Influence of external assessment on quality and safety in surgery: a qualitative study of surgeons' perspectives.

INTRODUCTION: Transparency about the occurrence of adverse events has been a decades-long governmental priority, defining external feedback to healthcare providers as a key measure to improve the services and reduce the number of adverse events. This study aimed to explore surgeons' experiences of assessment by external bodies, with a focus on its impact on transparency, reporting and learning from serious adverse events. External bodies were defined as external inspection, police internal investigation, systems of patient injury compensation and media. METHODS: Based on a qualitative study design, 15 surgeons were recruited from four Norwegian university hospitals and examined with individual semi-structured interviews. Data were analysed by deductive content analysis. RESULTS: Four overarching themes were identified, related to influence of external inspection, police investigation, patient injury compensation and media publicity, (re)presented by three categories: (1) sense of criminalisation and reinforcement of guilt, being treated as suspects, (2) lack of knowledge and competence among external bodies causing and reinforcing a sense of clashing cultures between the 'medical and the outside world' with minor influence on quality improvement and (3) involving external bodies could stimulate awareness about internal issues of quality and safety, depending on relevant competence, knowledge and communication skills. CONCLUSIONS AND IMPLICATIONS: This study found that external assessment might generate criminalisation and scapegoating, reinforcing the sense of having medical perspectives on one hand and external regulatory perspectives on the other, which might hinder efforts to improve quality and safety. External bodies could, however, inspire useful adjustment of internal routines and procedures. The study implies that the variety and interconnections between external bodies may expose the surgeons to challenging pressure. Further studies are required to investigate these challenges to quality and safety in surgery.

Intervention for reducing the overuse of upper endoscopy in patients <45 years: a protocol for a stepwise intervention programme.

Utilisation rates for healthcare services vary widely both within and between nations. Moreover, healthcare providers with insurance-based reimbursement systems observe an effect of social determinants of health on healthcare utilisation rates and outcomes. Even in countries with publicly funded universal healthcare such as Norway, utilisation rates for medical and surgical interventions vary between and within health regions and hospitals.Most interventions targeting overuse and high utilisation rates are based on the assumption that knowledge of areas of unwarranted variation in healthcare automatically will lead to a reduction in unwarranted variation. Recommendations regarding how to reduce this variation are often not very detailed or prominent.This paper describes a protocol for reducing the overuse of upper endoscopy in a Norwegian health region. The protocol uses a combination of digital tools and psychological methods targeting behavioural change in order to alter healthcare workers' approach to patient care.The aim of the planned intervention is to evaluate the effectiveness of a multifaceted set of interventions to reduce the overuse of upper endoscopy in patients under 45 years. A secondary aim is to evaluate the specific effect of the various parts of the intervention.

Reducing unwarranted variation: can a 'clinical dashboard' be helpful for hospital executive boards and top-level leaders?

BACKGROUND/AIM: In the past decades, there has been an increasing focus on defining, identifying and reducing unwarranted variation in clinical practice. There have been several attempts to monitor and reduce unwarranted variation, but the experience so far is that these initiatives have failed to reach their goals. In this article, we present the initial process of developing a safety, quality and utilisation rate dashboard ('clinical dashboard') based on a selection of data routinely reported to executive boards and top-level leaders in Norwegian specialist healthcare. METHODS: We used a modified version of Wennberg's categorisation of healthcare delivery to develop the dashboard, focusing on variation in (1) effective care and patient safety and (2) preference-sensitive and supply-sensitive care. RESULTS: Effective care and patient safety are monitored with outcome measures such as 30-day mortality after hospital admission and 5-year cancer survival, whereas utilisation rates for procedures selected on cost and volume are used to follow variations in preference-sensitive and supply-sensitive care. CONCLUSION: We argue that selecting quality indicators of patient safety, quality and utilisation rates and presenting them in a dashboard may help executive hospital boards and top-level leaders to focus on unwarranted variation.

Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events.

INTRODUCTION: In surgery, serious adverse events have effects on the patient journey, the patient outcome and may constitute a burden to the surgeon involved. This study aims to investigate facilitators and barriers to transparency around, reporting of and learning from serious adverse events among surgeons. METHODS: Based on a qualitative study design, we recruited 15 surgeons (4 females and 11 males) with 4 different surgical subspecialties from four Norwegian university hospitals. The participants underwent individual semistructured interviews and data were analysed according to principles of inductive qualitative content analysis. RESULTS AND DISCUSSION: We identified four overarching themes. All surgeons reported having experienced serious adverse events, describing these as part of 'the nature of surgery'. Most surgeons reported that established strategies failed to combine facilitation of learning with taking care of the involved surgeons. Transparency about serious adverse events was by some felt as an extra burden, fearing that openness on technical-related errors could affect their future career negatively. Positive implications of transparency were linked with factors such as minimising the surgeon's feeling of personal burden with positive impact on individual and collective learning. A lack of facilitation of individual and structural transparency factors could entail 'collateral damage'. Our participants suggested that both the younger generation of surgeons in general, and the increasing number of women in surgical professions, might contribute to 'maturing' the culture of transparency. CONCLUSION AND IMPLICATIONS: This study suggests that transparency associated with serious adverse events is hampered by concerns at both personal and professional levels among surgeons. These results emphasise the importance of improved systemic learning and the need for structural changes; it is crucial to increase the focus on education and training curriculums and offer advice on coping strategies and establish arenas for safe discussions after serious adverse events.

Hospital work environments affect the patient safety climate: A longitudinal follow-up using a logistic regression analysis model.

BACKGROUND: Occupational worker wellness and safety climate are key determinants of healthcare organizations' ability to reduce medical harm to patients while supporting their employees. We designed a longitudinal study to evaluate the association between work environment characteristics and the patient safety climate in hospital units. METHODS: Primary data were collected from Norwegian hospital staff from 970 clinical units in all 21 hospitals of the South-Eastern Norway Health Region using the validated Norwegian Work Environment Survey and the Norwegian version of the Safety Attitudes Questionnaire. Responses from 91,225 surveys were collected over a three year period. We calculated the factor mean score and a binary outcome to measure study outcomes. The relationship between the hospital unit characteristics and the observed changes in the safety climate was analyzed by linear and logistic regression models. RESULTS: A work environment conducive to safe incident reporting, innovation, and teamwork was found to be significant for positive changes in the safety climate. In addition, a work environment supportive of patient needs and staff commitment to their workplace was significant for maintaining a mature safety climate over time. CONCLUSIONS: A supportive work environment is essential for patient safety. The characteristics of the hospital units were significantly associated with the unit's safety climate scores, hence improvements in working conditions are needed for enhancing patient safety.

Associations between work satisfaction, engagement and 7-day patient mortality: a cross-sectional survey.

OBJECTIVE: This study examines the association between profession-specific work environments and the 7-day mortality of patients admitted to these units with acute myocardial infarction (AMI), stroke and hip fracture. DESIGN: A cross-sectional study combining patient mortality data extracted from the South-Eastern Norway Health Region, and the work environment scores at the hospital ward levels. A case-mix adjustment model was developed for the comparison between hospital wards. SETTING: Fifty-six patient wards in 20 hospitals administered by the South-Eastern Norway Regional Health Authority. PARTICIPANTS: In total, 46 026 patients admitted to hospitals with AMI, stroke and hip fracture, and supported by 8800 survey responses from physicians, nurses and managers over a 3-year period (2010-2012). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measures were the associations between the relative mortality rate for patients admitted with AMI, stroke and hip fractures and the profession-specific (ie, nurses, physicians, middle managers) mean scores on the 19 organisational factors in a validated cross sectional, staff survey conducted annually in Norway. The secondary outcome measures were the mean scores with SD on the organisational factors in the staff survey reported by each profession. RESULTS: The Nurse workload (beta 0.019 (95% CI0.009-0.028)) and middle manager engagement (beta 0.024 (95% CI0.010-0.037)) levels were associated with a case-mix adjusted 7-day patient mortality rates. There was no significant association between physician work environment scores and patient mortality rates. CONCLUSION: 7-day mortality rates in hospital wards were negatively correlated with the nurse workload and manager engagement levels. A deeper understanding of the relationships between patient outcomes, organisational structure and their underlying cultural barriers is needed because they may provide a better understanding of the harm and death risks for patients due to organisational characteristics.

