Is age an independent determinant of mortality in cardiac surgery as suggested by the EuroSCORE?

BACKGROUND: The proportion of older patients in cardiac surgery is continuously increasing. 37% of patients undergoing heart surgery in Germany in the year 2000 were 70 years of age and older. We have studied the role of age as a determinant of mortality in cardiac surgery in our institutional patient population. METHODS: We have calculated the EuroSCORE and the corresponding age-adjusted EuroSCORE in 8769 patients who underwent heart surgery between January 1996 and January 2002 and collected the information on the occurrence of postoperative complications and 30-days mortality. RESULTS: The multimorbidity increased with ascending age. Both the EuroSCORE and the age-adjusted EuroSCORE values increased significantly with age in the whole group of patients as well as in the group of patients who were alive 30 days after heart surgery. The incidence of postoperative complications and 30-days mortality increased significantly with age. In patients who died within 30 days after surgery, the EuroSCORE increased significantly with age, whereas the age-adjusted EuroSCORE did not. The occurrence of diabetes mellitus, arterial hypertension and atrial fibrillation, i.e., the risk factors not considered by the EuroSCORE, exhibited a significant age dependence in our patients. The univariate analysis identified the significant dependence of 30-days mortality on diabetes and atrial fibrillation. The stepwise logistic regression analysis showed the dependence of mortality on diabetes. CONCLUSIONS: On the background of the well-known age-dependent structural and functional changes of different body organs, our data show that age is a significant risk indicator in cardiac surgery, strongly correlating with morbidity and mortality. Consequently, special preventive and therapeutic measures are required in clinical environment in the case of elderly patients undergoing cardiac surgery

Komplikationen nach Sternotomie – eine interdisziplinäre Herausforderung

A mediastinitis is a rare complication (incidence 1–4%) following cardiac surgery with a mortality of up to 50%. Treatment is somewhat difficult since no standardized treatment options are established. Thus, every German clinic proceeds differently. It is thus the paper’s intention to describe an optimal treatment plan that guarantees higher patient safety, as well as determining whether the occurrence of postoperative infections can be diminished by raising awareness of involved risk factors.Backed up by first-hand experiences in the treatment of mediastinitis patients a therapy algorithm correlating to the amount of infection was developed. The treatment consists of radical surgical debridement, sternal restabilization (depending on the elapsed time between procedure and cardiac operation) and vacuum therapy (as short as possible). Plastic reconstruction (usually via M. pectoralis plasty) may be performed as soon as supporting condition is attained. If treatment fails, the reconstruction of defects of the anterior chest wall is achievable by different muscle flaps. Based on the results of early interdisciplinary cooperation, a therapy concept was developed, which is adaptable to the patient’s individual condition in order to ensure the best possible treatment concept concerning the patient’s recovery and safety

The history of the management of sternal osteomyelitis and mediastinitis – from Hippocrates until today

Even during the time of Hippocrates, Galen and their colleagues recognized mediastinal affections. However, they were not considered with the surgical treatment. First progress in the treatment options of this severe disease, still denoted as ‘terra incognita’, over to today’s gold standard are pictured.The mediastinitis-registry which was founded by the German Society for Thoracic and Cardiovascular Surgery (DGTHG) in 2011 and the recent establishment of the study group to adopt a guideline ‘diagnosis and therapy of postoperative mediastinitis/sternal osteomyelitis following cardiac surgery’ are attempts to a standardization of the treatment. Substantial advancement in the treatment of postoperative mediastinitis could be achieved in the past. The mortality dropped as low as less than 10%. With these implementations more benefit for the patients’ outcome can be expected

Current determinants of 30-day and 3-month mortality in over 2000 aortic valve replacements: impact of routine laboratory parameters

Florath I, Albert A, Hassanein W, et al. Current determinants of 30-day and 3-month mortality in over 2000 aortic valve replacements: impact of routine laboratory parameters. In: European Journal of Cardio-Thoracic Surgery. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY. Vol 30. ELSEVIER SCIENCE BV; 2006: 716-721.Objective: Haematological and biochemical measurements are performed routinely before surgery to exclude organ malfunction and blood cell and coagulation abnormalities. We aimed to test routinely obtained laboratory data as factors predicting operative risk. Methods: Between 1996 and 2003, 2198 patients underwent aortic valve replacement (AVR) (908 of them with concomitant CABG) in our institute. The mean age of the study population was 69 +/- 11 years (range 13-91, 43% female). Clinical and laboratory parameters based on the consolidated data mart set were evaluated by multiple logistic regression analysis. Results: The overall operative mortality (within 30 days) was 3.8% and the mortality after 3 months was 5.9%. In addition to clinical characteristics, the following laboratory values were identified as independent predictors of 30-day mortality: fasting blood glucose, antithrombine III, partial thromboplastine time and creatinine kinase. As independent predictors of 3-month mortality, the following laboratory values were indentified: fasting blood glucose, serum creatinine, antithrombine III, partial thromboplastine time, lactate dehydrogenase, sodium concentration and serum proteins. The discriminative power of the models increased if laboratory parameters were included in addition to preoperative clinical characteristics (from 0.75 to 0.79 and from 0.75 to 0.78 for 30-day and 3-month mortality, respectively). The discriminative power using the logistic EuroScore was tower (0.71 and 0.7, for 30-day and 3-month mortality, respectively). Conclusions: Laboratory parameters as objective markers for organ function and nutritional status are useful data for the prediction of 30-day and 3-month mortality after aortic valve replacement. Using modern methods of information technology, these valuable data which are stored electronically in most hospitals, can be used efficiently for research and quality control. (c) 2006 Elsevier B.V. All rights reserved

