Discriminative power of EuroSCORE in predicting morbidity and prolonged hospital stay in an Iranian sample population

EuroSCORE is a simple and rigorous risk stratification model and is, thus, commonly used in predicting the early and late outcomes of cardiac surgery across the world. We aimed to assess the discriminative power of the EuroSCORE model to predict postoperative morbidity and total prolonged length of stay in hospital [LOS] and Intensive Care Unit [ICU] stay in an Iranian group of cardiac surgical population. In a prospective study, the additive EuroSCORE model was applied to 570 patients undergoing isolated coronary artery bypass grafting [CABG] at Tehran Heart Center. The discrimination power of the EuroSCORE model was tested by the area under the receiver operating characteristic [ROC] curve and the calibration by comparing the observed and predicted outcomes across the risk spectrum assessed using the Hosmer-Lemeshow goodness-of-fit test. Mean age was 59.03 +/- 0.73 years and 429 out of 570 [75.3%] patients were men. The overall morbidity rate was 47.5%. The observed morbidity in the high-risk patients [EuroSCORE > 6] was significantly greater than that in the low-risk patients [EuroSCORE 14 days] and prolonged ICU stay [> 72 hours] were more prevalent in the high-risk group than in the low-risk group. The discriminative power of EuroSCORE in predicting morbidity, prolonged LOS, and ICU stay was poor with an area under the ROC curve of 0.617, 0.598, and 0.581, respectively. However, this risk score showed good calibrations for morbidity [p value = 0.119], prolonged LOS [p value = 0.958], and prolonged ICU stay [p value = 0.620]. EuroSCORE provided inappropriate discrimination in predicting early morbidity and prolonged LOS and ICU stay in our study population. Creating a revised model may enable us to accurately predict outcomes in Iranian CABG patients

Success rate, procedural complications and clinical outcomes of coronary interventions in octogenarians: a case-control study

Clinical trials of revascularization have routinely under-enrolled elderly subjects. Thus, symptom relief and improved survival might not apply to elderly patients, in whom the risk of mortality and disability from revascularization procedures seems to be high and co-morbidity is more prevalent. The present case control study was performed to draw a comparison in terms of the procedural success, procedural and in-hospital complications, and major adverse cardiac events [MACE] in a one-year follow-up of octogenarians [age >/= 80 years] with a selected matched younger control group in the Tehran Heart Center Angioplasty Registry. According to the Tehran Heart Center Interventional Registry of 9, 250 patients with a minimum follow-up period of one year between April 1993 and February 2010, 157 percutaneous coronary intervention [PCI] procedures were performed in 112 octogenarians. Additionally, 336 younger patients [459 PCI procedures] were selected from the database as the propensity-score matched controls. There were 147 [93.6%] and 441 [96.1%] successful PCI procedures in the elderly group and control group, respectively [p value = 0.204]. Procedural complications were seen in 5 [3.2%] of the elderly group and 16 [3.5%] of the control group [p value = 0.858]. Totally, 7 [6.3%] in-hospital complications occurred in the elderly group and 22 [6.8%] in the control group [p value = 0.866]. One-year MACE was seen in 9 [9.1%] of the elderly and 18 [5.8%] of the control group [p value = 0.26]. Procedural success and complications, in-hospital complications, and one-year MACE were not significantly different between our two study groups. Therefore, age alone should not be used as the sole criterion when considering revascularization procedures. Furthermore, PCI should not be refused in octogenarians if indicated

Measurement of atrial septal defect size: a comparative study between transesophageal echocardiography and balloon occlusive diameter method

Transcatheter closure of atrial septal defect secundum [ASD-II] has become an alternative method for surgery. We sought to compare the two-dimensional transesophageal echocardiography [TEE] method for measuring atrial septal defect with balloon occlusive diameter [BOD] in transcatheter ASD-II closure. A total of 39 patients [71.1% female, mean age: 35.31 +/- 15.37 years] who underwent successful transcatheter closure of ASD-II between November 2005 and July 2008 were enrolled in this study. Transthoracic echocardiography [TTE] and TEE were performed to select suitable cases for device closure and measure the defect size before the procedure, and BOD measurement was performed during catheterization via TEE. The final size of the selected device was usually either equal to or 1-2 mm larger than the BOD of the defect. The mean defect size obtained by TEE and BOD was 18.50 +/- 5.08 mm and 22.86 +/- 4.76 mm, respectively. The mean difference between the values of ASD size obtained by TEE and BOD was 4.36 +/- 2.93 mm. In comparison with BOD, TEE underestimated the defect size in 94.9%, but TEE value being equal to BOD was observed in 5.1%. There was a good linear correlation between the two measurements: BOD=0.773 ASD size by TEE+8.562; r2=67.9.1%. A negative correlation was found between TEE sizing and the difference between BOD and TEE values [r=-0.394, p value=0.013]. In this study, BOD was larger than ASD size obtained by two-dimensional TEE. However, TEE maximal defect sizing correlates with BOD and may provide credible information in device size selection for transcatheter ASD closure

