatment were significantly reduced (P = 0.005 and P = 0.008, respectively). Echocardiographic follow-up showed significant improvement of TV dysfunction in all patients. CONCLUSIONS Our results suggest that isolated TV surgery can be performed safely and greatly improve patients’ functional status. Our findings support the importance of optimal surgical timing and patient selection.

OBJECTIVE: To describe the associations among preoperative characteristics, intraoperative and postoperative factors, and mortality and morbidity after open-heart surgery in patients age ≥80 years.METHODS: This retrospective multicenter register study was based on prospectively collected data of all patients age ≥80 years undergoing open-heart surgery in western Denmark between 1999 and 2016. Logistic regression was used to estimate the associations among preoperative characteristics, intraoperative and postoperative factors, and morbidity and mortality. Bonferroni correction was used for multiple comparisons.RESULTS: The study population included 2342 patients age ≥80 years undergoing open-heart surgery. We observed an association between severely impaired preoperative renal function and death within 1-year postsurgery (odds ratio [OR], 4.6; 95% confidence interval [CI], 2.7-7.2). Furthermore, renal clearance 180 minutes were associated with a >50% probability of death within 1 year. The adjusted OR for death within 1 year was increased significantly with a postoperative length of stay in intensive care of ≥3 days (OR, 5.9; 95% CI, 4.1-8.6) and a duration of postoperative mechanical ventilation ≥2 days (OR, 7.5; 95% CI, 4.1-13.9). Various preoperative and intraoperative characteristics were associated with in-hospital dialysis, in particular cardiopulmonary bypass time >180 minutes (OR, 11.6; 95% CI, 4.7-28.5).CONCLUSIONS: Our findings emphasize the importance of careful referral regarding the procedural burden for very elderly patients and may provide support for informed patient discussions about prognosis and recovery.

Background: In coronary artery bypass grafting (CABG), the use of fractional flow reserve (FFR) is insufficiently investigated. Stenosis assessment usually relies on visual estimates of lesion severity. This study evaluated health-related quality of life (HRQoL) and angina after FFR- versus angiography-guided CABG. Methods: One hundred patients referred for CABG were randomized to FFR- or angiography-guided CABG. In the FFR group, lesions with FFR>0.80 were deferred, while the surgeon was blinded to the FFR values in the angiography group. Before and 6 months after CABG, HRQoL was assessed by the health state classifier EQ-5D of the EuroQoL 5-level instrument and angina status based on the Canadian Cardiovascular Society classification system were registered. Results: Six-month angiography included FFR evaluations of deferred lesions. In total, completed EQ-5D of the EuroQoL 5-level instrument questionnaires were available in 86 patients (43 in the FFR versus 43 in the angiography-guided group). HRQoL was significantly improved and angina significantly decreased from baseline to 6 months after CABG with no difference between the randomization groups. Graft failure rates and clinical outcomes were similar in both groups. Patients with graft failure or FFRP =0.004) and more angina compared with patients without graft failure or FFR≥0.80 at 6-month follow-up. Conclusions: FFR- versus angiography-guided CABG demonstrated similar improvements in HRQoL and angina 6 months after CABG. Graft failure or low FFR in deferred lesions were associated with low HRQoL and angina. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02477371

Evaluation of 3-year clinical outcome of hybrid myocardial revascularization (HMR) compared to conventional revascularization strategies in patients with multivessel coronary artery disease involving the proximal left anterior descending artery.

