Effectiveness of Dexmedetomidine as Myocardial Protector in Children With Classic Tetralogy of Fallot Having Corrective Surgery: A Randomized Controlled Trial.

OBJECTIVES: Efficacy of dexmedetomidine (DEX) as a cardioprotective agent in Indonesian children undergoing classic tetralogy of Fallot (TOF) repair with cardiopulmonary bypass (CPB). DESIGN: A prospective, parallel trial using block randomization along with double-blinded preparation of treatment agents by other parties. SETTING: National Cardiovascular Center Harapan Kita, Indonesia. PARTICIPANTS: Sixty-six children with classic TOF scheduled for corrective surgery. No children were excluded. All patients had fulfilled the criteria for analysis. INTERVENTIONS: A total of 0.5 µg/kg bolus of DEX was added to the CPB priming solution, followed by 0.25 µg/kg/h maintenance during bypass. The placebo group used normal saline. Follow-ups were up to 30 days. MEASUREMENTS AND MAIN RESULTS: Troponin I was lower in the DEX group at 6 hours (30.48 ± 19.33 v 42.73 ± 27.16, p = 0.039) and 24 hours after CPB (8.89 ± 5.42 v 14.04 ± 11.17, p = 0.02). Within a similar timeframe, DEX successfully lowered interleukin-6 (p = 0.03; p = 0.035, respectively). Lactate was lower in the Dex group at 1, 6, and 24 hours after CPB (p < 0.01; p = 0.048; p = 0.035; respectively). Dexmedetomidine increased cardiac output and index from 6 hours after bypass, but vice versa in systemic vascular resistance. Reduction of vasoactive inotropic score was seen during intensive care unit monitoring in the Dex group (p = 0.049). Nevertheless, DEX did not significantly affect the length of ventilation (p = 0.313), intensive care unit stay (p = 0.087), and mortality (p > 0.99). CONCLUSIONS: Dexmedetomidine during CPB is an effective cardioprotective agent in TOF children having surgery. Postoperative mortality was comparable across groups.

Risk Factors Associated With Prolonged Mechanical Ventilation and Length of Stay After Repair of Tetralogy of Fallot.

BACKGROUND: This study examined preoperative, intraoperative, and postoperative data to identify factors that are associated with prolonged mechanical ventilation (PMV) and prolonged intensive care unit length of stay (ICU LOS) in tetralogy of Fallot (TOF) patients undergoing repair surgery. METHODS: A retrospective study was carried out after approval from the institutional review board. All patients (age 0-52 years) who underwent TOF repair from January 2016 to September 2022 were included. Prolonged mechanical ventilation was defined as >24 h of ventilation, while prolonged ICU LOS was defined as ICU stay >3 days. RESULTS: A total of 922 patients were included, among whom 288 (31.2%) were intubated for >24 h and 222 (24.1%) stayed in ICU for >3 days. Younger age (odds ratio [OR] = 2, 95% confidence interval [CI] 1.2-3.3, P = .007), lower weight (OR = 2.1, 95% CI 1.2-3.5, P = .003), and residual lesion (OR = 3.27, 95% CI 1.2-8.7, P = .017) were associated with PMV. Moreover, independent risk factors for prolonged ICU LOS are similar to PMV risk factors, including younger age (OR = 2.3, 95% CI 1.28-4.12, P = .005), lower weight (OR = 2.83, 95% CI 1.58-5, P < .001), underweight status (OR = 1.7, 95% CI 1.12-2.57, P = .012), and residual lesion (OR = 3.79, 95% CI 1.43-10.05, P = .007). Both aortic cross-clamp and cardiopulmonary bypass times did not exhibit clinically significant risk factors toward PMV and prolonged ICU LOS. CONCLUSIONS: The risk factors for PMV and prolonged ICU LOS were residual lesion, younger age, and lower weight. Nutritional status contributed to the risk of prolonged ICU LOS, but not PMV. Consideration of these factors may provide optimal care to improve the outcome following TOF corrective surgery.