Changes in the rate of publicly financed knee arthroscopies: an analysis of data from the Norwegian patient registry from 2012 to 2016.

OBJECTIVE: To examine rates of publicly financed knee arthroscopic surgery in Norway between 2012 and 2016. DESIGN: Analysis of anonymised data from the National Patient Registry. INTERVENTIONS: Beginning in 2012, South-Eastern Norway Regional Health Authority implemented administrative measures to bring down rates of knee arthroscopy. Similar measures were not introduced in the other three Regional Health Authorities. MAIN OUTCOME MEASURES: We analysed annual national rates of publicly financed knee arthroscopies in 2012 and 2016. We compared the rates in South-Eastern Norway Regional Health Authority with corresponding rates in the rest of the country. Variations by county, public hospital versus publicly reimbursed private hospital, gender and age were also assessed. RESULTS: The overall annual rate of arthroscopic procedures declined by 33% from 2012 to 2016, from 310 to 207 per 100 000 inhabitants, respectively. Hospitals in South-Eastern Norway Regional Health Authority reported a 48% reduction, compared with mean 13% in the other three Regional Health Authorities. In public hospitals, rates decreased nationally by 42%, while rates in publicly reimbursed private hospitals increased by 12%. Rates in publicly reimbursed private hospitals decreased by 30% in South-Eastern Norway Regional Health Authority but increased by 63% in the other Regional Health Authorities. The proportion of patients ≥50 years (excluding meniscal repairs) in Norway was 54% in 2012 and fell to 46% in 2016. Average rates per county varied by a factor of 3:1. CONCLUSION: We report a marked overall reduction of knee arthroscopic procedures from 2012 to 2016 in publicly funded hospitals. The largest decrease was reported in South-Eastern Norway Regional Health Authority, and this coincides in time with implemented administrative measures. The results suggest that the trend of increasing rates of knee arthroscopies can be reversed through purposeful professional and administrative interventions.

A systematic review of hospital accreditation: the challenges of measuring complex intervention effects.

BACKGROUND: The increased international focus on improving patient outcomes, safety and quality of care has led stakeholders, policy makers and healthcare provider organizations to adopt standardized processes for evaluating healthcare organizations. Accreditation and certification have been proposed as interventions to support patient safety and high quality healthcare. Guidelines recommend accreditation but are cautious about the evidence, judged as inconclusive. The push for accreditation continues despite sparse evidence to support its efficiency or effectiveness. METHODS: We searched MEDLINE, EMBASE and The Cochrane Library using Medical Subject Headings (MeSH) indexes and keyword searches in any language. Studies were assessed using the Cochrane Risk of Bias Tool and AMSTAR framework. 915 abstracts were screened and 20 papers were reviewed in full in January 2013. Inclusion criteria included studies addressing the effect of hospital accreditation and certification using systematic reviews, randomized controlled trials, observational studies with a control group, or interrupted time series. Outcomes included both clinical outcomes and process measures. An updated literature search in July 2014 identified no new studies. RESULTS: The literature review uncovered three systematic reviews and one randomized controlled trial. The lone study assessed the effects of accreditation on hospital outcomes and reported inconsistent results. Excluded studies were reviewed and their findings summarized. CONCLUSION: Accreditation continues to grow internationally but due to scant evidence, no conclusions could be reached to support its effectiveness. Our review did not find evidence to support accreditation and certification of hospitals being linked to measurable changes in quality of care as measured by quality metrics and standards. Most studies did not report intervention context, implementation, or cost. This might reflect the challenges in assessing complex, heterogeneous interventions such as accreditation and certification. It is also may be magnified by the impact of how accreditation is managed and executed, and the varied financial and organizational healthcare constraints. The strategies hospitals should impelment to improve patient safety and organizational outcomes related to accreditation and certification components remains unclear.

