An attempt at data verification in the EACTS Congenital Database: data before and after verification differ significantly.
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Confidence Intervals↗
Biomedical subjects
Markus Neuhäuser
Publications and source records attributed to Markus Neuhäuser.
Thyrotropin receptor autoantibodies are independent risk factors for Graves' ophthalmopathy and help to predict severity and outcome of the disease.
OBJECTIVE: The objective of this study was to examine whether TSH-receptor antibody [TSH binding inhibitory antibodies (TBII)] levels are associated with the severity of Graves' ophthalmopathy (GO) over the entire course of the disease. METHODS AND PATIENTS: A total of 159 patients with GO were followed for 12-24 months. One year after the first symptoms of GO, all patients were classified into mild or severe GO according to their clinical manifestations. TBII were measured every 3 months after onset of GO. Receiver operating characteristic plot analysis was performed to assess the power to discriminate both patient groups by TBII (specificity >90%). RESULTS: TBII levels and prevalence at each time point during follow-up were significantly higher in patients with a severe course of GO compared with patients with a mild course of GO. Prognostic statements on the course of the disease were possible for about half of the GO patients at all time points (except the first). If at first presentation and at consecutive time points TBII levels were less than 5.7, 2.6, 1.5, 1.5, 1.5, and 1.5 IU/liter, the patients had a 2.3- to 15.6-fold higher chance of a mild course. If 5-8 months after GO onset and at consecutive time points TBII levels were above 8.8, 5.1, 4.8, 2.8, and 2.8 IU/liter, the patients had a 8.7- to 31.1-fold higher risk of a severe course. This relationship of TBII to the severity was independent from age and smoking. CONCLUSION: Follow-up measurements of TBII allow, in half of the patients, assessment of the prognosis of GO and, therefore, could be of additional help for the disease management.
Antithyroid Agents↗
Administration of C1-esterase inhibitor during emergency coronary artery bypass surgery in acute ST-elevation myocardial infarction.
OBJECTIVE: Myocardial inflammatory response including complement activation was demonstrated as an important mechanism of ischemia-reperfusion injury and complement inhibition by C1-esterase inhibitor (C1-INH) has recently shown to have cardioprotective effects in experimental and clinical settings. METHODS: The effects of C1-INH on complement activation, myocardial cell injury, and clinical outcome were studied in patients undergoing emergency CABG due to acute ST-elevation myocardial infarction (STEMI) with (group 1, CABG+STEMI+C1-INH, n=28) and without (group 2, CABG+STEMI, n=29) bolus administration of C1-INH (40 IU kg(-1)) during reperfusion and 6 h postoperatively (20 IU kg(-1)) besides the same study protocol. C1-INH activity, C3c and C4 complement activation fragments, and cardiac troponin I (cTnI) were measured preoperatively and up to 48 h postoperatively and compared to another elective set of CABG patients without STEMI as controls (group 3, CABG-STEMI, n=10). Clinical data, adverse events, and patient outcome were recorded prospectively. RESULTS: Patient characteristics were not different between groups 1 and 2. No drug-related adverse events were observed. Constant plasma levels of C1-INH were found in group 1, but not in groups 2 and 3. Plasma levels of C3c and C4 complement fragments were reduced in all three groups after surgery throughout the observation time, but tended to be lower in groups 1 and 2 compared with group 3. Preoperative cTnI levels were elevated but not different between the groups 1 and 2. The area under curve (AUC), as well as the postoperative cTnI serum levels, was significantly lower (P<0.05) in group 1 with a treatment delay < or = 6 h between reperfusion and symptom onset compared to group 2 at 36 h (47.9+/-11.1 ng/ml vs 97.7+/-17.2 ng/ml; mean+/-SEM), and 48 h (33.5+/-5.8 ng/ml vs 86.5+/-19.2 ng/ml) after surgery, but remained unchanged between groups among patients with a treatment delay of more than 6-24 h. In-hospital adverse events and postoperative complications, ICU and hospital stay, as well as in-hospital mortality (14.3% vs 13.8%; P=NS) were not different between groups 1 and 2. CONCLUSIONS: C1-INH administration in emergency CABG with acute STEMI is safe and effective to inhibit complement activation and may reduce myocardial ischemia-reperfusion injury as measured by cTnI.
Aged↗
Prognostic significance of multiple previous percutaneous coronary interventions in patients undergoing elective coronary artery bypass surgery.
