Biomedical subjects
Antonio Maria Calafiore
Publications and source records attributed to Antonio Maria Calafiore.
Is surgery always mandatory for type A aortic dissection?
BACKGROUND: The International Registry of Aortic Dissections showed that 42% of the unoperated patients with type A acute aortic dissection were discharged from the hospital after intensive medical treatment. We analyzed our experience to identify a preoperative score for in-hospital mortality to propose an alternative strategy for type A acute aortic dissection. METHODS: From 1980 to 2004, 616 consecutive patients with type A acute aortic dissection underwent surgery in our center. The preoperative univariate risk factors with a probability value less than 0.05 were entered into multivariate analysis. A risk equation was developed: predicted mortality = exp(beta 0 + sigma beta i X i)/[1 + exp(beta 0 + sigma beta i X i)]. RESULTS: Early mortality was 25.1% (154 of 616 patients). Five risk factors were identified: age, coma, acute renal failure, shock, and redo operation. The beta i values are age 0.023, shock 0.771, reoperation 0.595, coma 1.162, acute renal failure 0.778; the constant (beta 0) is -2.986. CONCLUSIONS: Our large, single-center experience allowed us to develop a mathematical model to predict 30-day mortality for type A acute aortic dissection. When the expected mortality is 58% or less, surgery is always indicated. When the predicted mortality is greater than 58%, the possibility of survival is similar, according to International Registry of Aortic Dissections data, for surgery and medical treatment. In such cases surgery can no longer be considered mandatory, and a careful evaluation of the individual patient is recommended to choose the more suitable strategy.
Bilateral internal mammary artery grafting.
The superiority of the left internal mammary artery over the saphenous vein graft led many surgeons to adopt bilateral internal mammary artery (BIMA) as a good surgical option for further improving late outcome of patients undergoing myocardial revascularization. However, routine use of BIMA was limited by some potential drawbacks: the increase of deep sternal wound problems, especially in diabetic patients; the shortness of right internal mammary artery (RIMA), which limited its utilization as an in situ graft; the low patency rate if grafted to the right coronary artery; and the longer operative time. The skeletonization of the internal mammary artery along with a better glucose control in diabetic patients significantly reduced the incidence of deep sternal problems. Another problem to solve was finding the optimal target of the RIMA. The general consensus is that RIMA appears to be more efficient if grafted to the lateral wall. The Y or T configuration of double mammary arteries could be more helpful to reach the lateral target vessels. Finally, recent reports clearly demonstrate the superiority of BIMA over single internal mammary artery in terms of survival or quality of life. The latter finding has also been reported in diabetic patients.
Papillary fibroelastoma of the anterolateral papillary muscle: an unusual case.
We describe the case of a 75-year-old female admitted to our ward with a diagnosis of papillary fibroelastoma discovered during routine control. The patient was completely asymptomatic without any previous event of embolization or valve incompetence. We report this rare case of papillary fibroelastoma for its unusual location with large involvement of the anterolateral papillary muscle (its prevalence in the literature is about 1%).
Complete myocardial revascularization: between myth and reality.
Myocardial revascularization in patients with multi-vessel coronary artery disease may be accomplished, by percutaneous interventions or surgery, either on all diseased lesions or directed to selectively targeted coronary segments. The extent of planned revascularization is often a major determinant of treatment strategy. Revascularization of all diseased coronary segments-complete myocardial revascularization-has a potential long-term benefit, but is more complex and may increase in-hospital untoward events. Revascularization may otherwise be incomplete, either because of the operator's inability to treat all diseased coronary segments or by choice of deciding to selectively revascularize only large areas of myocardium at risk. Although incomplete revascularization may negatively affect long-term outcomes, it may be, when wisely chosen, the preferred treatment strategy in selected patient categories because of its lower immediate risks. The patient's clinical status, ventricular function, and the presence of co-morbidities may orient clinical decisions in favour of incomplete revascularization.
Single versus bilateral internal mammary artery for isolated first myocardial revascularization in multivessel disease: long-term clinical results in medically treated diabetic patients.
