Comparison of Early and Late Mortality in Men and Women After Isolated Coronary Artery Bypass Graft Surgery in Stockholm, Sweden, 1980 to 1989

AbstractObjectives. We sought to analyze early and late mortality after coronary artery bypass graft surgery (CABG) in relation to gender.Background. Early mortality after CABG is generally higher in women than in men, but the causes are controversial. Few studies have investigated long-term mortality after CABG in relation to gender.Methods. In all, 3,326 men and 607 women underwent isolated CABG in Stockholm from 1980 to 1989. Mortality for these patients was followed by means of the National Cause of Death Register, from the time of operation until the end of 1990. Survival was evaluated by life-table methods and by proportional hazards regression.Results. Early mortality (within 30 days) was 3% in women and 1.7% in men, corresponding to a relative risk of 1.8 (95% confidence interval [CI] 1.0 to 3.0) in women compared with men. When age and body surface area were taken into account, the relative risk was 1.0 (95% CI 0.5 to 2.0), which was not markedly different but multivariate analyses that included hypertension, diabetes mellitus, previous myocardial infarction, left ventricular function and number of diseased vessels. Only small gender differences in mortality were observed for 5 years after the operation among those who survived for 30 days.Conclusions. The results suggest that men and women run similar risks of early and late mortality after CABG when patient characteristics are taken into account.(J Am Coll Cardiol 1997;29:659–64

Increased platelet reactivity and platelet–leukocyte aggregation after elective coronary bypass surgery

Inflammatory mechanisms are activated, and thrombotic complications occur during the initial months after coronary artery bypass grafting (CABG). Therefore, changes over time of platelet activation and platelet–leukocyte interactions after CABG are of interest. Whole-blood flow cytometry was performed before, and 4–6 days, one month, and three months after elective CABG in 54 men with stable coronary artery disease treated with acetylsalicylic acid (ASA). Single platelets and platelet–leukocyte aggregates (PLAs) among monocytes (P-Mon), neutrophils (P-Neu), and lymphocytes (P-Lym) were studied without and with stimulation by submaximal concentrations of ADP, thrombin, and the thromboxane analog U46619. White blood cell counts were increased during the initial postoperative course, and platelet counts were increased after one month. Platelet P-selectin expression was significantly enhanced at one month when stimulated by thrombin and U46619 and at three months with ADP and thrombin. All PLAs subtypes were increased at one month without stimulation in vitro. P-Mon and P-Neu stimulated by ADP, thrombin, or U46619 were significantly increased one month after the operation but decreased compared to baseline at three months. Agonist stimulated P-Lyms were increased at one month and remained increased at three months after ADP stimulation. There was significant platelet activation and formation of PLAs unstimulated and after agonist stimulation by ADP, thrombin, and a thromboxane analog after CABG in patients with stable coronary artery disease irrespective of ASA treatment. Changes observed up to three months after CABG support further studies of the clinical implications of protracted increases in platelet activation and platelet–leukocyte interactions

Multi-Organ Expression Profiling Uncovers a Gene Module in Coronary Artery Disease Involving Transendothelial Migration of Leukocytes and LIM Domain Binding 2: The Stockholm Atherosclerosis Gene Expression (STAGE) Study

