Frailty assessment to predict short term outcomes after cardiac surgery.

BACKGROUND: Frailty has been used to predict outcome in gerontology but has only recently been applied to measures of perioperative risk stratification. It provides information on physiological reserve not addressed by current scoring systems which are heavily reliant on age. METHODS: We enrolled 123 patients over 70-years old (mean age 77.1 years, 69% male) undergoing open cardiac surgery, and assessed in 11 different frailty measures. These were combined into a cumulative score that was stratified into robust (49%), borderline (37%), and frail (14%) groups. The groups were compared for a short-term composite measure comprising mortality, deep sternal wound infection, inter-facility discharge or prolonged length of stay, as well as 3-month mortality and quality of life and 6-month mortality. RESULTS: Frail patients had a considerably higher incidence of an unfavorable composite outcome (52.9%) compared to their borderline (28.3%) and robust (13.3%) counterparts (p = 0.003). Hospital mortality was 4/123 (3.3%) with a further 3 within 30 days, and 2 late deaths occurred within 6 months postoperatively. This was statistically significant with greater mortality at 6 months in the frail cohort. Quality of life at 3 months showed a trend towards greater improvement in the borderline patients compared to either the robust or frail groups. DISCUSSION: Frailty status impacts on both short- and intermediate-term outcomes, including postoperative quality of life. In an ageing population where nonmaleficence and resource allocation are increasingly important, individual assessment in marginal surgical candidates may provide additional information to both the patient and clinician.

Does moderate tricuspid regurgitation require attention during mitral valve surgery?

BACKGROUND: This study aims to determine whether tricuspid regurgitation (TR) ≥ 2+ requires attention during mitral valve surgery. METHODS: From April 1999 to 2009, 161 patients undergoing primary, isolated mitral valve procedures were assessed. Preoperative moderate TR (≥2+) was present in 56 of 161 patients and tricuspid valve repair (TVR: ring annuloplasty) was carried out on 22 of 56 patients with TR ≥ 2+. Baseline echocardiogram included TR severity (ASE criteria), TR velocity, estimated right atrial pressure, visual assessment of right ventricular failure and strain. Follow-up was 47 ± 33 months (96% complete); 91 of 161 patients overall (57%) and 44 of 45 patients with TR ≥ 2+ had follow-up echocardiogram. RESULTS: Patients with moderate TR had worse baseline functional class and operative risks, both worst in the non-TVR group. Overall mortality was 15% (n = 23), comprising 2.5% (4/161) 30-day mortality and 12% (9/157) late death. Poorer preoperative TR was associated with worse survival by univariate analysis (P = 0.046), after correction for right ventricular function and pulmonary artery pressure (P = 0.049), age and diabetes (P = 0.041). Despite lower risk of TR ≥ 2+ with TVR, 5-year survival was 42%, which was less than TR < 2+ and that of non-TVR group (90%, P = 0.003). Improvement in overall functional class (NYHA) was better in the non-TVR group (TVR: preoperative 2.1 ± 1.5; post-operative 1.2 ± 1.1 (P = 0.02) versus non-TVR: preoperative 1.8 ± 1.4, post-operative 1.2 ± 0.9 (P < 0.0001)). There was no difference in quality of life (QOL) indices (SF-36 questionnaire) at follow-up between patients with TR < 2+ and TR ≥ 2+ preoperatively, or across all levels of TR before or after surgical repair. CONCLUSIONS: Preoperative TR ≥ 2+, non-TVR group had more favourable functional class and mid-term survival with comparable QOL and echocardiographic parameters to the TVR group.

Is alpha-B crystallin an independent marker for prognosis in lung cancer?