BACKGROUND: We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVG), increases the quality of the results of coronary bypass grafting in medically treated diabetic patients who undergo first myocardial revascularization, when compared with the use of a single left internal mammary artery (LIMA) and SVG. METHODS: From October 1991 to December 2001, 558 diabetic patients with multivessel coronary disease had first isolated myocardial revascularization using LIMA and SVG (group LIMA) in 217 cases and BIMA +/- SVG (group BIMA) in 341. Propensity score analysis identified 400 patients, 200 for each group, with similar preoperative characteristics. Thirty-day outcome and 8-year freedom from death from any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area, redo/percutaneous transluminal coronary angioplasty (PTCA), redo/PTCA in a grafted area, target cardiac events, and any event were evaluated. Follow-up ranged from 2.0 to 12.2 years (mean 6.0 +/- 2.0). RESULTS: There was no difference between groups except the cardiac deaths, which were significantly higher in the LIMA group (7 versus 0, p = 0.015). The BIMA group showed better 8-year freedom from death any cause (86.7 +/- 3.2 versus 79.5 +/- 4.1, p = 0.0274), cardiac death (96.3 +/- 1.4 versus 88.4 +/- 4.0, p = 0.0406), acute myocardial infarction (99.5 +/- 0.5 versus 92.0 +/- 3.9, p = 0.0092), and acute myocardial infarction in a grafted area (99.5 +/- 0.5 versus 93.4 +/- 3.7, p = 0.0204). Cox analysis confirmed that the use of LIMA and SVG was an independent predictor for lower freedom from death (hazard ratio [HR] = 1.8, p = 0.0310), cardiac death (HR = 1.9, p = 0.0426), AMI (HR = 9.7, p = 0.0033) and AMI in a grafted area (HR = 8.2, p = 0.0410). CONCLUSIONS: In diabetic patients with multivessel disease who undergo first myocardial revascularization, BIMA +/- SVG provides higher freedom from death, any cause, and cardiac-related death, if compared with LIMA + SVG. It plays a protective role in reducing the incidence of late AMI.
Intraoperative ischemia and long-term events after minimally invasive coronary surgery.
BACKGROUND: Concern has been raised about the effects of prolonged left anterior descending (LAD) artery occlusion during minimally invasive direct coronary artery bypass graft surgery (MIDCABG). We sought to assess the impact of myocardial dysfunction during MIDCABG on long-term outcome and the protective role of collateral circulation on myocardial ischemia. METHODS: Myocardial function was evaluated in 92 patients by intraoperative transesophageal echocardiography during MIDCABG. RESULTS: Wall motion score index increased during LAD occlusion (p < 0.00l) and reverted after LAD reopening (p < 0.001 versus occlusion and p = not significant versus baseline). The change in wall motion score index (occlusion versus baseline) was higher in patients with multivessel disease (p < 0.05) and in patients with LAD Thrombolysis in Myocardial Infarction study classification flow grade 2 or less without collateral circulation (p < 0.05). Myocardial stunning was documented in 12 patients (13%). The 5-year adverse event rate (including death, myocardial infarction, and revascularization) was 12%. By multivariate Cox regression analysis, multivessel disease, but not perioperative ischemia or stunning, was the only predictor of event-free survival. CONCLUSIONS: During MIDCABG anterior wall dysfunction is transient, with prompt recovery after completion of the anastamosis in most cases; myocardial stunning can be documented in a minority of patients. Flow either antegrade or retrograde in the LAD territory plays a protective role against the development of ischemia. Multivessel disease, but not perioperative ischemia or stunning, predicts long-term event-free survival.
Late results of first myocardial revascularization in multiple vessel disease: single versus bilateral internal mammary artery with or without saphenous vein grafts.