BACKGROUND: A possible relationship between increased perioperative risk during coronary artery bypass grafting (CABG) and previous percutaneous coronary intervention (PCI) is debatable. We sought to determine the impact of previous PCI on patient outcome after elective CABG. METHODS AND RESULTS: Between January 2000 and January 2005, 2626 consecutive patients undergoing first-time isolated elective CABG as the primary revascularization procedure (group 1) were evaluated for in-hospital mortality and major adverse cardiac events (MACEs) and were compared with 360 patients after single PCI (group 2) and with 289 patients after multiple PCI sessions (group 3) before elective CABG. Unadjusted univariate and risk-adjusted multivariate logistic-regression analysis revealed previous multiple PCIs to be strongly associated with in-hospital mortality (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.52 to 3.21; P<0.001) and MACEs (OR, 2.28; 95% CI, 1.38 to 3.59; P<0.001). To control for selection bias, a computed propensity-score matching based on 13 patient characteristics and preoperative risk factors was performed separately comparing group 1 versus 2 and group 1 versus 3. After propensity matching, conditional logistic-regression analysis confirmed previous multiple PCIs to be strongly associated with in-hospital mortality (OR, 3.01; 95% CI, 1.51 to 5.98; P<0.0017) and MACEs (OR, 2.31; 95% CI, 1.45 to 3.67; P<0.0004). CONCLUSIONS: In patients with a history of multiple PCI sessions, perioperative risk for in-hospital mortality and MACEs during subsequent elective CABG is increased.
Aged↗
Prognostic value of preoperative cardiac troponin I in patients undergoing emergency coronary artery bypass surgery with non-ST-elevation or ST-elevation acute coronary syndromes.
BACKGROUND: Cardiac troponin I (cTnI) is a highly sensitive and specific biomarker which has been shown to predict patient outcome pre- and postoperatively following elective coronary artery bypass surgery (CABG). Whether preoperatively elevated cTnI levels similarly predict the outcome in patients undergoing emergency CABG with acute myocardial infarction (AMI) is currently unknown. METHODS AND RESULTS: A possible correlation between preoperative cTnI and in-hospital mortality and major adverse cardiac events (MACE) was investigated in 57 patients with ST-elevation AMI (STEMI) in group 1 and 197 with Non-ST-elevation AMI (NSTEMI) in group 2, who were operated within 24 hours after onset of symptoms. Primary study end point was all-cause in-hospital mortality. Secondary end points were low cardiac output syndrome (LCOS) and hospital course. CTnI levels on admission were higher in group 1 compared with group 2 (7.1+/-1.8 versus 1.4+/-1.8 ng/mL; P<0.001). Overall in-hospital mortality was higher in group 1 compared with group 2 (14.3 versus 4.1%; odds ratio [OR], 3.9, 95% confidence interval [CI], 1.3 to 12.3; P<0.01). LCOS occurred in 16/57 (28.1%), and 18/197 (9.1%) patients, respectively (OR, 3.9, 95% CI, 1.7 to 8.8; P<0.001). Postoperative ventilation time, intensive care, and hospital stay were significantly longer in group 1 versus group 2. Multivariate logistic regression analyses revealed preoperative cTnI as the strongest independent predictor for in-hospital mortality (P<0.001) and MACE (P<0.001) in all AMI patients, regardless whether ST-elevation was included as an additional risk factor or not. CONCLUSIONS: Preoperative cTnI measurement before emergency CABG appears as a powerful and independent determinant of in-hospital mortality and MACE in acute STEMI and NSTEMI.
Aged↗
Emergency re-revascularization with percutaneous coronary intervention, reoperation, or conservative treatment in patients with acute perioperative graft failure following coronary artery bypass surgery.