OBJECTIVES To evaluate the cost-effectiveness and safety of simultaneous hybrid coronary revascularization (sHCR) compared to conventional coronary artery bypass grafting (CABG) in elective patients with multivessel coronary artery disease. METHODS Cost–utility analysis of a prospective cohort follow-up study comparing per protocol 50 sHCR patients to 50 contemporaneous matched patients undergoing CABG. Resource utilization data and health-related quality of life were collected prospectively, and the cumulative 1-year costs were assessed from the Danish health sector perspective. Effectiveness was measured by quality-adjusted life years using EuroQol-5D. Probabilistic sensitivity analyses using bootstrapping were conducted. Secondary safety measures including early clinical outcomes and freedom from major adverse cardiac or cerebrovascular events at 1 year were assessed. RESULTS The clinical trial was discontinued prematurely due to safety reasons after inclusion of 50 patients (24 sHCR; 26 CABG), as the chest tube output and the risk of postoperative pleural effusions requiring thoracocentesis were significantly increased following sHCR compared with CABG. Based on 48 patients available for 1-year follow-up, both treatment strategies were similarly effective (quality-adjusted life year difference between the groups −0.019), with a net cost difference in favour of conventional CABG estimated to be €2173 per patient. Exclusion of 1 outlier patient with chronic renal failure and deep sternal wound infection in the sHCR group resulted in an equalization of the total 1-year costs. CONCLUSIONS At 1 year, sHCR was less cost-effective than conventional CABG and associated with higher chest tube output and a higher risk of postoperative pleural effusions requiring thoracocentesis. Clinical trial registration NCT01496664.

The SWEDEGRAFT study (ClinicalTrials.gov Identifier: NCT03501303) tests the hypothesis that saphenous vein grafts (SVGs) harvested with the “no-touch” technique improves patency of coronary artery bypass grafts compared with the conventional open skeletonized technique. This article describes the rationale and design of the randomized trial and baseline characteristics of the population enrolled during the first 9 months of enrollment. The SWEDEGRAFT study is a prospective, binational multicenter, open-label, registry-based trial in patients undergoing first isolated nonemergent coronary artery bypass grafting (CABG), randomized 1:1 to no-touch or conventional open skeletonized vein harvesting technique, with a planned enrollment of 900 patients. The primary end point is the proportion of patients with graft failure defined as SVGs occluded or stenosed >50% on coronary computed tomography angiography at 2 years after CABG, earlier clinically driven coronary angiography demonstrating an occluded or stenosed >50% vein graft, or death within 2 years. High-quality health registries and coronary computed tomography angiography are used to assess the primary end point. The secondary end points include wound healing in the vein graft sites and the composite outcome of major adverse cardiac events during the first 2 years based on registry data. Demographics of the first 200 patients enrolled in the trial and other CABG patients operated in Sweden during the same time period are comparable when the exclusion criteria are taken into consideration. RCT# NCT03501303

OBJECTIVES Minimally invasive extracorporeal circulation (MiECC) is suggested to have favourable impact on blood loss compared to conventional extracorporeal circulation. We aimed to compare the impact of both systems on coagulation. METHODS Randomized trial comparing endogenous thrombin-generating potential early after elective coronary surgery employing either MiECC group (n = 30) or conventional extracorporeal circulation group (n = 30). Secondary outcomes were in vivo thrombin generation, bleeding end points and haemodilution, as well as morbidity and mortality up to 30-day follow-up. RESULTS Compared to the conventional extracorporeal circulation group, the MiECC group showed (i) a trend towards a higher early postoperative endogenous thrombin-generating potential (P = 0.06), (ii) lower intraoperative levels of thrombin–antithrombin complex and prothrombin fragment 1 + 2 (P CONCLUSIONS Conventional but not MiECC is associated with significant intraoperative thrombin generation despite full heparinization. No correlation between coagulation factors or bleeding end points with the degree of haemodilution could be ascertained. ClinicalTrials.gov identifier NCT03216720.