OBJECTIVE(S): We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVGs), if compared to the use of single IMA and SVG(s), increases the quality of the results of coronary bypass grafting in patients younger than 75 years who undergo first myocardial revascularization. METHODS: From September 1986 to December 1999, 1602 patients younger than 75 years underwent first myocardial revascularization using left internal mammary (LIMA) to left anterior descending (LAD) and SVG(s) (n=576) or BIMA (one IMA on the LAD) with or without SVG(s) (n=1026). Propensity score analysis was used to select 1140 patients with the same preoperative and operative characteristics. Thirty day outcome was evaluated as well as 10-year freedom from death by any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area (GA), redo/PTCA, redo/PTCA in a GA, target cardiac events (death from cardiac cause, AMI in a GA, redo/PTCA in a GA), and any event. Follow-up ranged from 3.5 to 16.8 years (mean 7.3+/-4.8 years). RESULTS: Thirty day mortality was 2.8% in Group LIMA and 2.1% in Group BIMA, P n.s.; incidence of major complications was, respectively, 7.0 versus 5.4%, P n.s. Group BIMA showed better 10-year freedom from cardiac death (96.5+/-0.8 versus 91.3+/-1.4, P=0.0288), AMI (98.0+/-0.6 versus 94.3+/-1.2, P=0.0180), AMI in a GA (98.4+/-0.6 versus 94.7+/-1.1, P=0.0057) and target cardiac events (93.9+/-1.1 versus 86.3+/-1.8, P=0.0388). Cox analysis confirmed that LIMA+SV(s) was an independent risk factor from lower freedom from cardiac death, AMI, AMI in a GA and cardiac events. CONCLUSIONS: As freedom from cardiac events is a main target of any revascularization procedure, we think that, when a patient undergoes a first coronary surgery and is younger than 75 years, BIMA grafting should not be denied, especially if his life expectancy is higher than 10 years.
Midterm results after septal reshaping for anteroseptal scars.
BACKGROUND: Midterm clinical and morphologic results of the septal-reshaping exclusion of anteroseptal dyskinetic or akinetic areas were evaluated. METHODS: From January to June 2003, 44 patients with myocardial infarction following left anterior descending coronary artery (LAD) occlusion underwent septal reshaping. The mean (+/- SD) New York Heart Association (NYHA) class of the patients at admission was 2.7 +/- 0.9. Angina was referred in 21 cases. The incision was started at the apex and directed parallel to the LAD toward the base of the heart. The septum was rebuilt with 1 or 2 U-stitches passed from the inside to join the anterior wall to the septum by starting as high as possible where the scar began and continuing in an oblique direction toward the new apex. An oval polyethylene terephthalate fiber (Dacron) patch was then sutured from the septum (at the end of the direct suture through the border with the inferior septum) to the anterior wall (between the healthy wall and the scarred wall) and up to the new apex. RESULTS: The 30-day mortality rate was 2.2% (1 patient, due to the failure of a previously implanted defibrillator). Three patients experienced acute renal failure. No patient had restrictive syndrome. After a mean follow-up period of 8.5 +/- 4.9 months (range, 4-22 months), the mean NYHA class improved from 2.7 +/- 0.9 to 1.6 +/- 0.5 (P < .001). The 18- month survival rate and the probability of being alive in NYHA class I or II were 93.2% +/- 2.0% and 90.9% +/- 4.3%, respectively. Echocardiographic results showed reductions in the left ventricle volume with a normalization of the stroke volume. The diastolic longitudinal length remained unchanged, and the diastolic sphericity index was reduced but not significantly. CONCLUSIONS: At 1 year after surgery, the good clinical and morphologic results demonstrate the safety and effectiveness of septal reshaping for anteroseptal scars.
Partial clamping of the brachiocephalic trunk for total ascending aorta replacement without circulatory arrest: early and midterm results.
BACKGROUND: The aim of this study was to evaluate in elective patients the early and midterm results of partial clamping of the brachiocephalic trunk (BCT) for total ascending aorta replacement (TAAR) without circulatory arrest. Contraindications to the procedure were BCT/aortic arch calcifications and chronic aortic dissection. METHODS: The right radial artery was cannulated to monitor the systemic pressure after the BCT was partially clamped. A specially designed clamp was applied obliquely to occlude approximately 50% of the BCT and part of the aortic arch. The distal tip of the clamp was positioned in front of the left subclavian artery. From January 2002 to October 2003, 92 patients underwent TAAR. In 62 patients (67.4%), partial clamping of the BCT was used. Twenty of these patients underwent isolated TAAR, 27 underwent aortic valve replacement and TAAR, 11 had a Bentall operation, and 2 had a Cabrol operation. The aortic valve was spared in the remaining 2 patients. The mean (+/- SD) aortic cross-clamping and cardiopulmonary bypass times were 96 +/- 31 minutes and 116 +/- 43 minutes, respectively. RESULTS: Early mortality was 1.6% (1 patient). No cerebrovascular accidents occurred, demonstrating the safety of the technique. The major complications were acute respiratory insufficiency in 2 cases and acute renal failure in 5. The mean follow-up time was 9.0 +/- 6.5 months. The mean 18- month and event-free survival rate was 96.6% +/- 0.9%. CONCLUSION: Partial clamping of the BCT for TAAR without circulatory arrest provides good early and midterm clinical results. Aortic arch clamping is not associated with cerebrovascular accidents.
Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease patients.
BACKGROUND: Off-pump coronary artery bypass surgery is widely performed because of its proved safety, but its effectiveness remains controversial. The aim of this retrospective study was to compare early and late results in patients with multivessel disease, operated on off-pump and on-pump. METHODS: From November 1994 to December 2001, 2957 patients with multivessel disease underwent isolated coronary revascularization, on-pump (n = 1924) and off-pump (n = 1033). Sixty-five patients (2.2%) who were converted from off-pump to on-pump were considered as part of the off-pump group. RESULTS: Stepwise logistic regression analysis showed that the use of cardiopulmonary bypass was an independent predictor for early death, early negative primary endpoints, and early major events. Conversion to on-pump was an independent risk factor for a higher incidence of death due to any cause and cardiac death, early negative primary endpoints, and early major events. Conversion, however, did not affect late clinical outcome. The 6-year freedom from death (any cause, cardiac cause), myocardial infarction, redo/coronary angioplasty and any events was similar in the two groups. CONCLUSIONS: These results suggest that off-pump surgery reduces early mortality and morbidity. These benefits are not at the expense of the long-term clinical outcome which seems to be similar in the two groups. Patients who require conversion from off-pump to on-pump have a much higher mortality and morbidity although this does not seem to influence their long-term clinical outcome.
Images in cardiovascular medicine. Multislice spiral computed tomography-assisted vein graft stenting.
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Immediate flow reserve of Y thoracic artery grafts: an intraoperative flowmetric study.
OBJECTIVES: Use of both internal thoracic arteries in a Y graft configuration can raise concerns about the possibility of the single left internal thoracic artery being able to meet the flow requirements of two or three distal territories. We evaluated intraoperatively the flow reserve of a Y thoracic artery graft distally anastomosed to the anterior and lateral territories. METHODS: In 21 patients who had Y thoracic artery grafts, the flow was measured in the main stem of the left internal thoracic artery, in the left internal thoracic artery branch, and in the right internal thoracic artery. A transit time Doppler flowmeter was used. Measurements were repeated after the injection of a bolus of 20 mug/kg dobutamine. RESULTS: At baseline condition, the mean blood flow was 44.8 +/- 24.2, 23.4 +/- 11.5, and 21.4 +/- 15.3 mL/min in the main stem of the left internal thoracic artery, in the left internal thoracic artery branch, and in the right internal thoracic artery, respectively. After dobutamine injection, these values increased to 93.2 +/- 49.8, 46.1 +/- 22.6, and 42.5 +/- 31.2 mL/min, respectively. Flow reserve was 2.1 +/- 0.6, 2.2 +/- 0.9, and 2.1 +/- 0.9 mL/min, respectively. CONCLUSIONS: Intraoperative injection of dobutamine increases the flow in the Y thoracic graft by more than two times, not only in the main stem but also in each branch. This finding attests to the safety of Y thoracic conduits in terms of hemodynamic potential.
Early and late outcome of myocardial revascularization with and without cardiopulmonary bypass in high risk patients (EuroSCORE > or = 6).