Erfahrungen mit Diabetikern in der Koronarchirurgie - Patienten mit einem besonderen Risikoprofil

Lauruschkat AH, Albert AA, Arnrich B, et al. Erfahrungen mit Diabetikern in der Koronarchirurgie - Patienten mit einem besonderen Risikoprofil. Clinical Research in Cardiology. 2006;95(1 Supplement):7-13.Background The objective of this paper was to analyze demographic and clinical characteristics of diabetic patients undergoing coronary artery bypass grafting on the basis of a significant number of cases. Methods The data of 8,195 patients who have undergone coronary bypass operations between 1996 and 2003 were analyzed. Non-diabetic patients (no DM), oral treated diabetics (DM oral) and insulin-treated diabetics (DM insulin) were compared in terms of their pre-operative, intra-operative and post-operative characteristics. The statistical analyses were performed with the support of SPSS 11.5 under application of chi-square and student-t tests. Results In cardiosurgery, diabetics differ in various ways from non-diabetic patients. They show a significantly higher prevalence of the known cardiovascular risk factors such as raised body mass index, age and hypertension. Furthermore they present a higher prevalence of vascular comorbidity such as peripheral vascular disease and carotid disease. At the postoperative stage, cerebral dysfunction occurred more often among the diabetic patients (no DM 5.2% vs. DM oral 7.3% vs. DM insulin 10.5%; p<0.05), they suffered from apoplexies more frequently (no DM 1.9% vs. DM oral 2.1% vs. DM insulin 3.2%; p<0.05), and they required re-intubation more frequently (no DM 2.6% vs. DM oral 3.1% vs. DM insulin 5.6%; p<0.05). Peri-operative mortality was highest in the group of insulin-treated diabetics (no DM 1.1% vs. DM oral 1.6% vs. DM insulin 1.8%; p<0.05). Conclusion In coronary surgery, diabetic patients represent an especially challenging patient group with an independent risk profile, who require specific consideration as far as the selection of the operative approach, on, one hand, and the post-operative follow-up, on the other hand, are concerned.Einleitung Anhand eines aussagekräftigen Patientenkollektivs sollten die demographischen, klinischen, operativen und postoperativen Daten diabetischer Koronarpatienten mit nichtdiabetischen Patienten verglichen werden. Methoden und Ergebnisse Es wurden die Daten von 8 195 Patienten untersucht, die sich im Zeitraumvon 1996 bis 2002 koronaren Bypassoperationen unterzogen. Nichtdiabetische Patienten (kein DM), mit oralen Antidiabetika therapierte Diabetiker (DM oral) und mit Insulin therapierte Diabetiker (DM Insulin) wurden hinsichtlich ihrer präoperativen Charakteristika und Risikofaktoren und hinsichtlich der Ergebnisse des postoperativen Verlaufs miteinander verglichen. Es zeigte sich, dass diabetische Koronarpatienten signifikant häufiger zahlreiche kardiovaskuläre Risikofaktoren und eine höhere vaskuläre Komorbidität aufwiesen als nichtdiabetische Patienten. Postoperativ litten Diabetiker häufiger unter Verwirrtheitszuständen (kein DM 5,2% vs. DM oral 7,3% vs. DM Insulin 10,5%; p<0,05), erlitten häufiger Schlaganfälle (kein DM 1,9% vs. DM oral 2,1% vs. DM Insulin 3,2%; p<0,05) und mussten häufiger reintubiert werden (kein DM 2,6% vs. DM oral 3,1% vs. DM Insulin 5,6%; p<0,05). Die 30-Tage-Mortalität war unter den Diabetikern signifikant erhöht (kein DM 1,1% vs. DM oral 1,6% vs. DM Insulin 1,8%; p<0,05). Schlussfolgerung Die Ergebnisse der vorliegenden Studie zeigen, dass diabetische Koronarpatienten in der Herzchirurgie ein eigenständiges Risikoprofil aufweisen, das in der Wahl der operativen Strategien und im postoperativen Verlauf eine besondere Herausforderung darstellt