Background: Despite treatment with the antiplatelet drug aspirin, some patients who undergo coronary artery bypass grafting (CABG) experience a thromboembolic event in the early postoperative period. The etiology of a reduced aspirin effect after CABG is still unsolved. Hence, we investigated whether patients who undergo CABG have a reduced absorption of aspirin after surgery, measured as levels of plasma salicylic acid (SA). Methods: In total, 53 patients were included between October 2015 and May 2018. Blood samples where obtained at the day before surgery, and at the first (day 1) and second (day 2) postoperative day. A subgroup of 10 patients had additional blood samples obtained on day 1. Plasma SA was measured using liquid chromatography-electrospray-ionization tandem-mass spectrometry. Multiplate Analyzer (Roche, Roche Diagnostics, Mannheim, Germany) and VerifyNow Aspirin Test (Accumetrics, San Diego, Calif) were used to assess platelet aggregation as a measurement of the antiplatelet effect of aspirin. Results: A comparison of the difference in change of SA concentration between the day before surgery with day 1 and day 2 showed a significantly reduced increase in SA plasma levels after intake of aspirin at day 1 and day 2 after surgery (P

BACKGROUND: The value of fractional flow reserve (FFR) evaluation of coronary artery stenosis in coronary artery bypass grafting (CABG) is uncertain, and stenosis assessments usually rely on visual estimates of lesion severity.OBJECTIVES: This randomized clinical trial evaluated graft patency and clinical outcome after FFR-guided CABG versus angiography-guided CABG.METHODS: A total of 100 patients referred for CABG were randomly assigned to FFR-guided or angiography-guided CABG. Based on the coronary angiogram, a heart team made a graft plan for all patients, and FFR evaluations were performed. In FFR-guided CABG, coronary lesions with FFR >0.80 were deferred, and a new graft plan was designed accordingly, whereas the surgeon was blinded to the FFR values in patients who underwent angiography-guided CABG. The primary endpoint was graft failure in the percentage of all grafts after 6 months.RESULTS: Angiographic follow-up at 6 months was available for 72 patients (39 vs. 33 in the FFR-guided and angiography-guided groups, respectively). Graft failures of all grafts were similar in both groups (16% vs. 12%; p = 0.97). Rates of death, myocardial infarction, and stroke were also similar in the study groups, and no difference was seen in revascularization before angiographic follow-up. After 6 months, deferred lesions (n = 24) showed a significant reduction in mean FFR from index to follow-up (0.89 ± 0.05 vs. 0.81 ± 0.11; p = 0.002). Index FFR did not influence graft patency.CONCLUSIONS: FFR-guided CABG had similar graft failure rates and clinical outcomes as angiography-guided CABG. However, FFR was reduced significantly after 6 months in deferred lesions. (Fractional Flow Reserve Versus Angiography Randomization for Graft Optimization [FARGO]; NCT02477371).

Objective: Reduced effect of antiplatelet therapy following coronary artery bypass grafting is associated with reduced graft patency. We sought to evaluate the impact of hybrid coronary revascularization on the effect of aspirin and clopidogrel and whether high baseline platelet aggregation, high postoperative levels of platelet turnover, and acute-phase response may contribute to the effect. Methods: We prospectively studied platelet aggregation (VerifyNow and Multiplate Analyzer), platelet turnover (immature platelets, mean platelet volume, and thrombopoietin), and acute-phase reactants (C-reactive protein, von Willebrand factor, and coagulation factor VIII) in 40 patients undergoing elective hybrid coronary revascularization (off-pump surgical revascularization through J-hemisternotomy followed by percutaneous coronary intervention [PCI]). Preoperative blood samples on- and off-aspirin were compared with blood samples obtained postoperatively, following PCI when dual antiplatelet therapy had been initiated and at 1-year follow-up. Results: The antiplatelet effect of aspirin was significantly reduced in the early postoperative period as measured by VerifyNow Aspirin but not by Multiplate ASPI test. The antiplatelet effect of clopidogrel was significantly reduced following PCI as measured by VerifyNow P2Y12 and Multiplate ADP test. The level of baseline aggregation did not predict the antiplatelet effect of aspirin or clopidogrel, and no association was found between platelet aggregation and postoperative platelet turnover or acute-phase reaction. Conclusions: A transient reduction in the antiplatelet effect of aspirin and clopidogrel was observed after hybrid coronary revascularization despite limited surgical trauma and off-pump technique. Neither baseline platelet aggregation nor postoperatively increased platelet turnover and acute-phase response could explain this finding. ClinicalTrials.gov identifier, NCT02293928.