OBJECTIVE: To evaluate 30-day and late results in high risk patients (European score (EuroSCORE) > or = 6) who underwent isolated myocardial revascularization with and without cardiopulmonary bypass (CPB). METHODS: From November 1994 to December 2001, 1266 patients with EuroSCORE > or = 6 underwent isolated myocardial revascularization. Among them, applying the propensity score, we were able to select 1020 patients operated on without CPB (group A, n=510) and with CPB (group B, n=510) with the same preoperative characteristics. The only differences were the higher incidence of patients with age between 61 and 65 years (9.4% in group A vs. 13.9% in group B, P=0.025) and the lower number of anastomoses/patient in group A (1.8+/-0.9 vs. 2.8+/-0.9, P<0.001). EuroSCORE were identical in both groups (7.8%). RESULTS: Thirty-day mortality was higher in group B (5.9 vs. 3.1%, P=0.035). Group A showed a lower incidence of cerebrovascular accidents (CVAs) (0.6 vs. 3.1%, P=0.003), whereas incidence of acute myocardial infarction (AMI) was similar (2.0% in group A vs. 2.5% in group B, P=ns). Early negative primary end-points and early major events incidences were higher in group B (8.2 vs. 3.9%, P=0.004, and 14.5 vs. 7.1%, P<0.001, respectively). Stepwise logistic regression confirmed that CPB was an independent predictor for higher early mortality (Odds ratio (OR) 2.0) and CVA, negative primary end-points and early major events incidences (OR 4.6, 2.3 and 2.4, respectively). Five-year freedom from the events explored (death due to any cause, cardiac death, AMI, AMI on a grafted area, redo/percutaneous transluminal coronary angioplasty (PTCA), redo/PTCA on a grafted area, target cardiac events (cardiac death, AMI in a grafted area and redo/PTCA in a grafted area) and any event were similar in both groups. CONCLUSIONS: In high risk patients myocardial revascularization without CPB shows better early outcome and similar clinical late results.
Myocardial revascularization with and without cardiopulmonary bypass: advantages, disadvantages and similarities.
OBJECTIVES: Off-pump coronary artery bypass surgery is becoming increasingly popular although its effectiveness remains controversial. Our goal was to investigate the effectiveness of on-pump and off-pump coronary artery bypass surgery on early (30 days) and long-term (5 years) clinical outcome in two groups of patients selected using propensity scores. METHODS: From November 1994 to December 2001, 4381 patients underwent isolated coronary surgery. Applying propensity score matching, 1922 patients were selected (off-pump n=961, on-pump n=961). RESULTS: Stepwise logistic regression analysis showed that the use of cardiopulmonary bypass was an independent predictor for early death, cerebral vascular accident, early negative primary endpoints (ENPEP), and early major events (EME). Five years freedom from both events was similar in the two groups. However, freedom from acute myocardial infarction (AMI) in grafted areas was higher in the off-pump than in the on-pump patients, a possible explanation being the lower postoperative creatine kinase myocardial band (CKMB) release. Grouping all patients according to CKMB peak release also showed that patients with normal release values had higher freedom from all cardiac events investigated. A subgroup analysis of 59 patients converted from off-pump to on-pump showed higher early mortality, ENPEP, and EME. Conversion, however, did not affect late clinical outcome. CONCLUSIONS: These results suggest that off-pump surgery reduces early mortality and morbidity. Conversion to on-pump carries high in-hospital mortality and morbidity. Long-term clinical outcome is similar in the two groups; however, off-pump patients seemed to have a higher freedom from AMI in the grafted area which might be related to the lower CKMB peak release when compared with patients undergoing on-pump surgery.
Effect of diabetes on early and late survival after isolated first coronary bypass surgery in multivessel disease.
OBJECTIVE: Diabetes has not yet been investigated as a risk factor for early and late cardiac-related death. METHODS: Patients operated on from January 1988 to December 1999 were considered; 767 were diabetic (group D) and 2593 were nondiabetic (group ND). Patients with preoperative hemodynamic deterioration were excluded. Early (30-day) mortality (any causes and cardiac causes) was evaluated with univariate analysis and stepwise logistic regression. Ten-year actuarial freedom from death of any cause and cardiac death was also assessed with univariate and Cox analyses. RESULTS: Early mortality was 2.2% (group D, 3.3%; group ND, 1.9%; P =.023). Early cardiac mortality was 1.3% (group D, 2.2%; group ND, 1.1%; P =.0016). Diabetes was an independent risk factor only for cardiac death and not for death of any cause. Five-year survival was 93.5% +/- 0.5% (group D, 92.5% +/- 1.1%; group ND, 93.9% +/- 0.6%; P =.0304). Diabetes was not an independent risk factor. Five-year freedom for cardiac death was 96.3% +/- 0.4% (group D, 94.9% +/- 0.9%; group ND, 96.6% +/- 0.4%; P =.0155). Diabetes was an independent risk factor. However, if only the patients who survived the first 30 days are considered, diabetes disappears as a risk factor (5-year freedom for cardiac death, 97.8% +/- 0.3%; group D, 97.3% +/- 0.8%; group ND, 97.9% +/- 0.4%; P = 0.2389). CONCLUSIONS: Diabetes is an independent risk factor for early cardiac death only. Long-term survival in patients who survive the first 30 days is not statistically significantly different for diabetic and nondiabetic patients. In fact, the rates appear very similar.