OBJECTIVE: Perioperative graft failure following coronary artery bypass grafting (CABG) results in acute myocardial ischemia/infarction (PMI), which may necessitate an acute secondary revascularization procedure to salvage myocardium, in order to preserve ventricular function and improve patient outcome. Whether acute percutaneous coronary (re)intervention (PCI), emergency reoperation, or conservative intensive care treatment should be applied, is currently unknown. METHODS: In order to identify the source of PMI and to pursue the appropriate re-revascularization strategy, coronary repeat angiography was emergently performed in 118 among 5427 consecutive isolated CABG patients with evidence of PMI. As a result, patients immediately underwent acute PCI (group 1), emergency reoperation (group 2), or were treated conservatively (group 3). Primary study endpoint was postoperative myocardial infarct size, as measured by peak cardiac troponin I (cTnI) serum levels. Secondary endpoints were perioperative left ventricular ejection fraction (LVEF%), assessed by transesophageal echocardiography, major adverse cardiac events, and short- and midterm mortality. RESULTS: Repeat coronary angiography revealed early perioperative bypass graft failure in 67 among 118 patients and 84 among 214 bypass grafts after CABG. The number and type of failing bypass grafts were comparable between groups 1 and 2, but significantly different to that of group 3 (P<0.007). Acute PCI was applied in 25 patients, redo-CABG in 15 patients, and conservative treatment in 27 patients. Procedural peak cTnI serum levels were significantly different between groups 1 and 2 (81+/-18 ng/ml vs 178+/-62 ng/ml; P<0.001). Global LVEF was reduced during the acute ischemic event when compared with preoperative values (P<0.01). Thereafter, LVEF improved during follow-up within each group (P<0.001), but did not differ between the three groups. In-hospital and 1-year mortality were 12.0% and 20.0% in group 1, 20.0% and 27% in group 2, and 14.8% and 18.5% in group 3, respectively (P=NS). CONCLUSIONS: Re-revascularization with emergency PCI may limit the extent of myocardial cellular damage compared with the surgical-based treatment strategy in patients with acute perioperative myocardial ischemia due to early graft failure following CABG.
Acute Disease↗
Beta-ray brachytherapy with 106Ru plaques for retinoblastoma.
PURPOSE: A retrospective analysis of 134 patients who received (106)Ru brachytherapy for retinoblastomas (175 tumors in 140 eyes). Treatment and follow-up were analyzed with special emphasis on tumor control organ, preservation, and late complications. RESULTS: Treated tumors had a mean height and diameter of 3.7+/-1.4 mm and 5.0+/-2.8 disk diameters, respectively. The radiation dose values were recalculated according to the calibration standard recently introduced by the National Institute of Standards and Technology. The recalculation revealed a mean applied dose of 419 Gy at the sclera (SD, 207 Gy) and 138 Gy (SD, 67 Gy) at the tumor apex. The 5-year tumor control rate was 94.4%. Tumor recurrence was more frequent in eyes with vitreous tumor cell seeding or fish-flesh regression. The estimated 5-year eye preservation rate was 86.5%. Previous treatment by brachytherapy or external beam radiotherapy, as well as a large tumor diameter, were significant factors for enucleation. The radiotherapy-induced complications after 5 years of follow-up were retinopathy (22%), optic neuropathy (21%), and cataract (17%). These complications were significantly more frequent after prior brachytherapy or external beam radiotherapy. CONCLUSION: Brachytherapy using (106)Ru plaques is a highly efficient therapy with excellent local tumor control and an acceptable incidence of side effects.
Adolescent↗
Liver transplantation and incidentally found hepatocellular carcinoma in liver explants: need for a new definition?
BACKGROUND: "Incidentally" identified hepatocellular carcinoma (iHCC) in liver explants after liver transplantation (LTx) is a frequently reported finding, which is characterized with a good prognosis. The purpose of this study was to evaluate the outcome of patients with these tumors in our series and in literature reports, and to compare their prognosis to that of HCC diagnosed preoperatively. METHODS: From April 1998 to December 2003, 432 patients underwent deceased-donor LTx at our center for nonmalignant indications. An additional 31 patients with a preoperative known HCC (pkHCC) received deceased-donor grafts. A literature search was performed intending to estimate the incidence of iHCC in liver explants and the outcome after LTx. RESULTS: iHCC was found in 5 of the 432 patients. All five patients are currently alive without evidence of tumor recurrence after a median follow-up of 43 months. On the other hand, in the group of the 31 patients with pkHCC, 22 of them are at the moment alive in a median follow-up of 28 months. When comparing the two groups, no difference in survival could be found (P=0.1419 in log-rank test). Literature reports of 705 instances with iHCC over the past 20 years showed a statistical "better survival" in only 24 cases. CONCLUSION: Literature reports showed a remarkable "deviation" of the expected tumor characteristics for the iHCC. Obviously, this is because of a widely characterization of iHCC, including also tumors which are rather undetected HCC during the waiting time to LTx. A more precise definition for the iHCC is needed.