On Temporal Validity Analysis of Association Rules

Arnrich B, Walter JA, Albrecht AA, Ennker J. On Temporal Validity Analysis of Association Rules. In: Proceedings of the International Joint Meeting EuroMISE 2004. Prag, Czech Republic: EuroMISE; 2004: 35

Herausforderungen und Nutzen eines Datamart Systems in der Herzchirurgie

Arnrich B, Walter JA, Albert AA, Ennker J. Herausforderungen und Nutzen eines Datamart Systems in der Herzchirurgie. Zeitschrift für Herz-, Thorax- und Gefäßchirurgie. 2004;18(1):13-19.Since heart surgery is a rather mature disciple, large data bases are essential for many new medical research questions. In this paper we discuss typical problems and challenges which appear at the integration of real-time and legacy data stored in multiple unconnected hospital information systems (HIS) operated by autonomous departments. We present a datamart system which integrates and consolidates all research relevant data, taking into account the modifications of the source data base structures. At this any considerable operational or maintenance contract liability risk for the existing HIS is minimized. The partial consistency and partial redundancy of the data within and across departments is tackled by plausibility checks and further used to derive attributes with semantic definitions which are not present in the original data sources. With the datamart clinical reporting, quality assessment and data preparation for comprehensive studies are enormously simplified. We introduced three examples of medical results we were able to achieve due to the large number of consolidated and extensive data records.Der hohe Entwicklungsstand in der Herzchirurgie erfordert große Datenbanken für die Untersuchung neuer medizinischer Fragestellungen. In diesem Artikel diskutieren wir typische Probleme und Herausforderungen bei der Integration von aktuellen und historischen Daten, die in den unverbundenen und von autonomen Fachabteilungen betriebenen klinischen Informationssystemen (KIS) gespeichert werden. Wir stellen ein Datamart-System vor, das alle für medizinische Forschung relevanten Daten integriert und konsolidiert. Dabei werden die Modifikationen in den Strukturen der Quelldatenbanken berücksichtigt und die Risiken im Arbeitsablauf der KIS minimiert. Der partiellen Konsistenz und Redundanz der Daten in und zwischen den Abteilungen wird durch Plausibilitätsregeln begegnet. Weiterhin können damit Attribute, die nicht in den originalen Datenquellen vorhanden sind, abgeleitet werden. Der Datamart hat das klinische Berichtswesen, das Qualitätsmanagement und die für umfassende Studien nötige Datenaufbereitung beträchtlich vereinfacht. Wir beschreiben die Ergebnisse von drei medizinischen Studien deren Durchführung durch den umfangreichen und konsolidierten Datenbestand ermöglicht wurde

Intraoperative transit time flow measurement: off-pump versus on-pump coronary artery bypass

Hassanein W, Albert AA, Arnrich B, et al. Intraoperative transit time flow measurement: off-pump versus on-pump coronary artery bypass. The annals of thoracic surgery. 2005;80(6):2155-2161.Background Off-pump coronary artery bypass grafting (OPCAB) has attracted increasing attention. Performing the anastomosis off-pump is technically more demanding. The objective of the study is to assess the quality of anastomosis in OPCAB in comparison with conventional on-pump coronary artery bypass grafting using the transit time flow measurement. Methods Four hundred forty-five patients operated on using OPCAB technique were included in the study. For each patient in this group a similar patient from the on-pump coronary artery bypass grafting population was selected according to the number of grafts, bypass material, and target coronary arteries. The mean flow and the pulsatile index were measured in every bypass graft in both groups. Results The average pulsatile index in OPCAB was 2.09 ± 1.03 (mean flow, 39 ± 22.63 mL/min), whereas with on-pump coronary artery bypass grafting it was 1.9 ± 0.98 (mean flow, 44.19 ± 23.58 mL/min); p = 0.005. Subgroup analysis showed significantly lower mean flows and higher pulsatile index with OPCAB in grafts to the obtuse marginal, diagonal, and right coronary artery, but not to the left anterior descending territory. Conclusions The quality of the anastomosis performed using the OPCAB technique might be jeopardized by less accessibility as in the case of lateral and posterior wall coronary arteries. Techniques to optimize the accessibility of the coronary artery like combining sling support with cup stabilizers, together with systematic training, should be strongly considered in OPCAB. Whenever there is good accessibility of the coronary artery as in the case of the left anterior descending, the anastomosis performed under OPCAB has a quality as good as that performed using the conventional technique