Survival curves to support quality improvement in hospitals with excess 30-day mortality after acute myocardial infarction, cerebral stroke and hip fracture: a before-after study.

OBJECTIVES: To evaluate survival curves (Kaplan-Meier) as a means of identifying areas in the clinical pathway amenable to quality improvement. DESIGN: Observational before-after study. SETTING: In Norway, annual public reporting of nationwide 30-day in-and-out-of-hospital mortality (30D) for three medical conditions started in 2011: first time acute myocardial infarction (AMI), stroke and hip fracture; reported for 2009. 12 of 61 hospitals had statistically significant lower/higher mortality compared with the hospital mean. PARTICIPANTS: Three hospitals with significantly higher mortality requested detailed analyses for quality improvement purposes: Telemark Hospital Trust Skien (AMI and stroke), Østfold Hospital Trust Fredrikstad (stroke), Innlandet Hospital Trust Gjøvik (hip fracture). OUTCOME MEASURES: Survival curves, crude and risk-adjusted 30D before (2008-2009) and after (2012-2013). INTERVENTIONS: Unadjusted survival curves for the outlier hospitals were compared to curves based on pooled data from the other hospitals for the 30-day period 2008-2009. For patients admitted with AMI (Skien), stroke (Fredrikstad) and hip fracture (Gjøvik), the curves suggested increased mortality from the initial part of the clinical pathway. For stroke (Skien), increased mortality appeared after about 8 days. The curve profiles were thought to reflect suboptimal care in various phases in the clinical pathway. This informed improvement efforts. RESULTS: For 2008-2009, hospital-specific curves differed from other hospitals: borderline significant for AMI (p=0.064), highly significant (p≤0.005) for the remainder. After intervention, no difference was found (p>0.188). Before-after comparison of the curves within each hospital revealed a significant change for Fredrikstad (p=0.006). For the three hospitals, crude 30D declined and they were non-outliers for risk-adjusted 30D for 2013. CONCLUSIONS: Survival curves as a supplement to 30D may be useful for identifying suboptimal care in the clinical pathway, and thus informing design of quality improvement projects.

Placebo effects in trials evaluating 12 selected minimally invasive interventions: a systematic review and meta-analysis.

OBJECTIVES: To analyse the impact of placebo effects on outcome in trials of selected minimally invasive procedures and to assess reported adverse events in both trial arms. DESIGN: A systematic review and meta-analysis. DATA SOURCES AND STUDY SELECTION: We searched MEDLINE and Cochrane library to identify systematic reviews of musculoskeletal, neurological and cardiac conditions published between January 2009 and January 2014 comparing selected minimally invasive with placebo (sham) procedures. We searched MEDLINE for additional randomised controlled trials published between January 2000 and January 2014. DATA SYNTHESIS: Effect sizes (ES) in the active and placebo arms in the trials' primary and pooled secondary end points were calculated. Linear regression was used to analyse the association between end points in the active and sham groups. Reported adverse events in both trial arms were registered. RESULTS: We included 21 trials involving 2519 adult participants. For primary end points, there was a large clinical effect (ES≥0.8) after active treatment in 12 trials and after sham procedures in 11 trials. For secondary end points, 7 and 5 trials showed a large clinical effect. Three trials showed a moderate difference in ES between active treatment and sham on primary end points (ES ≥0.5) but no trials reported a large difference. No trials showed large or moderate differences in ES on pooled secondary end points. Regression analysis of end points in active treatment and sham arms estimated an R(2) of 0.78 for primary and 0.84 for secondary end points. Adverse events after sham were in most cases minor and of short duration. CONCLUSIONS: The generally small differences in ES between active treatment and sham suggest that non-specific mechanisms, including placebo, are major predictors of the observed effects. Adverse events related to sham procedures were mainly minor and short-lived. Ethical arguments frequently raised against sham-controlled trials were generally not substantiated.