Carcinoma, Hepatocellular↗
Over-expression of p53/BAK in aseptic loosening after total hip replacement.
Particle-induced osteolysis is a major cause of aseptic loosening after total joint replacement. The possible induction of apoptosis has not been addressed in great detail. Thus far, it has been shown that ceramic and polyethylene particles can induce apoptosis of macrophages in vitro. The purpose of this study was to test the hypothesis that wears debris generated from total hip arthroplasty could induce cellular damage and apoptosis in vivo. We therefore determined by immunohistochemical methods if increased expression of p53, an important transcription factor, and BAK and Bcl-2, two important regulators of apoptosis, can be found in interface membranes and capsules of hips with aseptically loose implants. Strongly positive immunohistochemical staining for p53 and BAK was found in peri-implant tissues from patients with aseptic hip implant loosening. Differentiation of various cell types showed that macrophages stained positive for p53 in all capsule and interface specimens. p53 was frequently detected in giant cells. Positive staining of BAK in macrophages and giant cells was seen in all specimens. Some positive reactions were observed in fibroblasts, only two of 19 cases stained for p53 and three cases for BAK within synovial cells. Positive macrophages and giant cells were localized around polyethylene particles. While T-lymphocytes showed a regular BAK-staining, the other leukocytes were negative. Statistical analyses showed significant positive correlations (p < 0.001) between the presence of polyethylene and metal debris and the expression of BAK and p53. Polyethylene particles were surrounded by more positive macrophages and giant cells than were metal particles, indicating that polyethylene debris may be a stronger inductor of cell cycle arrest and apoptosis than metal debris. In this study apoptosis of macrophages, giant cells and T-lymphocytes in capsules and interface membranes of patients with aseptic hip implant loosening has been demonstrated in vivo. It is possible that the apoptotic cascade could evolve as a novel therapeutic target to prevent particle-induced osteolysis.
Adult↗
Postoperative upper airway obstruction after recovery of the train of four ratio of the adductor pollicis muscle from neuromuscular blockade.
Anesthetics, and even minimal residual neuromuscular blockade, may lead to upper airway obstruction (UAO). In this study we assessed by spirometry in patients with a train-of-four (TOF) ratio >0.9 the incidence of UAO (i.e., the ratio of maximal expiratory flow and maximal inspiratory flow at 50% of vital capacity [MEF50/MIF50] >1) and determined if UAO is induced by neuromuscular blockade (defined by a forced vital capacity [FVC] fade, i.e., a decrease in values of FVC from the first to the second consecutive spirometric maneuver of > or =10%). Patients received propofol and opioids for anesthesia. Spirometry was performed by a series of 3 repetitive spirometric maneuvers: the first before induction (under midazolam premedication), the second after tracheal extubation (TOF ratio: 0.9 or more), and the third 30 min later. Immediately after tracheal extubation and 30 min later, 48 and 6 of 130 patients, respectively, were not able to perform spirometry appropriately because of sedation. The incidence of UAO increased significantly (P < 0.01) from 82 of 130 patients (63%) at preinduction baseline to 70 of 82 patients (85%) after extubation, and subsequently decreased within 30 min to values observed at baseline (80 of 124 patients, 65%). The mean maximal expiratory flow and maximal inspiratory flow at 50% of vital capacity ratio after tracheal extubation was significantly increased from baseline (by 20%; 1.39 +/- 1.01 versus 1.73 +/- 1.02; P < 0.01), and subsequently decreased significantly to values observed at baseline (1.49 +/- 0.93). A statistically significant FVC fade was not present, and a FVC fade of > or =10% was observed in only 2 patients after extubation. Thus, recovery of the TOF ratio to 0.9 predicts with high probability an absence of neuromuscular blocking drug-induced UAO, but outliers, i.e., persistent effects of neuromuscular blockade on upper airway integrity despite recovery of the TOF ratio, may still occur.
Adult↗
A bootstrap test for the analysis of microarray experiments with a very small number of replications.