Aims: To assess the procedural feasibility and early safety of hybrid coronary revascularisation, combining off-pump left internal mammary artery grafting to the left descending coronary artery (LAD) through an inferior J-hemisternotomy (JOPCAB) with percutaneous coronary intervention (PCI) of non-LAD lesions. Methods and results: A total of 100 patients with multivessel coronary artery disease involving LAD were included in this prospective registry. Hybrid revascularisation was performed by JOPCAB, either prior to PCI (89%) or following PCI (11%). In 96% of the cases, the procedure was carried out according to the preoperative strategy and without perioperative (24 hours) major adverse cardiac or cerebral events. At one month, we observed no deaths, one stroke and two procedure-related myocardial infarctions. Five patients underwent reoperation for graft dysfunction, four of whom were identified by angiography without prior signs of ischaemia. Reoperation due to bleeding was necessary in six patients, and nine patients received red blood cell transfusion. Conclusions: Our prospective registry documented promising procedural feasibility and early safety of coronary hybrid revascularisation combining JOPCAB with PCI. ClinicalTrials Gov Identifier: NCT01496664.

Revascularization by coronary artery bypass grafting is superior to percutaneous coronary intervention in cases of complex multivessel coronary artery disease. The superiority is demonstrated by reduced rates of repeat revascularization, myocardial infarction and all-cause death. By contrast, stroke occurs more frequently after coronary artery bypass grafting. Hybrid coronary revascularization combines the survival benefits of left internal mammary artery-to-left anterior descending coronary artery grafting, fast recovery and minimized surgical trauma, reduced risk of stroke by avoidance of aortic manipulation and the long-term patency of drug-eluting stent treatment of left anterior descending coronary artery lesions. Accordingly, results from registry studies are compatible with the short- and long-term superiority of hybrid coronary revascularization as compared with conventional revascularization using percutaneous coronary intervention or coronary artery bypass grafting.

Since the 1990s, a large body of literature has been published regarding minimally invasive coronary artery bypass grafting. Varying techniques, complexity of the procedures and the necessity of patient selection have led to its inconsistent application. We describe the standardized technique of left internal mammary artery grafting to the left anterior descending coronary artery, off-pump through a left inferior J-hemisternotomy (JOPCAB). This approach is straightforward, safe, effective, and replicable in virtually all patients. JOPCAB requires no patient selection or other prerequisite than experience in standard off-pump technique. The left internal mammary artery is harvested under direct vision through a left inferior J-hemisternotomy. The left anterior descending coronary artery is exposed with left-sided pericardial stitches. The off-pump anastomosis is performed with the aid of a suction stabilization device and routine intracoronary shunting. Patients are fully heparinized during the procedure.

OBJECTIVES: This study compares the durability and risk of reoperation in patients undergoing aortic valve replacement (AVR) with either a Mitroflow or a Carpentier-Edwards (CE) pericardial bioprosthesis. Since AVR with bioprosthetic valves has increased progressively in recent years as compared to mechanical valves, especially in patients aged 60-70 years, there has been renewed interest in the long-term durability of current pericardial bioprostheses.METHODS: We compared 440 AVR with Mitroflow valves with 1953 AVR with CE pericardial valves implanted from 1999 to 2014 with regard to reoperation, reoperation for structural valve deterioration (SVD) and all-cause mortality.RESULTS: Ten-year freedom from explant of any cause was higher for CE Perimount (98 ± 0.7%) than for Mitroflow (95 ± 1.4%, P < 0.01). Reasons for explant for CE Perimount were SVD (n = 2), endocarditis (n = 8) and paraprosthetic leak (n = 10). The reasons for explant for Mitroflow were SVD (n = 11), endocarditis (n = 3) SVD and pericarditis (n = 1) and paraprosthetic leak (n = 2). Ten-year freedom from explant due to SVD was higher for CE Perimount (100%) than for Mitroflow (96%) (P < 0.01). In small aortic annuli (bioprosthesis size 19-21 mm), freedom from SVD at 10 years for CE Perimount and Mitroflow was 100 versus 96%, respectively. By multivariate analysis, it was found that bioprosthesis size was not a risk factor for SVD. The choice of valve type could not be demonstrated to influence long-term survival.CONCLUSIONS: The Mitroflow pericardial bioprosthesis provides less than optimal mid- and long-term durability compared with the CE Perimount pericardial valve, especially for small aortic diameter implants (19 and 21 mm). This study hereby confirms the existence of a real risk of valvular deterioration of the Mitroflow valve that might compromise the prognosis of the patients.