[Surgery for gallstone disease in two time periods]. / Kirurgi for gallesteinssykdom i to tidsperioder.

BACKGROUND: Laparoscopic cholecystectomy was introduced at our institution in October 1990. The perioperative results from 1.1.1991 to 31.12.1995 (first period) are compared with those from 1.1.2001 to 31.12.2005 (second period). MATERIAL AND METHODS: All patients who had undergone surgical treatment for gallstone disease at Asker and Baerum Hospital in the first or second period were included. Data retrieval was partly prospective and partly retrospective in both periods. RESULTS: Significantly more patients underwent cholecystectomy in the second than in the first period (843 vs. 342), but the proportion of patients that were operated on an acute indication was lower in the second (91 of 843) than in the first (79 of 342) period, p < 0.001. This coincided with a decline in the number of cholecystectomy patients with complications to gallstone disease (pancreatitis, cholangitis or acute cholecystitis) and a significant reduction of operating time and duration of hospital stay after the operation, whereas the number of per- and postoperative complications remained unchanged. INTERPRETATION: The number of patients operated for gallstone disease during the first 15 years of laparoscopic surgery has increased significantly. Fewer patients with acute cholecystitis are treated surgically, and the proportion of patients suffering from pancreatitis, cholangitis or acute cholecystitis before surgery appears to have declined.

Reconstruction of chronic aseptic sternal pseudoarthrosis after median sternotomy: initial experience with the Ley prosthesis.

It has previously been reported that the Ley prosthesis, a 0.5-mm-thick titanium alloy plate designed for reconstruction and stabilization of the unstable sternotomy, leads to shorter hospital stay and reduces the need for further surgical procedures in patients with postoperative mediastinitis after open heart surgery. We report our initial experience with the Ley prosthesis in patients with chronic aseptic sternotomy dehiscence. The study included 6 male patients (age 42-80 years) with opiate-derivate-dependent intractable pain and significantly reduced quality of life caused by noninfected sternal pseudoarthrosis and unstable sternotomy with large sternal bone tissue deficit. Four of the patients had undergone various surgical fixation procedures 8 days to 12 months after the primary operation. The patients were treated with reconstruction and stabilization of the sternum with the Ley prosthesis 10 to 40 months after the primary operation. In 1 patient bone transplantation was used. No immediate peri- or postoperative complications were observed, and all patients were discharged 4 to 11 days after surgery. One patient who received a bone transplant developed wound infection, and the prosthesis was removed 5 weeks after implantation. At 6-month follow-up all sternotomies were found stable, and patients reported that pain had decreased and quality of life was significantly improved. Our results demonstrate that the Ley prosthesis can be safely and efficiently used for the reconstruction and stabilization of the sternum in patients with intractable pain caused by noninfected postoperative sternal dehiscence and large sternal bone tissue deficit.

[Laparoscopic gastric bypass surgery in extreme overweight at a private hospital]. / Laparoskopisk gastrisk bypass ved ekstrem overvekt ved et privatsykehus.