Dexmedetomidine as a myocardial protector in pediatric heart surgery using cardiopulmonary bypass: a systematic review.

Background: In recent years, dexmedetomidine has been studied as a cardioprotective agent. However, studies on its application in pediatric heart surgery using cardiopulmonary bypass (CPB) remain limited. This systematic review aimed to provide information on the cardioprotective effect of dexmedetomidine in children undergoing heart surgery using CPB. Methods: The authors searched several databases (MEDLINE, Embase, Cochrane Library, etc.) to identify all trials comparing the levels of myocardial injury via biomarkers, including pediatric patients undergoing heart surgery using CPB who received dexmedetomidine versus placebo or other anesthetic agents. Literatures from non-primary studies were excluded. Two reviewers independently screened studies for eligibility and extracted data. The Cochrane Risk-of-Bias tool was implemented to evaluate any potential biases. Information from eligible studies was summarized and correspondingly reviewed based on any quantitative outcomes. Results: We identified six trials composed of 419 participants, three of which (n=241) showed significantly reduced interleukin-6 (IL-6) levels in the dexmedetomidine group, while one study (n=40) showed no IL-6 difference between groups. Cardiac troponin I (cTnI) and creatinine kinase-myocardial band (CK-MB), as myocardial injury biomarkers, were found to be lower in two trials (n=180). Despite several limitations hindering this review from pooling the data objectively, the majority of published studies indicated that dexmedetomidine is a seemingly efficacious agent protecting against cardiac injury during bypass. Conclusions: These studies suggest that dexmedetomidine has cardioprotective effects through the lowering of cardiac injury biomarkers while improving its clinical outcomes after heart surgery using bypass.

Indonesian Translation and Cross-Cultural Validation of Pediatric Anesthesia Parent Satisfaction (PAPS) Questionnaire.

BACKGROUND: Many questionnaires have been widely used to assess patient satisfaction. One of them is the Pediatric Anesthesia Parent Satisfaction (PAPS) questionnaire. However, in Indonesia, the parent satisfaction of pediatric patients undergoing surgery has never been studied. Knowing patient satisfaction can provide feedback to improve the quality of anesthesia services. Furthermore, the PAPS questionnaire has never been used in Indonesia, so it needs to be translated and tested for validity and reliability before being implemented in Indonesia. AIM: to validate the Indonesian version of the PAPS questionnaire Method: This study uses a descriptive-analytic method with a cross-sectional design. The PAPS Questionnaire was translated into Indonesian version with the following steps (1) forward translation, (2) establish an expert committee, and (3) backward translation. After that, pilot testing and FGD with the expert were conducted to obtain the final questionnaire. Pearson's correlation and confirmatory factor analysis (CFA) were employed for the validity test. Sampling measurement before CFA was carried out with Keyser-Meyer-Olkin (KMO) and Bartlett's test. Cronbach's alpha determined the reliability test evaluation. RESULT: Total number of subjects is 125 subjects. The PAPS questionnaire in the Indonesian version was obtained with help from INCULS and an anesthesiologist expert. Pearson's correlation found that all items ranged from r = 0.531-0.796 with p < 0.001. The CFA showed two factors that explained 65% of the total variance, with KMO being 0.937 (X2=1283.452, p < 0.001). Cronbach's alpha coefficient was 0.937. CONCLUSION: Indonesian version of the PAPS questionnaire is valid and reliable for assessing parents' satisfaction with the anesthesia services their child received.

Correlation Between Cardiac Index, Plasma Troponin I, Myocardial Histopathology, CPB and AoX Duration in Glutamine versus No Glutamine Administered Patients with Low Ejection Fraction Undergoing Elective On-Pump CABG Surgery: Secondary Analysis of an RCT.