Udgivelsesdato: 2009-Dec BACKGROUND: This study evaluated the overall incidence, prognosis, and risk factors for microbiologically documented Candida deep sternal wound infection (DSWI) after cardiac operations. METHODS: A retrospective observational study was performed at Aalborg Hospital, Aarhus University Hospital, Denmark, from January 1999 through November 2006. Included were all 83 of 4222 cardiac surgical patients with microbiologically documented DSWI requiring surgical revision. Various potential risk factors in patients with Candida DSWI were compared with those of patients with non-Candida DSWI. We compared markers of morbidity, in-hospital mortality, and 1-year mortality to evaluate the prognosis of the disease. RESULTS: DSWI developed in 2% of all patients, of whom, 17 (20.5%) had Candida DSWI, and 66 (79.5%) had non-Candida etiology. Candida was the primary causative organism in 11 of 17 Candida DSWI cases. No Candida DSWI was found during the first 3 years of the study. In-hospital and 1-year mortality were doubled in patients with Candida DSWI compared with patients with non-Candida DSWI. Candida DSWI was associated with significantly longer stay in the intensive care unit and need of prolonged mechanical ventilation. Risk factors for Candida etiology were Candida colonization in tracheal secretions or urine and reoperation before diagnosis of DSWI. CONCLUSIONS: Candida was a frequent causative agent of DSWI in our series and was associated with a very high morbidity and mortality. Cardiothoracic patients on mechanical ventilation when colonized with Candida were identified as a high-risk population for subsequent development of Candida DSWI.

Udgivelsesdato: 2005-Jul OBJECTIVES: Early assessment of the severity and the etiology is crucial in the management of acute pancreatitis. To determine the value of procalcitonin (PCT) as a prognostic marker and as an indicator of biliary etiology in the early phase of acute pancreatitis. METHODS: In a prospective study, 75 consecutive patients were included (severe pancreatitis in 12 patients, biliary etiology in 42 cases). The value of PCT as a prognostic marker was compared to C-reactive protein (CRP), hematocrit (HCT), acute physiology and chronic health evaluation (APACHE) II score, and Ranson score. The value of PCT as an indicator of biliary etiology was compared to alanine aminotransferase (ALT) and alkaline phosphatase (AP). The area under the receiver operating characteristic curve (AUC) was applied as a measure of the overall accuracy of the single markers and multiple scoring systems. RESULTS: The most accurate prediction of severe disease was provided by the APACHE II score on the day of admission (AUC: APACHE II, 0.78; CRP, 0.73; HCT, 0.73; and PCT, 0.61), and by CRP after 48 h (AUC: CRP, 0.94; Ranson score, 0.81; PCT, 0.71; APACHE II score, 0.69; and HCT, 0.46). ALT was the most accurate indicator of biliary pancreatitis (AUC: ALT, 0.83; AP, 0.81; and PCT, 0.68). CONCLUSIONS: PCT is of limited additional value for early assessment of severity and etiology in acute pancreatitis. CRP is found to be a reliable prognostic marker with a delay of 48 h, while ALT is validated as the best indicator of biliary etiology.