BACKGROUND: Laparoscopic gastric bypass surgery leads to significant weight loss and reduced morbidity in patients with severe obesity. The technique was introduced at the private Aleris hospital the autumn 2005. We here present the method and results from our initial experience. MATERIAL AND METHODS: Inclusion criteria were BMI > 40 kg/m2 or BMI 35-39,9 kg/m2 , with obesity-related co-morbidity for more than 5 years and insufficient effect of conservative treatment. The first 121 (103 women) consecutive patients who underwent gastric bypass surgery at Aleris Hospital were included. Characteristics were; mean age 40 years (18-68), mean preoperative body weight 134 kg (91-211) and BMI 44 m/kg 2 (35-64). Serious complications or major morbidity were defined as anastomosis- or intestinal leakage and bleeding requiring surgical treatment. RESULTS: No deaths or major morbidity was observed the first 30 days after surgery. One patient underwent successful surgery of a perforated ulcer localized distally to the gastro-jejunal anastomoses 3 months p.o. Mean operating time was 62 min (40-124) for patients who underwent isolated laparoscopic bypass. The mean hospitalisation time was 2.9 days (2-6). CONCLUSION: Our results demonstrate that bariatric surgery can be established successfully with a low rate of perioperative complications. We believe that thorough planning and experienced bariatric surgeons contribute to our favourable results. .

Effect of clopidogrel on midterm graft patency following off-pump coronary revascularization surgery.

OBJECTIVE: The aim of the study was to evaluate the effect of clopidogrel on midterm graft patency following off-pump coronary revascularization surgery. DESIGN: Ninety-four consecutive patients who underwent off-pump coronary artery bypass grafting between 1997 and 2002 were studied (58 men, 36 women; 61.7 +/- 9.8 years). The initial 36 patients (control group) received 75 to 160 mg acetyl salicylic acid (ASA) as an antiplatelet agent, whereas the consecutive 58 patients (clopidogrel group) received 75 mg clopidogrel postoperatively in addition to ASA. Intraoperatively, graft flow was assessed with transit-time flowmetry in all patients and the peripheral anastomoses were assessed with epicardial ultrasound in 28 patients. Sixty-two patients underwent angiography after a mean of 185 +/- 92 days. A total of 82 grafts were evaluated angiographically. Grafts with TIMI flow 2 and 3 were assessed as patent. RESULTS: At angiographic follow-up, the overall graft patency rate was 84% (31/37) in the control group and 93% (42/45) in the clopidogrel group (P value was not significant [ns]). Graft patency rates for left internal mammary artery (LIMA) grafts were 92% (23/25) versus 96% (28/29) (ns), and for saphenous vein grafts were 66% (7/11) versus 87% (14/16) (ns), respectively. CONCLUSION: The observed trend toward higher patency rates in patients treated with clopidogrel did not reach statistical significance. Further larger studies are necessary to confirm these preliminary results.

Effect of subcutaneous suture line and surgical technique on wound infection after saphenectomy in coronary artery bypass grafting: a prospective randomised study.

OBJECTIVE: The aim of the study was to evaluate the impact of an additional subcutaneous suture line on the incidence of postoperative (p.o.) infection at the vena saphena magna harvesting site (VSMHS) after coronary artery bypass grafting (CABG). METHODS: Two hundred and forty three patients undergoing CABG were included. Patients in Group A (n = 119) all operated by one physical assistant (PA) were prospectively randomised into Group A1 (n = 59) receiving intracutaneous closure suture alone whereas 60 patients (Group A2) received an additional subcutaneous suture line. Group B (n = 120), operated by surgical residents, served as control population. All patients were due to follow-up at six weeks p.o. RESULTS: Subcutaneous suture did not impact the p.o. infection rate (A2 vs. A1; 4/60 vs. 2/59, n.s.). A significant lower p.o. infection rate was observed in Group A vs. Group B (6/119 (5%) vs. 15/120 (13%) p < 0.05). CONCLUSION: Subcutaneous suture did not impact the p.o. infection rate at VSMHS. The infection rate observed in patients operated by an experienced PA was significantly lower than in patients operated by various surgical residents.

Guiding surgical cannulation of the inferior vena cava with transesophageal echocardiography.