Environmental exposures filtered through the genetic make-up of each individual alter the transcriptional repertoire in organs central to metabolic homeostasis, thereby affecting arterial lipid accumulation, inflammation, and the development of coronary artery disease (CAD). The primary aim of the Stockholm Atherosclerosis Gene Expression (STAGE) study was to determine whether there are functionally associated genes (rather than individual genes) important for CAD development. To this end, two-way clustering was used on 278 transcriptional profiles of liver, skeletal muscle, and visceral fat (n = 66/tissue) and atherosclerotic and unaffected arterial wall (n = 40/tissue) isolated from CAD patients during coronary artery bypass surgery. The first step, across all mRNA signals (n = 15,042/12,621 RefSeqs/genes) in each tissue, resulted in a total of 60 tissue clusters (n = 3958 genes). In the second step (performed within tissue clusters), one atherosclerotic lesion (n = 49/48) and one visceral fat (n = 59) cluster segregated the patients into two groups that differed in the extent of coronary stenosis (P = 0.008 and P = 0.00015). The associations of these clusters with coronary atherosclerosis were validated by analyzing carotid atherosclerosis expression profiles. Remarkably, in one cluster (n = 55/54) relating to carotid stenosis (P = 0.04), 27 genes in the two clusters relating to coronary stenosis were confirmed (n = 16/17, P<10$^{−27and−30}$). Genes in the transendothelial migration of leukocytes (TEML) pathway were overrepresented in all three clusters, referred to as the atherosclerosis module (A-module). In a second validation step, using three independent cohorts, the A-module was found to be genetically enriched with CAD risk by 1.8-fold (P<0.004). The transcription co-factor LIM domain binding 2 (LDB2) was identified as a potential high-hierarchy regulator of the A-module, a notion supported by subnetwork analysis, by cellular and lesion expression of LDB2, and by the expression of 13 TEML genes in Ldb2–deficient arterial wall. Thus, the A-module appears to be important for atherosclerosis development and, together with LDB2, merits further attention in CAD research

Multi-Organ Expression Profiling Uncovers a Gene Module in Coronary Artery Disease Involving Transendothelial Migration of Leukocytes and LIM Domain Binding 2: The Stockholm Atherosclerosis Gene Expression (STAGE) Study

Environmental exposures filtered through the genetic make-up of each individual alter the transcriptional repertoire in organs central to metabolic homeostasis, thereby affecting arterial lipid accumulation, inflammation, and the development of coronary artery disease (CAD). The primary aim of the Stockholm Atherosclerosis Gene Expression (STAGE) study was to determine whether there are functionally associated genes (rather than individual genes) important for CAD development. To this end, two-way clustering was used on 278 transcriptional profiles of liver, skeletal muscle, and visceral fat (n = 66/tissue) and atherosclerotic and unaffected arterial wall (n = 40/tissue) isolated from CAD patients during coronary artery bypass surgery. The first step, across all mRNA signals (n = 15,042/12,621 RefSeqs/genes) in each tissue, resulted in a total of 60 tissue clusters (n = 3958 genes). In the second step (performed within tissue clusters), one atherosclerotic lesion (n = 49/48) and one visceral fat (n = 59) cluster segregated the patients into two groups that differed in the extent of coronary stenosis (P = 0.008 and P = 0.00015). The associations of these clusters with coronary atherosclerosis were validated by analyzing carotid atherosclerosis expression profiles. Remarkably, in one cluster (n = 55/54) relating to carotid stenosis (P = 0.04), 27 genes in the two clusters relating to coronary stenosis were confirmed (n = 16/17, P<10−27and−30). Genes in the transendothelial migration of leukocytes (TEML) pathway were overrepresented in all three clusters, referred to as the atherosclerosis module (A-module). In a second validation step, using three independent cohorts, the A-module was found to be genetically enriched with CAD risk by 1.8-fold (P<0.004). The transcription co-factor LIM domain binding 2 (LDB2) was identified as a potential high-hierarchy regulator of the A-module, a notion supported by subnetwork analysis, by cellular and lesion expression of LDB2, and by the expression of 13 TEML genes in Ldb2–deficient arterial wall. Thus, the A-module appears to be important for atherosclerosis development and, together with LDB2, merits further attention in CAD research

Active chest tube clearance after aortic valve surgery did not influence amount residual pericardial fluid after aortic valve replacement in a randomised trial