Purpose: On-pump coronary artery bypass graft (CABG) causes myocardial ischemia, through the cardiopulmonary bypass (CPB) and aortic cross-clamping (AoX). Glutamine supplementation protects cardiac cells during cardiac ischemia. This study analysed the correlation between cardiac index (CI), plasma troponin I, myocardial histopathology, CPB and AoX duration in low ejection fraction patients receiving glutamine and no glutamine undergoing elective on-pump CABG. Material and Methods: This was a secondary analysis of a double-blind, randomised controlled trial of 60 patients, split into control and intervention (glutamine) groups. Glutamine was administered at a dose of 0.5 g/kg/24 hours. There were 29 patients in each respective groups after a total of two patients dropped out. Results: A negative correlation (p = 0.037) was observed between CPB duration and CI at 6 hours after CPB in the glutamine group. A positive correlation (p = 0.002) was also observed between AoX duration and plasma troponin I at 6 hours after CPB in the control group. However, no correlation was observed between myocardial histopathology and plasma troponin I level at 5 minutes after CPB. Conclusion: Significant negative correlation between CPB duration and CI at 6 hours after CPB in the glutamine group, along with significant positive correlation between AoX duration and plasma troponin I level at 6 hours after CPB in the control group demonstrated the myocardial protection qualities of intravenous glutamine administration in patients with low ejection fraction undergoing elective on-pump CABG surgeries.

Validation in Indonesia of two published scores for mortality prediction after cardiac surgery.

Introduction: No mortality risk prediction model has previously been validated for cardiac surgery in Indonesia. This study aimed at validating the EuroSCORE II and Age Creatinine Ejection Fraction (ACEF) score as predictors for in-hospital mortality after cardiac surgery a in tertiary center, and if necessary, to recalibrate the EuroSCORE II model to our population. Methods: This study was a single-center observational study from prospectively collected data on adult patients undergoing cardiac surgery from January 2006 to December 2011 (n = 1833). EuroSCORE II and ACEF scores were calculated for all patients to predict in-hospital mortality. Discrimination was assessed using the area under the curve (AUC) with a 95% confidence interval. Calibration was assessed with the Hosmer-Lemeshow test (HL test). Multivariable analysis was performed to recalibrate the EuroSCORE II; variables with P < 0.2 entered the final model. Results: The in-hospital mortality rate was 3.8%, which was underestimated by the EuroSCORE II (2.1%) and the ACEF score (2.4%). EuroSCORE II (AUC 0.774 (0.714-0.834)) showed good discrimination, whereas the ACEF score (AUC 0.638 [0.561-0.718]) showed poor discrimination. The differences in AUC were significant (P = 0.002). Both scores were poorly calibrated (EuroSCORE II: HL test P < 0.001, ACEF score: HL test P < 0.001) and underestimated mortality in all risk groups. After recalibration, EuroSCORE II showed good discrimination (AUC 0.776 [0.714- 0.840]) and calibration (HL test P = 0.79). Conclusions: EuroSCORE II and the ACEF score were unsuitable for risk prediction of in-hospital mortality after cardiac surgery in our center. Following recalibration, the calibration of the EuroSCORE II was greatly improved.

Perioperative Management for Emergency Surgery in Pediatric Patients with COVID-19: Retrospective Observational Study.