UNLABELLED: We studied 150 adult cardiac surgery patients to assess visualization of the venous cannula and the venous system by intraoperative transesophageal echocardiography and to register the incidence of cannulation of hepatic veins. The quality of images, the dimensions of the venous system, the position of the venous cannula, and the adequacy of venous return were registered. Acceptable image quality of the inferior vena cava and the right hepatic vein (RHV) was obtained in 95% and 87% of cases, respectively. Considerable individual variations were found in the dimensions of the venous system. The cannula position could be determined in 99% of the cases. Ten percent of venous cannulae were primarily placed in the RHV. A short distance between the eustachian valve and the RHV possibly predisposes to cannulation of the RHV. No other patient-related factors were associated with cannula position. Placement of the cannula deep in the inferior vena cava was associated with reduced venous return and may be a more important cause of reduced return than a cannula positioned in a hepatic vein. IMPLICATIONS: Correct positioning of the venous cannula draining blood to the cardiopulmonary bypass circuit is important. Intraoperative transesophageal echocardiography allows satisfactory determination of the cannula position in nearly all patients. Ten percent of venous cannulae are primarily positioned in the right hepatic vein and not in the inferior vena cava as intended.

Intraoperative color Doppler ultrasound assessment of anastomoses of the left internal mammary artery to the left anterior descending coronary artery during off-pump coronary artery bypass surgery correlates with angiographic evaluation at the 8-month follow-up.

OBJECTIVE: This study was performed to evaluate the correlation between intraoperative color Doppler ultrasound assessment of anastomoses of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) performed on the beating heart and the angiographic assessment after 8 months. METHODS: Twenty patients (M/F ratio, 14:6; mean age, 62 +/- 8 years) underwent epicardial color Doppler ultrasound imaging with a 10-MHz linear array GE Vingmed transducer combined with a GE Vingmed System FiVe. Transit-time flowmetry was used as intraoperative control. Follow-up coronary angiography after a median of 245 days (range, 128-320 days) allowed assessment of thrombolysis in myocardial infarction (TIMI) flow and FitzGibbon grading in all patients. Detailed quantitative coronary angiography was performed in 10 patients with an emphasis on comparing the LAD diameter at the toe of the anastomosis (D1) and in the downstream LAD (D2). RESULTS: Intraoperative ultrasound analysis revealed 19 patent LIMA-LAD anastomoses (95%). A >50% stenosis was detected in 1 anastomosis (5%), which was subsequently revised successfully. Follow-up angiographic evaluation showed TIMI-III flow and FitzGibbon grade A in 18 of 20 anastomoses (90%). One anastomosis was occluded, and one had FitzGibbon grade B stenosis. The D1/D2 ratios of the LAD measurements assessed with intraoperative ultrasound and follow-up quantitative coronary angiography were significantly correlated (r2 = 0.62; P < .01). CONCLUSION: Intraoperative color Doppler ultrasound allows a detailed evaluation of LIMA-LAD anastomoses during off-pump surgery, and the results correlate significantly with those of angiographic evaluation after 8 months. The present study shows that epicardial ultrasound is a promising tool for verification of LIMA-LAD anastomoses performed on the beating heart and may reduce the risk of impaired graft flow caused by technical errors.

Intraoperative color Doppler ultrasound assessment of LIMA-to-LAD anastomoses in off-pump coronary artery bypass grafting.