Tricuspid regurgitation improvement in relation to the amount of pulmonary artery pressure reduction

Given the common concomitance of tricuspid regurgitation [TR] with significant mitral stenosis, we aimed at exploring the relation between TR severity and pulmonary artery hypertension [PAH] in patients who underwent mitral balloon valvotomy [MBV]. We analyzed the echocardiography data of 133 consecutive patients [82.0% female, mean age 44.68 +/- 12.56 years] with different degrees of TR severity that underwent MBV between April 2006 and March 2008. The pulmonary artery systolic pressure [PAPs] > 35 mmHg was considered as PAH. Before MBV, 36.20% of the patients had moderate to severe TR, 92.5% PAH, and 18.0% right ventricular [RV] dilation [RV dimension >/= 33 mm]. After MBV, TR severity improved in 41.4%, worsened in 8.3%, and did not change in 50.4%. Before and after MBV, PAPs was significantly correlated with TR severity, and the mean PAPs change in patients with improved TR was significantly more than that of patients without TR improvement [p value=0.042]. Tricuspid regurgitation severity and mean PAPs [from 52.83 +/- 18.82 to 35.89 +/- 9.39 mmHg] decreased significantly after MBV [both p values < 0.001]; this reduction was significantly correlated to the amount of PAPs decrease. A cut-off point of >/= 19 mmHg reduction in PAPs had a specificity of 71.79% and sensitivity of 52.73% to show TR severity improvement [by Receiver-Operative-Characteristics analysis]. The mean of RV dimension decreased from 28.94 +/- 5.43 to 27.95 +/- 4.67 mm [p value < 0.001]. In contrast to patients with RV dilation, TR reduced significantly in patients without RV dilation [p value < 0.001]. Improvement in TR severity was directly correlated with the amount of PAPs reduction after MBV. More studies are needed to better define a cut-off value for PAPs reduction related to TR severity improvement

Role of surgeon in length of stay in ICU after cardiac bypass surgery

We presumed that the surgeon himself has an impact on the results after coronary artery bypass grafting [CABG] as there is no unique protocol for the discharge of post-operative cardiac patients at our institution. Therefore, we examined whether the surgeon himself has an impact on the intensive care unit [ICU] stay of isolated CABG patients. We prospectively studied a total of 570 consecutive patients undergoing elective CABG. Length of stay in the ICU was defined as the number of days in the ICU unit post-operatively. Seven operating surgeons were classified in 3 categories on the basis of the mean hospital stay of their patients [1, 2 and 3 if the mean total patients' stay in hospital was <8 days, between 8 to 10 days, and longer than 10 days; respectively]. Using a multivariable regression model, we determined the independent predictors of length of stay in the ICU [> 48 hours] and examined the role of surgeon in this regard. Incidence of post-operative arrhythmia and length of ICU stay were higher in the patients of surgeon category 3 than those of surgeon categories 1 and 2. Surgeon category 3 also operated on patients with higher Euro SCOREs than did surgeon categories 1 and 2. With the aid of a multivariable stepwise analysis, three variables were identified as independent predictors significantly associated with ICU length of stay: age, history of cerebrovascular accident, and surgeon category. Surgeon category may independently predict a prolonged length of stay in the ICU. We suggest that a unique discharge protocol for post-CABG patients be considered to restrict the role of surgeon in the ICU stay of these patients

Impact of isolated coronary artery bypass grafting on non-organic tricuspid regurgitation severity

Moderate non-organic tricuspid regurgitation [TR] concomitant with coronary artery disease is not uncommon, Whether or not TR improves after pure coronary artery bypass grafting [CABG], however, is unclear. The aim of this study was to evaluate the effect of isolated CABG on moderate non-organic TR. This study recruited 50 patients [40% female, mean age: 65.38 +/- 8.01 years, mean left ventricular ejection fraction [LVEF]: 45.74 +/- 13.05%] with moderate non-organic TR who underwent isolated CABG. TR severity before and after CABG was compared. Pulmonary arterial systolic pressure [PAPs] > 30mmHg and LVEF < 50% were considered elevated PAPs [EPAPs] and LV systolic dysfunction, respectively. Presence of Q-wave in leads II, III, and aVF was considered inferior myocardial infarction [inf. MI]. Pre-operatively, 81.5% of the patients had EPAPs, 16% right ventricle [RV] dilation, and 50% left ventricle [LV] and 16% RV systolic dysfunction. TR severity improved in 64% after CABG, whereas it remained unchanged or even worsened in others [P value < 0.001]. Patients with inf. MI showed no improvement in TR, while patients without inf. MI had significant TR regression after CABG [P value= 0.050]. Improvement of TR severity after CABG was not related to pre-operative RV size and function, LV systolic function, or PAPs reduction. Although TR severity decreased remarkably after isolated CABG, a considerable number of the patients had no TR regression. In addition, only absence of inf. MI was significantly correlated to TR improvement after CABG. Further prospective studies with long-term follow-up needed to determine the other factors predicting TR regression after isolated CABG