BACKGROUND: Alpha B-crystallin (CRYAB) is an oncogene that increases tumour survival by promoting angiogenesis and preventing apoptosis. CRYAB is an independent prognostic marker in epithelial tumours including head and neck squamous cell carcinoma and breast cancer where it is predictive of nodal status and associated with poor outcome. We explored the role of CRYAB in non-small-cell lung cancer (NSCLC). METHODS: Immunohistochemical analysis was performed on 50 samples. Following staining with anti-alpha-B crystallin antibody, a blinded pathologist scored samples for nuclear (N) and cytoplasmic (C) staining intensity. Analysis was performed using Cox's proportional hazards model. RESULTS: There were 32 adenocarcinomas and 18 squamous cell carcinomas. The median tumour size was T2, grade 2 moderately differentiated, and 10 patients had nodal spread. Recurrence was seen in 22 patients (46%). Mortality was 48%, with median time to mortality 871 days. N staining was detected in eight samples (16%), and C staining in 20 (40%), with both N and C staining positive in five (10%). Staining for CRYAB predicted neither recurrence (N stain p=0.78, C stain p=0.38) nor mortality (N stain p=0.86, C stain p=0.66). CONCLUSION: CRYAB did not predict outcomes in patients treated for NSCLC. Larger studies are required to validate this finding.

Surgical pulmonary embolectomy: mid-term outcomes.

BACKGROUND: Despite the widespread use of venous thromboembolism (VTE) prophylaxis in hospitalized patients, pulmonary embolism continues to occur. Massive pulmonary embolism is associated with a high mortality. Surgical embolectomy has traditionally been reserved for cases with haemodynamic collapse or where thrombolysis is contraindicated or has failed. METHODS: Data on 10 patients who underwent surgical embolectomy (40% male, mean age 49 years (range 25-72)) from January 2003 to February 2010 were prospectively collected and retrospectively analysed. RESULTS: Diagnosis was made using computed tomography pulmonary angiography in eight patients and echocardiography in two. Syncope was the most common presenting symptom (7 out of 10, 70%) and relative immobilization was the most common risk factor (7 out of 10, 70%). Four patients (40%) suffered preoperative cardiac arrest, with a further two on induction of anaesthesia. Thirty-day mortality was 4 out of 10 (40%), with one late death. Mean follow-up of five survivors was 39 months and included clinic review or telephone interview, SF-36 questionnaire for quality of life, transthoracic echocardiography for right ventricular (RV) function and respiratory function testing. All survivors received an inferior vena cava filter and 6 months of anticoagulation with no cases of recurrent thromboembolism. RV systolic dysfunction was severe in all cases prior to surgery, but improved to near normal at follow-up. CONCLUSIONS: Survivors had good quality of life, were functionally NYHA class I-II with normal respiratory function.

Return to work after coronary artery bypass in patients aged under 50 years.

BACKGROUND: This study was designed to identify factors associated with return to work and quality of life in patients undergoing primary coronary artery bypass at age <50 years. METHODS: 172 patients<50-years old underwent primary coronary artery bypass between January 2000 and December 2006. Predictors of return to work were analysed from variables in a prospectively collected database and on follow-up by the SF-36 questionnaire in 129 (75%) patients. RESULTS: 136 (79%) patients were working prior to surgery. The educational level was: primary 14.5%, secondary 47%, trade 22%, tertiary 13%, and postgraduate 3%. Type of occupation was blue collar 51%, white collar 41%, pensioner 27%, and unspecfied 8%. The mean follow-up was 86.4±23.4 months. One hundred and twenty-six (69%) patients attended cardiac rehabilitation. Forty (23%) patients experienced recurrence of symptoms; 11 (6%) required reintervention. One hundred and twenty-seven (93%) patients returned to work postoperatively. Univariate predictors of return to work were male sex, blue-collar work, and working prior to surgery. Independent predictors of return to work were working prior to surgery and blue-collar work. Patients who returned to work had significantly higher scores in all 8 domains on the SF36-Questionnaire compared to those who did not return to work. CONCLUSIONS: Preoperative employment and blue collar occupation were associated with a higher rate of return to work after coronary artery bypass in patients of working age. Patients who returned to work had significantly better measured quality of life than those who did not.

Ischemic cardiomyopathy: midterm survival and its predictors.