BACKGROUND: Although techniques for off-pump coronary artery bypass grafting (CABG) are continually being refined, angiographic follow-up studies have indicated a higher rate of anastomoses-related stenoses than expected after traditional on-pump CABG. This study was performed to evaluate the use of intraoperative epicardial color Doppler ultrasound to quality-assess left internal mammary artery (LIMA) to left anterior descending coronary artery (LAD) anastomoses performed on the beating heart. METHODS: Twenty-four LIMA-to-LAD anastomoses were evaluated with real-time epicardial ultrasound imaging using an ultrasound transducer positioned between the paddles of the stabilizer during off-pump procedures. The length of the anastomosis (D(A)), diameters of LIMA (D(M)), LAD at the toe of the anastomosis (D1), and 5 mm distally to the anastomosis (D2) were measured, and the ratios between these variables were calculated. The flow velocity through the anastomoses was visualized by color Doppler coding, and flow was assessed with transit-time flowmetry. RESULTS: The epicardial color Doppler ultrasound allowed accurate assessment of the anastomoses. Twenty-three (96%) of the primary anastomoses were confirmed as patent. Mean ratios of D1/D2, D(A)/D2, and D(M)/D2 were 0.89 +/- 0.13, 3.01 +/- 1.04 and 1.32 +/- 0.32, respectively. One anastomosis had a stenosis more than 50% detected by color Doppler ultrasound. After surgical revision, transit-time flow increased from 22 to 40 ml/min. CONCLUSIONS: Intraoperative color Doppler ultrasound allowed adequate imaging for quality assessment of LIMA-to-LAD anastomoses performed on the beating heart. One anastomosis was revised due to a technical error detected by epicardial color Doppler imaging. Epicardial ultrasound scanning is a valuable tool for intraoperative assessment of LIMA-to-LAD anastomoses during off-pump coronary surgery.

[Coronary surgery--arterial grafts instead of venous grafts?]. / Koronarkirurgi--arteriegraft i stedet for venegraft?

BACKGROUND: Recurrence of symptoms and the need for repeat interventions remains a clinical challenge following coronary artery bypass surgery, despite excellent early results. Saphenous vein graft failure has been identified as a main contributing factor to unsatisfactory long-term results. The use of multiple arterial grafts instead of venous grafts appears to be a promising treatment modality. This article describes our own experience with arterial revascularisation and gives a critical review of the literature. MATERIAL AND METHODS: Extended arterial revascularisation was performed in 30 patients at our institution between 1998 and 2001. Clinical follow-up was performed in all patients; re-angiography was done in six patients. 23 patients were operated on with bilateral mammary arteries; 11 patients received radial artery grafts. RESULTS: The median follow up was 12 months. All patients are alive, none suffered a new myocardial infarction. Our results are in accordance with the published literature. INTERPRETATION: Arterial grafting is a valuable tool in the armamentarium of modern coronary artery bypass surgery. Large randomised trials are required to clarify the role of extended arterial grafting in routine coronary bypass surgery.

[Preoperative expectations and clinical outcome of transmyocardial laser treatment in patients with angina pectoris]. / Preoperativ forventning og klinisk effekt ved transmyokardial laserbehandling mot angina pectoris.

BACKGROUND: The aims of this study were to evaluate the effect of transmyocardial laser treatment on quality of life and to assess the correlation between preoperative expectations and clinical improvement after one year. MATERIAL AND METHODS: 13 patients (median age 56 years) with disabling angina pectoris were subjected to transmyocardial holmium: YAG laser. Quality of life was assessed preoperatively and at three and 12 months by Hospital Anxiety and Depression Scale (HAD), Physical Symptom Distress Index (PSDI) and Life Satisfaction Index (LSI). Expectations were evaluated by Leedham's scale. RESULTS: A significant improvement in Canadian Cardiovascular Society Score (CCS) from 3.4 +/- 0.5 (mean +/- SD) preoperatively to 1.6 +/- 1.0 and 1.7 +/- 0.8 three and 12 months after treatment was observed (p < 0.01). Quality of life (PSDI and LSI) improved. No significant changes in ejection fraction or exercise performance were found. Preoperative expectations were generally high, but did not correlate significantly with improvements in CCS or quality of life. INTERPRETATION: Although no changes in objective parameters were found, the lack of significant correlations between preoperative expectation and subjective clinical improvement indicate that the improvement of angina pectoris only partly can be explained by placebo effects.