We determined sensitive markers of coagulation and fibrinolysis in plasma of 20 patients with malignant colorectal disease as compared to 17 patients with benign colorectal disease. Thrombin/antithrombin III complex (TAT), soluble fibrin (SF), total fibrinogen and fibrin degradation products (TDP), plasminogen activator inhibitor type-1 (PAI-1), urokinase-type plasminogen activator (uPA) and uPA receptor (uPAR) were measured preoperatively, starting anesthesia, during surgery and postoperatively. The purpose was to verify the supposed hypercoagulable state of cancer patients. In addition, we investigated whether the hemostatic alterations induced by general anesthesia and major abdominal surgery differed between the two groups. Patients with colorectal cancer showed initially an altered balance of hemostasis with a preponderance of procoagulant activity and fibrinolytic inhibition, as noted by marginally elevated TAT and PAI-1 plasma levels. The stimulus of anesthesia induction alone was sufficient to trigger not only activation of coagulation in these patients but also further activation of fibrinolysis and increased fibrinolytic inhibition. The marked activation of coagulation and fibrinolysis and enhanced fibrinolytic inhibition during surgery was more pronounced in patients with malignancy as compared to the control group. Postoperatively, a shift of the normal balance of hemostasis with a slight preponderance of fibrinolytic inhibition was observed, as evidenced by a marginally elevated PAI-1 plasma levels. The results of this study strengthen the hypothesis of a hypercoagulable state in patients with colorectal malignancy that may favor the development of thrombosis in this patient group.

Infections are common complications of bite wounds, changing in severity from local cellulitis to life-threatening septicaemia. Treatment recommendations are often contradictory and rarely reflect evidence-based medicine. Risk factors associated with higher rates of infection include localization on the hands, puncture wounds and age older than 50 years. The literature is critically reviewed for evidence-based treatment of bite wounds. The results are discussed with respect to common practice in Denmark.

Saphenous vein grafts are the most common conduits used for coronary artery bypass grafting (CABG); however, no more than 60% of vein grafts remain open after 10 years and graft failure is associated with poor clinical outcome. The “no-touch” harvesting technique—where a sheet of perivascular tissue is retained around the vein—improves graft patency to over 80% after 16 years of follow-up, but the mechanism for the improved patency rate is unclear. In this study, we investigated acute functional differences between vein grafts harvested conventionally and by “no-touch” technique and explored the importance of perivascular tissue for reducing surgical trauma, minimizing excessive distension, and releasing vasoactive paracrine factors. Segments of human saphenous veins were obtained from CABG surgery and their functional properties investigated by isometric and isobaric myography. We found a broad diameter-tension relationship for human saphenous veins, with peak capacity for active tension development at diameters corresponding to transmural pressures around 60 mmHg. Across the investigated transmural pressure range between 10 and 120 mmHg, maximal tension development was higher for “no-touch” compared to conventionally harvested saphenous veins. Contractile responses to serotonin, noradrenaline, and depolarization induced with elevated extracellular [K+] were significantly larger for saphenous veins harvested by “no-touch” compared to conventional technique. Conventional vein grafts are routinely pressurized manually in order to test for leaks; however, avoiding this distension procedure did not change the acute contractile function of the conventionally excised saphenous veins. In contrast, even though surgical removal of perivascular tissue during conventional harvesting was associated with a substantial decrease in force development, removal of perivascular tissue by careful dissection under a stereomicroscope only marginally affected contractile responses of veins harvested by “no-touch” technique. In conclusion, we show that saphenous veins harvested by “no-touch” technique have greater contractile capacity than veins harvested by conventional technique. The different capacity for smooth muscle contraction is not due to vasoactive substances released by the perivascular tissue. Instead, we propose that the larger tension development of saphenous veins harvested by “no-touch” technique reflects reduced surgical damage, which may have long-term consequences that contribute to the superior graft patency.