BACKGROUND: the aim of the study was to analyze all-cause mortality and predictors of long-term survival after myocardial revascularization for ischemic cardiomyopathy. METHOD: data of 101 patients (mean age, 63.86 years; age range, 30-85 years; 92% male), operated on with stable coronary artery disease and left ventricular ejection fraction <30% between April 2000 and June 2010, were analyzed. RESULTS: operative mortality was 1.9% (2/101). There was a significant improvement in left ventricular ejection fraction from 25.99% ± 3.8% preoperatively to 34% ± 12% postoperatively (p <0.0001). The mean duration of follow-up was 56.3 ± 33 months, and it was 97% complete (98/101). There were 18/96 (18.75%) late deaths. Overall actuarial survival at 1, 3, 5, and 10 years was 96%, 89%, 83% and 75%, respectively. Univariate predictors of late death were preoperative arrhythmia, cerebrovascular disease, peripheral vascular disease, and logistic EuroSCORE. Multivariate predictors of late death were cerebrovascular disease and preoperative arrhythmia. CONCLUSION: our study suggests that myocardial revascularization for ischemic cardiomyopathy improves left ventricular ejection fraction and is associated with favorable long-term survival. Patients with cerebrovascular disease and preoperative arrhythmias had poorer outcomes.

Association between body mass index and outcome of coronary artery bypass.

Studies have shown disparate findings regarding body mass index and outcomes after coronary artery bypass. We analyzed body mass index and other clinical variables that might predict morbidity and mortality after primary isolated coronary artery bypass. Data on 4,425 patients (79% men) were reviewed retrospectively. They were classified as underweight (1.6%), normal weight (65%), obese (32%), and morbidly obese (1.4%) according to body mass index <20, 20-29, 30-39, and >40 kg·m(-2), respectively. Multiple logistic regression was used for correlates of 30-day outcome. Cox regression was used for predictors of late outcome in underweight and morbidly obese patients. There were 45 (1%) deaths and 234 (5%) cases of morbidity within 30 days. Independent correlates of 30-day morbidity were smoking, logistic EuroSCORE, blood and blood product transfusions. Correlates of 30-day mortality were logistic EuroSCORE and blood transfusion. The only independent predictor of late death in underweight and morbidly obese patients was preoperative arrhythmia. Body mass index was not a predictor of 30-day morbidity or mortality. The 1-, 3-, and 7-year survival rates were not significantly different between underweight and morbidly obese patients. Body mass index did not affect short-term outcomes after primary coronary artery bypass grafting.

Surgical management and mid-term outcomes of 108 patients with infective endocarditis.

This study evaluates the early and mid-term outcomes, predictors of mortality and morbidity and quality of life of patients operated for infective endocarditis. Data on 108 patients undergoing 113 surgical procedures during October 1998 to January 2010 was prospectively collected. NYHA Class was >III in 49 (43.4%) cases. Thirty-seven (33%) patients had isolated mitral valve procedures, 58 (51%) had aortic valve, two had tricuspid valve and 16 had multivalvular procedures. Active endocarditis was noted in 86 (76%) procedures, native valve endocarditis in 105 (93%) and prosthetic valve endocarditis in eight procedures. Logistic EuroSCORE at presentation was >14 in 18 (17%) patients. Staphylococcus aureus was the most common organism isolated. Follow-up was carried out in 76/85 (88.37%) of surviving patients, and the mean follow-up time was 37.2 months. Functional class and quality of life (using EQ-5D Health Questionnaire) were assessed by telephone interviews. NYHA Class on follow-up was I-II in 62/76 (83%). Multivariate predictor of 30-day mortality was peripheral vascular disease (p = 0.025) whilst multivariate predictors of long-term survival were male sex (p = 0.01), peripheral vascular disease (p = 0.02) and bypass time (p = 0.006). The overall survival was 87% at one year and 80% at five years. Thirty-three percent (25/76) patients reported a score reflecting full health. Optimal antibiotic therapy and timely surgical intervention were associated with improved functional class, quality of life and mid-term survival.