Background: The first wave of COVID-19 in 2020 created massive challenges in providing safe surgery for pediatric patients with COVID-19. Inevitably, emergency surgery and the unknown nature of the disease place a burden on the heavily challenged surgical services for pediatrics in a developing country. Lessons from the pandemic are important for future disaster planning. Aim: To describe the characteristics of pediatric surgical patients with COVID-19 undergoing emergency surgery during the first wave and its perioperative narrative in a developing country. Methods: The study was a multicenter retrospective descriptive study in eight Indonesian government-owned referral and teaching hospitals. The authors reviewed confirmed COVID-19 pediatric patients (≤18 years old) who underwent surgery. Institutional review board clearances were acquired, and data were evaluated in proportion and percentages. The writing of this paper follows the STROBE guidelines. Results: About 7791 pediatric surgical cases were collected, 73 matched the study criteria and 24 confirmed cases were found. Cases were more common in females (58.3%), who were above 12 years old (37.5%) and who were asymptomatic (62.5%). Laparotomy (33.3%), general anesthesia (90.4%) and intubation (80.8%) were common, while use of video laryngoscopy (40%) and rapid sequence intubation (28.8%) were rare. The mean length of stay was 12 ±13.3 days, and in-hospital mortality was 8.3%. Discussions: Lockdown and school closure were successful in protecting children, hence the low incidence of pediatric surgical cases with COVID-19 during the first wave. Many hospitals were unprepared to perform surgery for a droplet or airborne infectious disease, and COVID-19 testing was not available nationally in the early pandemic, hence the use of protective protection equipment  during these early pandemic times are often not efficient. Conclusion: The incidence of COVID-19 in pediatric surgical patients is low. The rapidity and availability of preoperative testing for a new emerging disease are essential in a pandemic.

Health Professionals Perception of Enhanced Recovery After Surgery: A Scoping Review.

PURPOSE: The Enhanced Recovery After Surgery (ERAS) program is currently poorly implemented by healthcare workers. Furthermore, several inhibiting and supporting factors for this implementation have been discovered to influence healthcare workers' perception of the program. This study aims to investigate the perception of healthcare workers regarding the ERAS program. DESIGN: A scoping review in a systematic manner. METHODS: A systematic search was performed using six databases: PubMed, ScienceDirect, SCOPUS, EBSCO, Proquest, and Sage Journals, from August 2011 to August 2021. The data was extracted using an excel worksheet, and the results obtained were presented descriptively. FINDINGS: This study selected a total of 10 articles, where both qualitative and quantitative methods were used to discuss the perceptions of healthcare workers about ERAS. CONCLUSIONS: Based on this study's findings, not all healthcare workers have a good perception of ERAS. The implementation of ERAS is often hindered by several factors, including resistance to change and lack of knowledge about the program. However, good teamwork and support from hospital management can support the program's implementation.

Validation for EuroSCORE II in the Indonesian cardiac surgical population: a retrospective, multicenter study.

BACKGROUND: In 2011, the European System for Cardiac Operative Risk (EuroSCORE) II was created as an improvement of the additive/logistic EuroSCORE for the prediction of mortality after cardiac surgery. OBJECTIVE: To validate EuroSCORE II in predicting the mortality of open cardiac surgery patients in Indonesia. METHODS: We performed a multi-center retrospective study of cardiac surgery patients from three participating centers (Dr. Sardjito Hospital, Kariadi Hospital, and Abdul Wahab Sjahranie Hospital) between January 1st, 2016, and December 31st, 2020. Discrimination and calibration tests were performed. RESULTS: The observed mortality rate was 9.5% (73 out of 767 patients). The median EuroSCORE II value was 1.13%. The area under the curve for EuroSCORE II was 0.71 (95% CI: 0.65-0.77), suggesting fair discriminatory power. Calibration analysis suggested that EuroSCORE II underestimated postoperative mortality. Gender, age, chronic pulmonary disease, limited mobility, NYHA, and critical pre-operative state were significant predictors of post-cardiac surgery mortality in our population. CONCLUSION: This study suggested that the EuroSCORE II was a poor predictor for postoperative mortality in Indonesian patients who underwent cardiac surgery procedures. Therefore, EuroSCORE II may not be suitable for mortality risk prediction in Indonesian populations, and surgical planning should be decided on an individual basis.

Myocardial Protecting Role of Glutamine in Patients with Low Ejection Fraction Undergoing Elective On-Pump Coronary Artery Bypass Graft Surgery.