Objective. Evaluate if the use of active clearance of chest tubes after aortic valve surgery influenced bleeding and reduced postoperative residual pericardial effusion. Design. Prospective randomised trial comparing PleuraFlow® 32 F chest tube with FlowGlide™ active clearance to a standard Argyle® 32 F chest tube in 100 patients undergoing aortic valve surgery. Chest tube outputs and pericardial effusion measurements assessed by two-dimensional transthoracic echocardiography were recorded before hospital discharge. Results. Postoperative chest tube outputs per hour did not differ between the two groups. The median chest tube output was 400 mL for patients who had a PleuraFlow® chest tube vs. 490 mL for patients with an Argyle® chest tube (p =.08). Pericardial effusions ≥ 2 mm were detected in 76% vs. 68% of the patients (p =.50) and postoperative atrial fibrillation occurred in 42% vs. 34% (p =.54), respectively. Conclusions. Use of active clearance chest tubes, compared to standard chest tubes after aortic valve surgery did not differ significantly regarding postoperative bleeding or degree of pericardial effusion as measured by echocardiography prior to hospital discharge

Validation of a modified EuroSCORE risk stratification model for cardiac surgery: the Swedish experience.

Objective: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is used to identify patients at high risk for aortic valve replacement (AVR) in whom alternative procedures, such as trans-catheter aortic valve implantation (TAVI), may be appropriate. The aim of the present study was to calibrate and validate the EuroSCORE for different cardiac surgery procedures to improve patient selection for valve surgery. Methods: The study included 46516 patients undergoing open cardiac surgery during 2001-2007. A fivefold cross-validation technique was used to calibrate four different models. Model discrimination was determined by the area under the receiver operating characteristic (ROC) curve and model calibration by the Hosmer-Lemeshow (H-L) test. Results: The actual and predicted 30-day mortality was 3.2%. The discrimination (ROC area) of the calibrated 30-day mortality prediction models was 0.79 for coronary bypass surgery, 0.77 for mitral valve surgery (MVS), and 0.75 for miscellaneous procedures, compared with 0.78 (p=0.199), 0.74 (p=0.077), and 0.72 (p=0.001), respectively, for the original EuroSCORE. The discrimination for AVR was the same for the calibrated and the original EuroSCORE model (0.70). The H-L test gave a p-value of 0.104 for the calibrated and <0.001 for the original EuroSCORE model. Conclusions: A calibration of EuroSCORE resulted in an acceptable predictive capacity for 30-day mortality, and improved discrimination and calibration for MVS and miscellaneous procedures. However, the poor discriminatory for the AVR procedure suggests that the EuroSCORE may not be satisfying for assessing risk prior to TAVI and that more optimized risk stratification models may be needed

Obesity and the risk of early and late mortality after coronary artery bypass graft surgery.

BACKGROUND: Obesity is often considered to be a significant risk factor for postoperative mortality when selecting candidates for coronary artery bypass grafting (CABG). METHODS: We included all patients undergoing a first isolated CABG at the Karolinska Hospital in Stockholm, Sweden, between 1980 and 1995 (n = 6728). Patients were categorized on the basis of body mass index (BMI): non-overweight (BMI or =30 kg/m2). Multivariate Cox regression was used to assess the risk of re-operation for bleeding, deep sternal wound infection, and early (< or =30 days) and late (< or =5 years) mortality rates. RESULTS: The average length of follow-up was 6.5 years. There were 252 re-operations for bleeding, 53 deep sternal wound infections, and 628 deaths. Patients who were obese had a significantly lower risk of re-operation for bleeding (risk ratio [RR], 0.32; 95% CI, 0.19-0.53), but a greater risk of deep sternal wound infection (RR, 2.66; 95% CI, 1.21-5.88) compared with patients who were not overweight. However, patients who were obese and patients who were not overweight experienced similar 30-day (RR, 0.65; 95% CI, 0.34-1.27), 1-year (RR, 0.56; 95% CI, 0.29-1.10), and 5-year mortality rates (RR, 0.91; 95% CI, 0.66-1.25). Results for patients who were overweight were consistent with those of patients who were obese. CONCLUSION: Patients who are obese are not at a greater risk of early and late mortality after CABG compared with patients who are not overweight, although they appear to have a lower risk of re-operation for bleeding and a greater risk of deep sternal wound infection. Therefore, obesity per se is not a contraindication for CABG