Risk stratification analysis of operative mortality in coronary artery bypass surgery.

OBJECTIVE: We assessed the operative mortality of coronary artery bypass grafting (CABG) surgery using risk stratification. METHODS: In 294 consecutive patients who underwent CABG with or without concomitant surgery from August 1994 to December 1999, we compared operative mortality calculated conventionally and by risk stratification. Scores for each patient were calculated using the Parsonnet additive model and stratified based on the probability of operative mortality. RESULTS: Overall crude hospital mortality was 4.8%-4.0% among patients younger than 80 years and 14% among those 80 years of age or older (p = 0.0692). Hospital mortality was 12% in urgent/emergency surgery, and 1.5% in elective surgery (p < 0.0002), and 4.5% in CABG alone and 7.4% in CABG with concomitant surgery (p = 0.3763), and 25% in patients receiving vein grafts only and 3.0% in those receiving at least 1 artery graft (p = 0.0003). Overall patient distribution was 32% good, 20% fair, 20% poor, 11% high-risk, and 16% extremely high-risk. Predicted mortality was 2.2% for patients who were a good risk, 6.7% for fair-risk, 12% for poor-risk, 16% for high-risk, and 25% for extremely high-risk patients. Actual operative mortality was 1.0% for good-risk, 0% for fair-risk, 3.4% for poor-risk, 6.3% for high-risk, and 18% for extremely high-risk patients, making actual mortality significantly lower than that predicted. CONCLUSION: Comparing predicted mortality and actual mortality enabled us to objectively calculate operative results and assess operative quality.

[Early and mid-term results after cardiac or thoracic aortic surgery in patients aged 70 years and older--survival and quality of life].

The early and mid-term survival after cardiac or thoracic aortic surgery and influence of age to the operative mortality were examined in 168 consecutive patients aged 70 years and older from August 1994 to December 1998, together with assessment of postoperative quality of life (QOL). The mean age was 74.1 +/- 3.7 years old (70 to 86 years). 80 patients had IHD, 59 had VHD, 28 had TAA. Preoperative risk score was classified in 5 groups (good, fair, poor, high, extremely high) based on Parsonnet method. Current QOL of the survivors was assessed using Asanoi method with questionnaire by a letter. There were 9 early deaths (5.4%). Following the Parsonnet model observed mortality was absolutely lower than predicted mortality. When age score was excluded in the Parsonnet model, the observed mortality became almost equal with the predicted mortality. There were 22 late deaths (6.9%/P-Y). The actuarial survival rate of age 70 to 74 group was significantly higher than the age 75 years and older group (p = 0.0021). The actuarial survival rate of TAA group was significantly lower than the VHD or IHD group (p < 0.02). Postoperative NYHA and activity score of TAA group were better than VHD or IHD group. We got satisfactory answers for operation in 95% current survivors. Patients aged 70 years and older will be undergone cardiac or thoracic aortic surgery at a reasonable risk and well satisfaction.

Left ventricular myxoma: report of a case.

Although recent advances in echocardiography have made it easier to detect cardiac tumors, left ventricular myxomas are still rare and often not found until the patient presents with a history of syncopal episodes or systemic embolization. Left ventricular myxomas are usually benign and curable; however, unreliable excision of the myxoma due to poor visualization of the left ventricular cavity can result in recurrence. To prevent recurrence, it is necessary to select the most appropriate surgical approach to excise the myxoma completely. We report herein the case of a patient in whom surgical excision of a left ventricular myxoma arising from the posterior wall of the left ventricle was successfully performed.

Valve surgery in elderly patients 70 years or older: early and late results.

Between April 1986 and March 1997, 75 patients (Group E) who were 70 years or older underwent valvular operations, and another 73 patients who were under 70 years constituted a comparison group (Group Y). Valve replacement was performed on 131 patients (Group E; 65 patients, Group Y; 66 patients), reparative procedures on 11 patients (Group E; 7, Group Y; 4), and aortic root replacement on 5 (Group E; 3, Group Y; 2). Coronary artery bypass grafting was concomitantly performed on 13 patients (Group E; 7, Group Y; 6). In the elderly patients, preoperative clinical status, including cardiac and non cardiac organ functions, was not necessarily more severe than that in the younger patients, however, perioperative restoration of cardiac and pulmonary functions required a longer time in Group E than Group Y. There were no significant differences in operative mortality rate, long-term survival rate, the probability of freedom from all events related to native and prosthetic valves, and in activity of daily life between Group E and Group Y. These results suggest that valvular operation for elderly patients 70 years or older may be safely performed with operative risks similar to those of younger patients by application of modern surgical techniques.