Purpose: Myocardial injury due to on-pump coronary artery bypass grafting (CABG) in patients with low ejection fraction (EF) is associated with poor outcomes. This study determines whether intravenous glutamine could protect the myocardium during on-pump CABG in patients with low EF. Materials and Methods: This was a double-blind, randomized controlled trial to assess glutamine as a myocardial protector during on-pump CABG in patients with left ventricle EF of 31-50%, conducted from January to October 2021. Patients in the glutamine group (n = 30) received 0.5 g/kg of 20% glutamine solution diluted with 0.9% NaCl up to 500 mL in total volume over a period of 24 hours. Patients in the control group (n = 30) received 0.9% NaCl over the same period. The primary outcomes were plasma troponin I and plasma glutamine levels. Secondary outcomes included α-ketoglutarate (α-KG) levels and histopathology scoring of the right atrial appendage tissue, plasma lactate levels, hemodynamic measurement, and morbidity. Results: Twenty-nine patients from each group (58 in total) were included in the analysis. Plasma troponin I levels at 6 and 24 hours after cardiopulmonary bypass (CPB) were significantly lower in the glutamine than the control group (mean 3.43 ± 1.51 ng/mL vs mean 4.41 ± 1.89 ng/mL; p = 0.034; median 3.08 ng/mL [min-max: 1.30-6.59] vs median 3.77 ng/mL [min-max: 0.00-36.53]; p = 0.038, respectively). Plasma glutamine levels at 24 hours after CPB were significantly higher in the glutamine than the control group (mean 935.42 ± 319.10 µmol/L vs mean 634.79 ± 243.89 µmol/L, p = 0.001). Plasma lactate levels at 6 and 24 hours after CPB were significantly lower in the glutamine than the control group (median 5.30 mmol/L [min-max: 1.20-9.50] vs median 5.70 mmol/L [min-max: 2.80-11.30], p = 0.042; mean 2.08 ± 0.67 mmol/L vs mean 2.46 ± 0.69 mmol/L, p = 0.044, respectively). Myocardial injury score was significantly lower in the glutamine than the control group (mean 1.30 ± 0.24 vs mean 1.48 ± 0.26, p = 0.011). Conclusion: Perioperative administration of 0.5 g/kg intravenous glutamine solution over the period of 24 hours has myocardial protection effect in patients with low EF who undergo elective on-pump CABG.

The Effect of Low Preoperative Ejection Fraction on Mortality After Cardiac Surgery in Indonesia.

Background: Among cardiac surgery patients, low preoperative left ventricular ejection fraction (LVEF) is common and has been associated with poor outcomes. The objective of this study was to assess the association between LVEF and postoperative mortality in patients undergoing open-heart surgery in several hospitals in Indonesia. Methods: We conducted a multicenter study with the retrospective design using data from patients undergoing open-heart surgery in 4 institutions in Indonesia. Data regarding LVEF and other potential risk factors were extracted from medical records and compiled in one datasheet. Statistical analyses were performed to assess if low LVEF was associated with postoperative mortality and identify other potential risk factors. Results: A total of 4789 patients underwent cardiac surgery in participating centers during the study period. Of these, 189 subjects (3.9%) had poor preoperative LVEF. Poor LVEF was associated with postoperative mortality (adjusted OR 2.761, 95% CI 1.763-4.323, p < 0.001). Based on types of surgery, LVEF had a significant association with mortality only in CABG patients, while there was no such association in valve surgery and inconclusive in congenital surgery patients. Other significant independent predictors of in-hospital mortality included age more than 65 years old, non-elective surgery, the complexity of procedures, history of cardiac surgery, organ failure, CARE score ≥ 3, NYHA class ≥ III, and poor right ventricular function. Conclusion: Patients with low preoperative LVEF undergoing open-heart surgery had a higher risk of postoperative mortality. Cardiac surgery can be performed with acceptable mortality rates. Accurate selection of patients, risk/benefit evaluation, and planning of surgical and anesthesiological management are mandatory to improve outcomes.