Comparison of short-term clinical outcome of non-ST elevation versus ST elevation myocardial infarction

Studies on the prognosis of ST elevation myocardial infarction [STEMI] versus non-ST elevation myocardial infarction [non-STEMI] have shown different results. The present study was designed to compare the early outcome and left ventricular systolic function of patients with ST and non-ST elevation myocardial infarction. The patients' information was derived from 10,065 consecutive patients hospitalized in Tehran Heart Center with acute MI [2007 patients with STEMI and 8058 with non-STEMI]. The baseline clinical characteristics, post-MI complications, left ventricular systolic functions, and 30-day mortality rates were compared. A history of current cigarette smoking, opium addiction, and brain stroke was more frequent in the STEMI patients, whereas hyperlipidemia, hypertension, and obesity were found more in the non-STEMI group. Ejection fraction was higher in the non-STEMI patients than that in the STEMI group, and anterior wall infarction was detected more frequently in the STEMI cases. A history of coronary artery bypass grafting and also percutaneous coronary intervention was observed more in the non-STEMI group. Amongst the in-hospital complications, ventricular arrhythmias [1.4 vs. 0.5, P<0.001] and pulmonary edema [0.4 vs. 0.1, P=0.002] were more prevalent in the STEMI cases. The 30-day mortality rate in the STEMI group was higher than that in the non-STEMI group [5.5 vs. 2.4, P<0.001]. Early mortality in both groups was dependant on advanced age, diabetes mellitus, post-MI bradycardia, and atrioventricular block. Also, female gender and pulmonary edema in the STEMI group and family history of MI in the non-STEMI patients could predict 30-day mortality. There were several differences in the baseline characteristics and early outcome between the two types of STEMI and non-STEMI. The 30-day mortality rate was higher in the STEMI group than that in the non-STEMI group

Coronary artery bypass surgery versus medical treatment in patients with low ejection fraction and coronary artery disease

We compared the outcomes in patients with a low ejection fraction [EF] and multivessel coronary artery disease [CAD] who either underwent coronary artery bypass grafting [CABG] or received medical treatment [MT] after a viability study via dobutamine stress echocardiography [DSE]. We considered patients with CAD and left ventricular ejection fraction [LVEF] 25% [100% vs. 40%, p < 0.05]. The patients with CAD and a low EF had the same survival rate after both CABG and MT at mid-term follow-up. Long-term follow-up is needed to show the survival benefit of CABG in such patients with an acceptable extent of viable myocardium

Do C-reactive protein and lipoprotein [a] have different impacts on the severity of coronary artery disease in diabetic and non-diabetic patients?

The potential role of lipoprotein [a] changes and also inflammation in coronary artery disease [CAD] have rendered these processes one of the most interesting objects of study in patients affected by type 2 diabetes mellitus. The aim of the current study was to evaluate lipoprotein [a] and other lipid profiles and also C-reactive protein [CRP] as the predictors of cardiovascular disease severity in non-insulin dependent diabetic subjects in comparison with non-diabetic CAD patients. Between June and September 2004, 372 patients with CAD were enrolled at Tehran Heart Center. Non-insulin dependent diabetics accounted for 102 of the cases, and the remaining 270 were non-diabetics. The severity of CAD was evaluated using the Gensini score, and the effect of patient variables such as serum lipid concentrations and CRP on CAD severity in the diabetics was investigated and compared with that of the non-diabetics. The mean of the Gensini score, CRP, and serum concentrations of all the lipid profiles were similar between the diabetic and non-diabetic patients. In the diabetic group, a high CRP concentration [?=0.200, Rs= 0.040; P=0.046] was effective on the Gensini score, whereas lipoprotein [a] and lipid profiles did not influence CAD severity. In the non-diabetics, no significant relationships were found between the Gensini score and all the studied laboratory indices. A high CRP level is an important predictor of the severity of CAD in diabetic patients with CAD