Total replacement of the ascending aorta without circulatory arrest.
OBJECTIVE: If the aortic arch is clamped between the brachiocephalic trunk and the left common carotid artery and the brachiocephalic trunk is also clamped, the total ascending aorta can be replaced without circulatory arrest. Candidates for this technique need to have the following characteristics: preoperative demonstration of Willis polygon patency by means of transcranial Doppler ultrasonography, preoperative computed tomographic scan that shows no calcification in the arch or in the brachiocephalic trunk, and preoperative or intraoperative evidence of separate origins of the brachiocephalic trunk and the left common carotid artery. METHODS: In three different institutions (with different time frames in each) from December 2000 to December 2001, the possibility of replacing the total ascending aorta without circulatory arrest was evaluated in 14 cases. In 10 of them it was possible (feasibility of 71.4%). During the procedure continuous electroencephalographic monitoring was performed. RESULTS: No patient died in the early or midterm follow-up. None of the patients had any cerebral complications. The electroencephalographic activity was normal during the period of brachiocephalic trunk occlusion. In 5 patients a postoperative spiral computed tomographic scan showed good surgical results. CONCLUSIONS: The technique described here allows replacement of the total ascending aorta without circulatory arrest in selected cases. Furthermore, the evidence of lack of right cerebral hypoperfusion in all the procedures we performed allows future exploration of the possibility of avoiding cerebral monitoring.
Day 0 intensive care unit discharge - risk or benefit for the patient who undergoes myocardial revascularization?
OBJECTIVE: Day 0 intensive care unit (ICU) discharge allows to use one ICU bed for two patients. Results of this policy were analysed. METHODS: From January 1998 to June 2001, 1194 patients who had myocardial revascularization in the morning were discharged on the same day (Group 0, n=647), or one (Group 1, n=521) or many days (Group 2, n=26) after surgery. Criteria for day 0 discharge were: early extubation with at least 2h of observation, stable hemodynamic status, no significant bleeding, no arrhythmias, normal EKG and normal neurological evolution. RESULTS: Mean ICU stay was 4.0+/-1.2h in Group 0, 17.5+/-4.0 h in Group 1 and 65.8+/-46.6h in Group 2 (P(1), among Groups, <0.001; P(2), between Groups 0 and 1, <0.001). In 613 cases (94.7% of patients in Group 0) the same ICU bed was used for another patient. Postoperative in-hospital stay was 4.1+/-2.3 d in Group 0, 4.9+/-3.1 d in Group 1 and 7.4+/-6.8 in Group 2 (P(1)<0.001; P(2)<0.001). Fifteen patients (1.2%) were readmitted to the ICU, seven in Group 0 (1.1%), five in Group 1 (1.0%) and three (11.5%) in Group 2 (P(1)<0.001, P(2) n.s.), because of bleeding (five cases in Group 0, two in Group 1, none in Group 2; P(1)<0.001, P(2)), cerebrovascular accident (two cases in Group 0, none in Group 1, three in Group 2; P(1)<0.001, P(2) n.s.), acute myocardial infarction (no case in Groups 0 and 2, two in Group 1; P(1) n.s., P(2) n.s.) and acute renal failure (no case in Group 0 and 2, one case in Group 1; P(1) n.s., P(2) n.s.). Nine patients (0.8%) died (three, 0.5%, in Group 0, three, 0.6%, in Group 1 and three, 11.5%, in Group 2; P(1)<0.001, P(2) n.s.), four (one in Group 0, two in Group 1 and one in Group 2, P(1) 0.006, P(2) n.s.) in the hospital (two from cardiac and two from non-cardiac causes) and five (two in Group 0, one in Group 1 and two in Group 2, P(1)<0.001, P(2) n.s.) outside the hospital within the 30th day of surgery (one from cardiac and four from non-cardiac causes). No patient in Group 0 died from cardiac causes. CONCLUSIONS: Day 0 ICU discharge can be obtained in selected patients without an increased risk of death or of ICU readmission. The impact in terms of resource saving is striking.