Predictive Factors for Cardiopulmonary Resuscitation Failure.

OBJECTIVES: Patients with chronic diseases are often admitted to the hospital through the emergency room of the hospital because of complaints of dyspnoea, urinary retention, decreased consciousness and cardiac arrest requiring resuscitation. The purpose of this study is to find predictive factors for failure of cardiopulmonary resuscitation (CPR) in patients of chronic diseases. MATERIALS AND METHODS: This cross-sectional study took medical records of patients who were carried out from primary healthcare center in Yogyakarta from 2017 to 2019. Bivariate statistical analysis used Fisher's exact test to determine the relative risk; if P < 0.25, then multivariate analysis with logistic regression continued with the backward method to obtain the odds ratio (OR). RESULTS: The results indicate that cardiac arrest patients with sepsis are most likely to fail at CPR, whereas male patients are 9.1 times (OR 9.1); patients with acidosis, 8.1 times (OR 8.1); and patients with asystole heart rhythm, 7.8 times (OR 7.8, P < 0.05). We can conclude that male patients with sepsis, acidosis or asystole heart rhythm will almost certainly fail to receive resuscitation. CONCLUSION: Sepsis or septic shock, the male gender, acidosis, and asystole rhythm can be determinants of mortality in patients with chronic diseases who undergo CPR. It is necessary for one to test the application of the checklist or data from other hospitals and score the predictive factors to make the determination of the success of CPR easier.

The Attitude of Health Care Workers on Enhanced Recovery After Surgery for Cesarean Delivery: A Scoping Review.

OBJECTIVE: Previous systematic reviews have found that the enhanced recovery after surgery (ERAS) protocol for cesarean delivery can vary from one study to another, and the attitudes of health care professionals regarding ERAS methods and the implementation of the ERAS for cesarean delivery remain unclear. We aimed to identify the attitudes of health professionals toward ERAS in the context of cesarean delivery. DATA SOURCES: Systematic searches were conducted in 6 databases: PubMed, ScienceDirect, EBSCO, Scopus, the Cochrane Library, and Sage Journals from September 2010 to September 2020. STUDY SELECTION: A total of 4 articles were selected for analysis. All articles use survey methods and present health professional attitudes toward ERAS for cesarean delivery. DATA EXTRACTION AND SYNTHESIS: Data were extracted using Excel spreadsheets. The results obtained are presented descriptively. CONCLUSION: This review illustrates that there are many ERAS protocols that health care professionals have not yet implemented for cesarean delivery. Policymakers can use this knowledge to inform the promotion of the ERAS protocol for cesarean delivery.

Outcome of adult congenital heart disease patients undergoing cardiac surgery: clinical experience of dr. Sardjito hospital.

BACKGROUND: Patients with congenital heart disease require surgery to correct the cardiac defect they had in order to prevent heart failure. Unfortunately, data regarding outcome of adult CHD in Indonesia is still limited. In contrast with developed countries, many congenital heart surgery patients in developing countries are adults. The purpose of this study was to investigate the outcomes of cardiac surgery procedures among adult congenital heart disease patients, and what factors that might influence the outcome of surgery. METHODS: A retrospective study was performed on adult congenital heart disease patients undergoing cardiac surgery at Dr. Sardjito Hospital between April 2018 and March 2019. Variables included in the study were demographic characteristics, laboratory test results, comorbidities, premedication, Cardiopulmonary Bypass (CPB) and ischemia duration were included in the analysis. Outcomes were in-hospital mortality, hospital length of stay, and ICU length of stay. RESULTS: A total of 25 congenital heart disease patients [19 Atrial Septeal Defect (ASD) patients, and 6 Ventricular Septal Defect (VSD) patients] underwent a cardiac surgery procedure at Dr. Sardjito Hospital during the study period. Mean age was 31 ± 14.92 years. The majority of patients had pulmonary hypertension. During the study period, none of the patients died during postoperative care in the hospital, mean hospital length of stay (LOS) was 8.35 ± 3.39 days and ICU LOS was 26.53 ± 11.33 h. CONCLUSION: Surgery in adult patients with congenital heart disease may be successfully performed with low morbidity and mortality.

