or an evaluation of the results of cardiovascular surgery, crude operative mortality rate (ie, the number of deaths divided by the number of operations) is generally employed, although these raw outcome data do not reflect the preoperative condition of the individual patient. Therefore, to resolve that problem, risk stratification analysis was developed 1-3 for 2 major uses: one is estimating the risk of surgical mortality faced by an individual patient, as an aid to patients and physicians contemplating cardiovscular surgery, and the other is as a tool for measuring the quality of surgical care. Recently, the European System for Cardiac Operative Risk Evaluation (Euro SCORE) additive model was introduced, and it has global scores with simple and objective definitions provided at the data collection stage. 2 We used the EuroSCORE algorithm to assess the biennial trend towards a reduction in operative mortality rate in order to assess the quality of cardiac and thoracic aortic surgical care in our institution. MethodsBetween August 1994 and December 2000, 803 consecutive patients had surgery for cardiac and thoracic aortic disease: 486 men (61%) and 317 women (39%), aged from 13 to 90 years old (mean, 63±12 years). All patients selected had to have undergone cardiovascular surgery with cardioCirculation Journal Vol.66, February 2002 pulmonary bypass, so those who had off-pump coronary artery bypass grafting (CABG) were excluded. The patient population was divided into 3 time periods: early (August 1994 through September 1996, n=260), middle (October 1996 through September 1998, n=259), and late (October 1998 through December 2000, n=284). The distribution of the surgery performed is shown in Table 1, and the data for the EuroSCORE risk factors, which was entered into a database, is shown in Table 2. Expected or predicted mortality was calculated for individual patients using the EuroSCORE additive model, arranged sequentially in order of predicted score. The study population was divided into 5 clinically relevant risk categories: 0-2% risk, 3-5% risk, 6-8% risk, 9-11% risk, and 12+% risk. Mortality was defined as death from any cause within 30 days of operation or within the same hospital admission, and expected mortality was compared with observed or actual mortality for each risk category.The continuous data were expressed as the mean ± one standard deviation, and categorical variables were expressed as percentages. Statistical analysis was conducted using StatView 5.0 (SAS Institute Inc, Cary, NC, USA). Comparison of 2 groups was performed for categorical variables with the chi-square test with 2 × 2 contingency tables or Fisher's exact test as appropriate. The receiver operating characteristic (ROC) curves were plotted to assess the discrimination abilities (accuracy) of the EuroSCORE. 4 The area under the ROC curve was calculated as an index for how well the model could discriminate between patients who lived and those who died. The discriminative power of the model is thought excellent if the area under ...

No abstract

This report describes 2 cases of a type A acute aortic dissection combined with myocardial infarction caused by a retrograde dissection into the left main trunk of the coronary artery. Successful surgical treatments, including the replacement of the ascending aorta, aortic valve resuspension and coronary artery bypass grafting, were performed in both patients, and they recovered well from cardiogenic shock. However, left ventricular function of both patients remained depressed postoperatively, which limited their quality of life. Because no definite method for salvaging infarcted myocardium has yet been established, either more timely surgery or the preoperative placement of a perfusion catheter in the left main coronary artery is mandatory.

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Experiments were carried out to test the hypothesis that preconditioning reduces the impairment of recovery of cardiac mechanical function and that this effect is mediated by activation of adenosine A1 receptors. Isolated hearts were Langendorff-perfused at 37 degrees C with oxygenated blood and paced at 3 Hz. They were divided into 5 groups, all subjected to 45 min global ischemia followed by one hour of reperfusion: 1) Control hearts (n = 7) which received no treatment or short ischemia before the long ischemia, 2) preconditioned hearts (n = 7), submitted to 5-min zero-flow global ischemia, followed by 5 min reperfusion before the long ischemia, 3) hearts pretreated with sulfophenyltheophylline (SPT 100 microM) before preconditioning and long ischemia (n = 6), 4) hearts in which preconditioning was substituted by administration of 10 microM phenyl-isopropyl-adenosine (PIA) over 5 min, and 5) hearts in which preconditioning was substituted by the administration of 1.5 mg adenosine over 5 min. Hemodynamic results show significant improvement of the postischemic recovery of left ventricular developed pressure (DP) by preconditioning. SPT pretreatment did not reverse the improvement of recovery, obtained by preconditioning, whereas PIA treatment could not mimic preconditioning. Adenosine treatment caused some improvement of recovery of DP, but which remained lower compared to that caused by preconditioning. The contracture developed during ischemia persisted in control hearts, whereas contracture disappeared in non-treated preconditioned hearts. SPT did not prevent the decrease in contracture by preconditioning although values remained slightly higher than in the non-treated preconditioned hearts. PIA did not substitute for preconditioning in preventing contracture. In the adenosine treated group, some decrease of contracture occurred during reperfusion, but values remained significantly higher than in preconditioning. We conclude that receptor A1 activation is not the main mechanism underlying improved functional recovery conferred by preconditioning since an A1 receptor blocker (SPT) cannot reverse the effect of preconditioning and an A1 receptor agonist (PIA) cannot mimic it. Administration of exogenous adenosine reduces functional impairment to a certain extent, but less than preconditioning.

The protective effects of the glutathione peroxidase system against functional damage induced by perfusion of isolated hearts with adriamycin, an anthracycline antibiotic, were studied. We used selenium deficient rats, in which cardiac glutathione peroxidase activity was only 3% of control rats. Both contractile tension and coronary flow decreased during perfusion with the antibiotic. The degree of decline was significantly greater in the selenium deficient hearts than in the control hearts. The increase in malondialdehyde, a product of lipid peroxidation, induced by adriamycin perfusion was more evident in selenium deficient hearts, though the level of reduced glutathione was well maintained. Isolated mitochondrial function also decreased after aerobic adriamycin perfusion and the decrease was greater in selenium deficient rats. These observations indirectly suggest that the decrease in cardiac function induced by adriamycin is protected by the glutathione peroxidase system and that the decrease may be due, at least in part, to damage to the mitochondria caused by oxygen radicals generated by adriamycin.

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This retrospective analysis was performed to determine the early and late outcome in patients 70 years and older undergoing aortic valve replacement (AVR). From October 1994 to May 2001, 49 patients (24 men and 25 women, age 70 to 88 years [mean 74 +/- 4.6 years]) underwent primary AVR with or without concomitant procedures. Twenty-one received mechanical valves and 28 bioprostheses. Age was different between both groups: 72 +/- 2.3 years (mechanical) and 76 +/- 5.1 years (bioprosthetic) (p = 0.0005). Aortic stenosis was present in 25 patients (51%). Follow-up was 100% complete at a mean follow-up of 2.9 years (range 0.3-6.5 years). Overall hospital mortality was 4.1% (2/49). There were no postoperative complications in 24% of patients. Postoperative hospital stay or hospital survival was 27 +/- 13 days. Survival at 3 and 5 years was 89 +/- 5% and 80 +/- 7%, respectively. Three late deaths were due to noncardiac causes and 1 each had a cardiac or valve-related cause (thromboembolism). Other valve-related complications such as anticoagulant-related hemorrhage, perivalvular leak, endocarditis, prosthetic valve failure, and reoperation were not noted in any of the 49 patients. The actuarial survival curve was similar in each group of bioprosthetic versus mechanical and septuagenarians versus octogenarians. Under the selection criteria for AVR currently applied in our hospital, geriatric patients showed a satisfactory early outcome and medium-term survival benefit.