Does hypothermic circulatory arrest or prolonged cardiopulmonary bypass time affect early outcome in reoperative aortic surgery?

AIM: Prolonged cardio-pulmonary bypass (CPB) time, usually necessary for reoperations, is known to increase mortality in coronary bypass procedures and aortic reoperations. We investigated if prolonged CPB time and arch reconstruction in reoperations of the thoracic aorta affect in-hospital outcome. METHODS: Twenty-nine patients underwent reoperations on the thoracic aorta. The reoperations performed were aortic root replacement with composite graft without aortic arch involvement in ten patients, isolated ascending aorta replacement in six patients, aortic arch replacement as a primary procedure in two patients, and aortic arch in conjunction with ascending or descending aorta replacement in 11 patients. RESULTS: Fourteen patients had aortic reoperation with deep hypothermic circulatory arrest (DHCA) and 15 without DHCA. The in-hospital mortality rate was 13.8%. The use deep hypothermic circulatory arrest or CPB time did not affect early outcome. Previous coronary artery bypass procedure was independent predictor of in-hospital mortality. Seven patients required re-exploration for bleeding. One patient suffered from stroke and finally five patients had prolonged ventilation, two requiring tracheostomy. There have been no deaths in the follow-up period. None of the patients has required repeat surgical intervention on the heart or the aorta. CONCLUSION: The use of DHCA or prolonged CPB time do not affect early outcome in reoperations of the thoracic aorta.

Independent predictors for early and midterm mortality after thoracic surgery.

BACKGROUND: The purpose of the present study was to determine independent predictors for early and midterm mortality for the whole context of thoracic surgery. METHODS: We studied 1453 consecutive patients who underwent thoracic surgery between 2002 and 2005. Operations included lung resections (n = 504), mediastinal (n = 468), pleural and pericardial (n = 226), esophageal (n = 83), chest wall (n = 85), tracheal (n = 50) and other procedures (n = 37). Midterm survival data (mean follow-up 2.0 +/- 1.1 years) were obtained from the National Death Index. Multivariate logistic regression was used to assess in-hospital mortality. Independent predictors for midterm mortality were determined by multivariate Cox regression analysis. RESULTS: There were 47 (3.2 %) in-hospital and 312 (21.5 %) late deaths. Independent predictors for in-hospital mortality included Zubrod score (OR 2.72, P < 0.001), ASA score (OR 3.42, P < 0.001), pneumonectomy (OR 20.71, P = 0.001) and no history of cerebrovascular events (OR 0.27, P = 0.011). Independent predictors for midterm mortality included age (HR 1.03, P < 0.001), weight loss (HR 1.57, P = 0.005), Zubrod score (HR 1.47, P < 0.001), primary lung cancer (HR 1.98 P < 0.001), intrathoracic extrapulmonary metastases (HR 2.78, P < 0.001), primary chest wall tumor (HR 0.14, P = 0.008), diabetes requiring insulin (HR 1.71, P = 0.017), no preoperative renal failure (HR 0.57, P = 0.004), no comorbidities (HR 0.54, P = 0.009), ASA score (HR 1.69, P < 0.001), postoperative radiation treatment (HR 1.90, P = 0.016), pneumonectomy (HR 2.18, P = 0.040), reoperation for bleeding and/or postoperative transfusion (HR 3.10, P = 0.027) and postoperative pulmonary complications (HR 1.89, P = 0.013). CONCLUSIONS: We determined independent predictors for in-hospital and midterm mortality for the whole context of thoracic surgery. Zubrod and ASA scores affect both early and midterm mortality.

The importance of independent risk-factors for long-term mortality prediction after cardiac surgery.

The purpose of the present study was to determine independent predictors for long-term mortality after cardiac surgery. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) was developed to score in-hospital mortality and recent studies have shown its ability to predict long-term mortality as well. We compared forecasts based on EuroSCORE with other models based on independent predictors. Medical records of patients with cardiac surgery who were discharged alive (n = 4852) were retrospectively reviewed. Their operative surgical risks were calculated according to EuroSCORE. Patients were randomly divided into two groups: training dataset (n = 3233) and validation dataset (n = 1619). Long-term survival data (mean follow-up 5.1 years) were obtained from the National Death Index. We compared four models: standard EuroSCORE (M1); logistic EuroSCORE (M2); M2 and other preoperative, intra-operative and post-operative selected variables (M3); and selected variables only (M4). M3 and M4 were determined with multivariable Cox regression analysis using the training dataset. The estimated five-year survival rates of the quartiles in compared models in the validation dataset were: 94.5%, 87.8%, 77.1%, 64.9% for M1; 95.1%, 88.0%, 80.5%, 64.4% for M2; 93.4%, 89.4%, 80.8%, 64.1% for M3; and 95.8%, 90.9%, 81.0%, 59.9% for M4. In the four models, the odds of death in the highest-risk quartile was 8.4-, 8.5-, 9.4- and 15.6-fold higher, respectively, than the odds of death in the lowest-risk quartile (P < 0.0001 for all). EuroSCORE is a good predictor of long-term mortality after cardiac surgery. We developed and validated a model using selected preoperative, intra-operative and post-operative variables that has better discriminatory ability.