Length of intensive care unit stay following cardiac surgery: is it impossible to find a universal prediction model?

OBJECTIVES: Accurate models for prediction of a prolonged intensive care unit (ICU) stay following cardiac surgery may be developed using Cox proportional hazards regression. Our aims were to develop a preoperative and intraoperative model to predict the length of the ICU stay and to compare our models with published risk models, including the EuroSCORE II. METHODS: Models were developed using data from all patients undergoing cardiac surgery at St. Olavs Hospital, Trondheim, Norway from 2000-2007 (n = 4994). Internal validation and calibration were performed by bootstrapping. Discrimination was assessed by areas under the receiver operating characteristics curves and calibration for the published logistic regression models with the Hosmer-Lemeshow test. RESULTS: Despite a diverse risk profile, 93.7% of the patients had an ICU stay <2 days, in keeping with our fast-track regimen. Our models showed good calibration and excellent discrimination for prediction of a prolonged stay of more than 2, 5 or 7 days. Discrimination by the EuroSCORE II and other published models was good, but calibration was poor (Hosmer-Lemeshow test: P < 0.0001), probably due to the short ICU stays of almost all our patients. None of the models were useful for prediction of ICU stay in individual patients because most patients in all risk categories of all models had short ICU stays (75th percentiles: 1 day). CONCLUSIONS: A universal model for prediction of ICU stay may be difficult to develop, as the distribution of length of stay may depend on both medical factors and institutional policies governing ICU discharge.

Preoperative and intraoperative prediction of risk of cardiac dysfunction following open heart surgery.

CONTEXT: Cardiac dysfunction following open heart surgery is a major determinant of subsequent morbidity and mortality. OBJECTIVES: To develop a specific risk prediction model for postoperative cardiac dysfunction based on preoperative variables, to investigate whether prediction could be improved by inclusion of selected intraoperative variables and to compare our model with five previously published risk scores. DESIGN: Single-centre prospectively collected data. SETTING: Tertiary care centre, Middle Norway. PATIENTS: Four thousand nine hundred and eighty-nine patients (all eligible) undergoing open cardiac surgery from 2000 to 2007. MAIN OUTCOME MEASURES: Logistic regression models for postoperative cardiac dysfunction: predictive accuracy/calibration, discrimination as shown by area under the receiver operating characteristics curve, internal validity as indicated by bootstrapping, comparison of goodness-of-fit with predictions based on alternative risk scores. RESULTS: The preoperative model included chronic cardiac insufficiency, previous myocardial infarction, previous cardiac operation, pulmonary hypertension, renal dysfunction, low haemoglobin concentration, urgent operation and operation type other than isolated coronary artery bypass surgery. The area under the curve was 0.838 [95% confidence interval (CI) 0.812-0.864]. Risk prediction was accurate apart from a slight overestimation in the 2% of highest risk patients. Inclusion of a few intraoperative variables (inotropic or vasoconstrictor drugs, plasma or red cell transfusion) improved the model slightly, increasing the area under the curve to 0.875 (95% CI 0.854-0.896) or 0.890 (95% CI 0.863-0.902) for two equivalent models. On the basis of estimated shrinkage factors of 0.94, 0.97 and 0.98, respectively, the models should behave with 6% or less error in future datasets. Our preoperative model was significantly better than the previously published risk scores (P < 0.0002 for comparison of area under the curves). CONCLUSION: The preoperative model including variables obtained easily in routine clinical work performed well and was improved only slightly by inclusion of intraoperative variables. Performance was better than those of the five previously published risk scores.