[Surgery for aortic valvular disease with congenital quadricuspid aortic valve].

A case of quadricuspid aortic valve is reported. A 69-year-old man was hospitalized with chest oppression at rest and abnormal electrocardiogram and diagnosed aortic regurgitation by echocardiography and aortic angiography. Aortic regurgitation was grade III according to Seller. Aortic valve replacement was performed successfully with a 21 mm St. Jude Medical valve. The aortic valve showed four cusps consisting of two equal larger cusps and two equal smaller cusps which was type C according to Hurwitz. Each valve was thickened and adhered, and fenestrations were found at each commissure. The right coronary ostium was small but not displaced. Twenty five cases in literature which were corrected surgically are also reviewed. Quadricuspid aortic valve is a rare anomaly but must be considered as a malformation which leads to severe valve failure in later life.

[Use of inferior epigastric artery for coronary artery bypass grafting].

The usefulness of the free inferior epigastric artery (IEA) as a coronary bypass graft was studied. Among 149 patients for coronary bypass grafting (CABG) between October 1992 and December 1994, the free IEA was used in 12 patients. The mean number of distal anastomosis was 3.7 per patient. The mean distal size of the IEA was 1.3 mm in diameter and the mean length was 9.4 cm. The IEA graft was anastomosed to the obtuse marginal branch in 5, to the diagonal branch in 4, and the right ventricular branch in 3. The proximal anastomosis of the IEA was constructed to the ascending aorta in three and to the saphenous vein (SVG) or to the internal thoracic artery (ITA) in 4 or 5, respectively. Postoperative angiogram demonstrated patent graft in ten and occluded graft in two in whom the size of IEA was less than 1.0 mm in distal diameter and the IEA was anastomosed to the aorta or to the SVG. The IEA was considered to be useful alternative arterial graft when it was used as "interposed graft" of which proximal anastomosis was made to the ITA and size-matching of the graft to the coronary artery was appropriate. The long-term patency of the graft can determine the true efficacy of the IEA for CABG.

[Reconstructive surgery for acquired mitral regurgitation].

Between December, 1967, and July, 1994, 96 patients underwent repair of the mitral valve for acquired mitral valve regurgitation. According to Carpentier's classification, mitral valve pathology resulting in valve regurgitation was classified into three types; 4 patients assigned to type I, 63 type II, and 29 type III. The operative mortality rate was 1.0%. Follow-up data were available in 95 patients from 0.5 year to 25.3 years (mean average 8.8 years). The late mortality rate were not different between patients with valve pathology of type I, II and those with valve pathology of type III. Thromboembolism occurred on three patients for an embolic rate of 0.4% per patient-years. Twenty-eight patients required reoperation for residual MR and dehiscence of suture lines (type II; 10 cases, reoperation-free rate at 20 years, 83.2%) or recurrent MR due to progression of valve deformity (type III, 18 cases, reoperation-free rate at 20 years, 14.8%). These results demonstrate that patients with type I and II valve are good candidates for MVP, and that high incidence of reoperation for recurrent MR may limit the application of MVP to selected patients with type III valve.

[The study of continuous arterial infusion chemotherapy with 5-FU and CDDP in patients with hepatocellular carcinoma].

Between Feb. 1992 and March in 1994, 14 patients with hepatocellular carcinoma (7: recurrence, 7: unresectable) received continuous arterial infusion of 5-FU and CDDP via implanted reservoir. For the next five days, 10 mg/body of CDDP and 250 mg/body of 5-FU using arterial infusion were administered. It was discontinued for two days, as one course, and 4 courses were basally administered. The duration of the administration was 24 or 6 hours/day. Side effects consisted of nausea or loss of appetite for 7 (50%), suppression of bone marrow for 3 (21%), and they disappeared after the agents were discontinued. However, there were 3 patients with gastro-duodenal ulcer, so careful follow-up was necessary. The efficacy rate was 64% and two-year survival rate was 57% and thus this treatment seemed to be effective. Further study on the duration and dose of the administration is necessary to improve the therapeutic effect and QOL.