RESUMEN
Background: The Gatti and the bilateral internal mammary artery (BIMA) scores were created to predict the risk of deep sternal wound infection (DSWI) after bilateral internal thoracic artery (BITA) grafting. Methods: Both scores were evaluated retrospectively in two consecutive series of patients undergoing isolated multi-vessel coronary surgical procedures-i.e., the Trieste (n = 1,122; BITA use, 52.1%; rate of DSWI, 5.7%) and the Besançon cohort (n = 721; BITA use, 100%; rate of DSWI, 2.5%). Baseline patient characteristics were compared between the two validation samples. For each score, the accuracy of prediction and predictive power were assessed by the area under the receiver-operating characteristic curve (AUC) and the Goodman-Kruskal gamma coefficient, respectively. Results: There were significant differences between the two series in terms of age, gender, New York Heart Association functional class, chronic lung disease, left ventricular function, surgical priority, and the surgical techniques used. In the Trieste series, accuracy of prediction of the Gatti score for DSWI was higher than that of the BIMA score (AUC, 0.729 vs. 0.620, p = 0.0033). The difference was not significant, however, in the Besançon series (AUC, 0.845 vs. 0.853, p = 0.880) and when only BITA patients of the Trieste series were considered for analysis (AUC, 0.738 vs. 0.665, p = 0.157). In both series, predictive power was at least moderate for the Gatti score and low for the BIMA score. Conclusions: The Gatti and the BIMA scores seem to be useful for pre-operative evaluation of the risk of DSWI after BITA grafting. Further validation studies should be performed.
Asunto(s)
Puente de Arteria Coronaria/efectos adversos , Arterias Mamarias/trasplante , Esternón/cirugía , Infección de la Herida Quirúrgica/epidemiología , Encuestas y Cuestionarios/normas , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Comorbilidad , Puente de Arteria Coronaria/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Curva ROC , Reproducibilidad de los Resultados , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores SexualesRESUMEN
OBJECTIVE: Retrograde cerebral perfusion (RCP) is a brain protection technique that is adopted generally for anticipated short periods of deep hypothermic circulatory arrest (DHCA). However, the real impact of this technique on cerebral protection during DHCA remains a controversial issue. METHODS: For 344 (59.5%) of 578 consecutive patients (mean age, 66.9 ± 10.9 years) who underwent cardiovascular surgery under DHCA at the present authors' institution (1999-2015), RCP was the sole technique of cerebral protection that was adopted in addition to deep hypothermia. Surgery of the thoracic aorta was performed in 95.9% of these RCP patients; in 92 cases there was an aortic arch involvement. Outcomes were reviewed retrospectively. The focus was on postoperative neurological dysfunctions. RESULTS: There were 33 (9.6%) in-hospital deaths. Thirty-one (9%) patients had permanent neurological dysfunctions and 66 (19.1%) transitory neurological dysfunctions alone. Age older than 74 years (odds ratio [OR], 1.88, P = .023), surgery for acute aortic dissection (OR, 2.57; P = .0009), and DHCA time longer than 25 minutes (OR, 2.44; P = .0021) were predictors of neurological dysfunctions. The 10-year nonparametric estimate of freedom from all-cause death was 61.8% (95% confidence interval, 57.8%-65.8%). Permanent postoperative neurological dysfunctions were risk factors for cardiac or cerebrovascular death (hazard ratio, 2.6; P = .039) even after an adjusted survival analysis (P < .04). CONCLUSIONS: According to the study findings, RCP, in addition to deep hypothermia, combines with a low risk of neurological dysfunctions provided that DHCA length is 25 minutes or less. Permanent postoperative neurological dysfunctions are predictors of poor late survival.
Asunto(s)
Circulación Cerebrovascular , Trastornos Cerebrovasculares/prevención & control , Paro Circulatorio Inducido por Hipotermia Profunda , Perfusión/métodos , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/mortalidad , Trastornos Cerebrovasculares/fisiopatología , Distribución de Chi-Cuadrado , Paro Circulatorio Inducido por Hipotermia Profunda/efectos adversos , Paro Circulatorio Inducido por Hipotermia Profunda/mortalidad , Supervivencia sin Enfermedad , Femenino , Humanos , Italia , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Perfusión/efectos adversos , Perfusión/mortalidad , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
PURPOSE: Risk stratification is of utmost importance for patients with infective endocarditis (IE) who need surgery. However, for these critically ill patients, aspecific scoring systems are used to predict the risk of death after surgery. The aim of this study was both to analyze the risk factors for in-hospital death, which complicates surgery for IE and to create a mortality risk score based on the results of this analysis. METHODS: Outcomes of 138 consecutive patients (mean age 60.6 ± 8.5 years) who had undergone surgery for IE in an Italian cardiac surgery center between 1999 and 2015 were reviewed retrospectively and a risk factor analysis (multivariable logistic regression) for in-hospital death was performed. The discriminatory power of a new predictive scoring system was assessed with the receiver-operating characteristic (ROC) curve analysis. RESULTS: Twenty-eight (20.3%) patients died in hospital following surgery. Anemia [odds ratio (OR) 11.0, p = 0.035), New York Heart Association class IV (OR 2.61, p = 0.09), critical state (OR 4.97, p = 0.016), large intracardiac destruction (OR 6.45, p = 0.0014), and surgery of the thoracic aorta (OR 7.51, p = 0.041) were independent predictors of hospital death. A new scoring system was devised to predict in-hospital death after surgery for IE (area under ROC curve, 0.828, 95% confidence interval, 0.754-0.887). The score outperformed six of seven scoring systems, for early death after cardiac surgery, that were considered. CONCLUSIONS: A simple scoring system based on risk factors for in-hospital death was specifically created to predict mortality risk after surgery for IE. Prospective studies are needed for the score validation.
Asunto(s)
Endocarditis/cirugía , Mortalidad Hospitalaria , Complicaciones Posoperatorias/mortalidad , Anciano , Análisis Factorial , Femenino , Humanos , Italia/epidemiología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Complicaciones Posoperatorias/etiología , Curva ROC , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: The Gatti score is a weighted scoring system based on risk factors for deep sternal wound infection (DSWI) that was created in an Italian center to predict DSWI risk after bilateral internal thoracic artery (BITA) grafting. No external evaluation based on validation samples derived from other surgical centers has been performed. The aim of this study is to perform this validation. PATIENTS AND METHODS: During 2015, BITA grafts were used as skeletonized conduits in all 255 consecutive patients with multi-vessel coronary disease who underwent isolated coronary bypass surgery at the Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France. Baseline characteristics, operative data, and immediate outcomes of every patient were collected prospectively. A DSWI risk score was assigned to each patient pre-operatively. The discrimination power of both models, pre-operative and combined, of the Gatti score was assessed with the calculation of the area under the receiver operating characteristic curve. RESULTS: Fourteen (5.5%) patients had DSWI. Major differences both as the baseline characteristics of patients and surgical techniques were found between this series and the original series from which the Gatti score was derived. The area under the receiver operating characteristic curve was 0.78 (95% confidence interval: 0.64-0.92) for the pre-operative model and 0.84 (95% confidence interval: 0.69-0.98) for the combined model. CONCLUSIONS: The Gatti score has proven to be effective even in a cohort of French patients despite major differences from the original Italian series. Multi-center validation studies must be performed before introducing the score into clinical practice.