Incidence, predictors, and significance of abnormal cardiac enzyme rise in patients treated with bypass surgery in the arterial revascularization therapies study (ARTS).

BACKGROUND: Although it has been suggested that elevation of CK-MB after percutaneous coronary intervention is associated with adverse clinical outcomes, limited data are available in the setting of coronary bypass grafting. The aim of the present study was to determine the incidence, predictors, and prognostic significance of CK-MB elevation following multivessel coronary bypass grafting (CABG). METHODS AND RESULTS: The population comprises 496 patients with multivessel coronary disease assigned to CABG in the Arterial Revascularization Therapies Study (ARTS). CK-MB was prospectively measured at 6, 12, and 18 hours after the procedure. Thirty-day and 1-year clinical follow-up were performed. Abnormal CK-MB elevation occurred in 61.9% of the patients. Patients with increased cardiac-enzyme levels after CABG were at increased risk of both death and repeat myocardial infarction within the first 30 days (P=0.001). CK-MB elevation was also independently related to late adverse outcome (P=0.009, OR=0.64). CONCLUSIONS: Increased concentrations of CK-MB, which are often dismissed as inconsequential in the setting of multivessel CABG, appear to occur very frequently and are associated with a significant increase in both repeat myocardial infarction and death beyond the immediate perioperative period.

Comparison between closed drainage techniques for the treatment of postoperative mediastinitis.

BACKGROUND: It is not clear which closed drainage technique is preferred as initial therapy for mediastinitis as soon as it is detected after cardiac surgery. A comparison is made between a continuous irrigation system and vacuum drainage using redon catheters. METHODS: A retrospective cohort study of patients undergoing cardiac surgery between January 1, 1989 and January 1, 1997 was made. Patients who developed a deep surgical site infection at the sternotomy site and who were treated with one of the two closed drainage techniques were included. Patient characteristics and procedure-related variables were analyzed. Also, variables related to the drainage procedure were included. Outcome parameters were treatment failure, total hospital stay, postoperative hospital stay and in-hospital mortality. RESULTS: The study population consisted of 11,488 patients, of whom 102 developed a deep surgical site infection (0.89%). The final study population consisted of 60 patients who fulfilled the inclusion criteria. From those, 29 were treated with continuous irrigation and 31 were treated with vacuum drainage. Both groups were comparable for patient characteristics and procedure-related variables. Treatment failure was more than three times as likely in the continuous irrigation group (relative risk: 3.2, 95% confidence interval: 1.3 to 7.7). Also, postoperative (p = 0.03) and total hospital stay (p = 0.03) were significantly longer in the group treated with continuous irrigation (mean prolongation of 14 and 13 days, respectively). After correcting for confounding, using multivariate analysis, the treatment method employed was found to be an independent and statistically significant variable associated with treatment failure (p = 0.04). CONCLUSIONS: Closed drainage using vacuum-drainage system is the initial therapy of choice for patients with mediastinitis after cardiac surgery, because it is associated with significantly less treatment failure and a shorter stay in hospital.

Death on the waiting list for cardiac surgery in The Netherlands in 1994 and 1995.

OBJECTIVE: To describe the causes and circumstances of death regarding patients who died in 1994 and 1995 while on a waiting list for cardiac surgery in the Netherlands. DESIGN: Retrospective multicentre case study. SETTING: 11 Dutch cardiac surgery centres. PATIENTS: All patients reported as dying while on the waiting list for cardiac surgery in 1994 and 1995. MAIN OUTCOME MEASURES: Classification of death by an independent adjudication committee into "erroneously reported", "waiting list related" or "not waiting list related". Death was judged as "waiting list related" if the clinical course would have been substantially different if there had been unrestricted surgical capacity. RESULTS: 138 and 129 deaths were reported in 1994 and 1995, respectively. 43 deaths (16%) were considered as erroneously reported. 181 of the remaining 224 cases were adjudicated as waiting list related. Median time from acceptance for surgery to death was 35 days (interquartile range 14-75 days). 97 of 181 deaths occurred within six weeks following addition to the waiting list. The estimated incidence of death ranged from 1.33 per 1000 patient-weeks during weeks 2-4 to 0.68 per 1000 patient-weeks after 12 weeks. CONCLUSIONS: The causes and circumstances of death are waiting list related for approximately 100 patients per year in the Netherlands. At least half of the deaths may occur within the first six weeks. Waiting lists for cardiac surgery engender high risks for the patients involved.

Papillary fibroelastoma of the aortic valve in a patient with an acute myocardial infarction.

We describe a patient with a myocardial infarction in whom a tumor near the aortic valve was identified by routine transthoracic echocardiography. Transesophageal echocardiography proved to be particularly useful in identifying the attachment of the tumor to the aortic valve and enabled a surgical approach through the ascending aorta. On microscopic examination, the tumor appeared to be a papillary fibroelastoma.