Cardiac surgery in the presence of dialysis: effect on mid-term outcomes and quality of life.

BACKGROUND: this study evaluates the impact on short and mid-term outcomes and quality of life of dialysis dependent patients undergoing cardiac surgery. The benefit to patients from a bio-psycho-social perspective is put into context via an inter-personal patient interview. METHODS: the study period was from February 1999 to February 2009. Data on 45 dialysis dependent patients undergoing cardiac surgery was prospectively collected and analysed retrospectively. The mean age was 59.9 years and sex ratio (M:F) of 32:13. All patients were New York Heart Association (NYHA) class >2 preoperatively. Fifty-five percent (25/45) of these patients had coronary artery bypass graft surgery (CABG) and 28% (12/45) aortic valve replacement surgery alone. Forty-two variables were studied to define predictors of outcome. Follow-up was 100% (18/18) with a mean follow-up time of 48.1 months (0-124 months). They were followed up with quality of life and functional coping score surveys (SF-36). RESULTS: the main postoperative morbidities were pulmonary complications 20% (9/45), multi-organ failure 11% (5/45) and blood transfusion rates 40% (18/45). The 30 day mortality of the dialysis patients was 13.3% (6/45) and late death was 54% (21/39). Increasing age, pulmonary complications and blood product usage were the significant predictors of both 30 day mortality (age: p=0.02, pulmonary: p=0.003, blood product usage: p=0.03) and late death (age: p=0.008, pulmonary: p=0.02, blood product usage: p=0.02). New York Heart Association class was I-II in 83% (15/18) on long term follow up. All five patients awaiting renal transplants received their transplant in the first six months post-operatively. The overall survival at one year was 78% and five years was 40%. On SF-36 health questionnaire all patients scored less on physical functioning than the Australian norms (24.89 ± 4.10). CONCLUSIONS: cardiac surgery in the presence of renal failure is associated with significant morbidity and mortality. The overall survival and quality of life of dialysis patients undergoing cardiac surgery is poor.

Early and mid-term outcomes following surgical management of infective endocarditis with associated cerebral complications: a single centre experience.

BACKGROUND: Surgical management of patients with infective endocarditis (IE) who have suffered preoperative cerebrovascular complications remains controversial. This study evaluates the impact of timing from stroke to valvular surgery on the early and mid-term neurological sequelae, functional status and quality of life in this high-risk group of patients with IE. METHOD: Data on 13/108 (12%) patients with IE who suffered cerebrovascular complications during the period 1998-2009 was prospectively collected. Mean follow-up was 37.2 months (100% complete). RESULTS: Three of 13 (23%) suffered haemorrhagic stroke, 10/13 (77%) had embolic events (nine, stroke; one, TIA). The clinical diagnosis was made by a neurologist in 6/13 (46%) and confirmed in all by CT scan. Twelve of 13 had motor deficit involving MCA territory. Thirty-day mortality was 2/13 (one, cardiac; one, neurological) with no late deaths. The mean time from embolic stroke to surgery was 2.3 weeks (range 3-60 days). The reason for operating on eight patients in less than two weeks was heart failure in five, uncontrolled sepsis, AMI and TIA (one each). 2/8 (25%) suffered additional postoperative neurological events (one, brain death, one, new MCA stroke). On follow-up of the remaining eight patients with embolic events, five had improved neurology and three had stable neurology. The mean time to surgery from haemorrhagic stroke was 5.8 weeks (range 3-60 days). Deficit improved in two patients (<1 week, 1; >8 weeks, 1). On follow-up the NYHA class was I-II in 6/11 (56%). The EQ-5D questionnaire was used to assess quality of life. Mean index for the group was 0.67 using the US preference-weighted index score (SD 0.27). CONCLUSIONS: Results regarding timing for haemorrhagic stroke cannot be defined from the small numbers. Timely surgical intervention (embolic greater than two weeks and preferably four weeks in absence of heart failure) is associated with acceptable neurological outcome, functional class and quality of life.