In microarray studies it is common that the number of replications (i.e. the sample size) is small and that the distribution of expression values differs from normality. In this situation, permutation and bootstrap tests may be appropriate for the identification of differentially expressed genes. However, unlike bootstrap tests, permutation tests are not suitable for very small sample sizes, such as three per group. A variety of different bootstrap tests exists. For example, it is possible to adjust the data to have a common mean before the bootstrap samples are drawn. For small significance levels, which can occur when a large number of genes is investigated, the original bootstrap test, as well as a bootstrap test suggested for the Behrens-Fisher problem, have no power in cases of very small sample sizes. In contrast, the modified test based on adjusted data is powerful. Using a Monte Carlo simulation study, we demonstrate that the difference in power can be huge. In addition, the different tests are illustrated using microarray data.
Algorithms↗
Endovascular stent-graft placement in aortic dissection: a meta-analysis.
AIMS: This article summarizes all available published data with respect to clinical success, complications, and outcomes of endovascular stent-graft placement among patients with descending aortic dissection (AD). METHODS AND RESULTS: We performed a meta-analysis of all published series on retrograde endovascular stent-graft placement encompassing >or=3 patients with AD. Thirty-nine studies, involving a total of 609 patients, were included. Procedural success was reported in 98.2+/-0.5% of patients. Major complications were reported in 11.1+/-1.4%, with the most dreaded neurologic complications in 2.9+/-0.7% patients. Periprocedural stroke was encountered more frequently than paraplegia (1.9+/-0.6% vs. 0.8+/-0.4%). Overall complications were significantly higher in patients undergoing stent-graft placement for acute AD than in patients with chronic AD (21.7+/-2.8% vs. 9.1+/-2.3%, P=0.005). The overall 30-day mortality was 5.3+/-0.9%, and was three-fold higher in patients with acute AD when compared with chronic AD (9.8+/-2.2% vs. 3.2+/-1.4%, P=0.015). In addition, 2.8+/-0.7% of patients died over a mean follow-up period of 19.5+/-7.1 months. Kaplan-Meier analysis yielded overall survival rates of 90.6+/-1.6% at 6 months, 89.9+/-1.7% at 1 year, and 88.8+/-1.9% at 2 years, respectively. CONCLUSION: Endovascular stent-graft placement in type B-AD is technically feasible with success rates of >95% in selected cohort. Although minimally invasive, major complications occurred in 14-18% of patients depending upon the acuity of presentation, with very low incidence of paraplegia. Both, acute and mid-term mortality of this novel treatment strategy appear to favourably compare with surgical treatment but further studies are necessary to compare stent-graft placement with medical treatment in uncomplicated AD.
Acute Disease↗
Adaptive designs based on the truncated product method.
BACKGROUND: Adaptive designs are becoming increasingly important in clinical research. One approach subdivides the study into several (two or more) stages and combines the p-values of the different stages using Fisher's combination test. METHODS: Alternatively to Fisher's test, the recently proposed truncated product method (TPM) can be applied to combine the p-values. The TPM uses the product of only those p-values that do not exceed some fixed cut-off value. Here, these two competing analyses are compared. RESULTS: When an early termination due to insufficient effects is not appropriate, such as in dose-response analyses, the probability to stop the trial early with the rejection of the null hypothesis is increased when the TPM is applied. Therefore, the expected total sample size is decreased. This decrease in the sample size is not connected with a loss in power. The TPM turns out to be less advantageous, when an early termination of the study due to insufficient effects is possible. This is due to a decrease of the probability to stop the trial early. CONCLUSION: It is recommended to apply the TPM rather than Fisher's combination test whenever an early termination due to insufficient effects is not suitable within the adaptive design.
Data Interpretation, Statistical↗
Diagnostic discrimination between graft-related and non-graft-related perioperative myocardial infarction with cardiac troponin I after coronary artery bypass surgery.
AIMS: The rise of markers for myocardial injury indicates early graft-related or non-graft-related perioperative myocardial infarction (PMI) after coronary artery bypass grafting (CABG). A diagnostic discrimination between these two situations may enable adequate therapeutic measures, limiting myocardial damage, and improving outcome. METHODS AND RESULTS: In a prospective study, 94 among 3308 consecutive CABG patients underwent acute reangiography because of evidence of PMI. Of these 94 patients, 56 had graft-related PMI (group 1), 38 patients had non-graft-related PMI (group 2), and 95 patients without evidence of PMI and angiographically patent grafts served as control (group 3). Cardiac troponin I (cTnI), creatine kinase (CK), and its MB fraction were determined. CTnI, but not CK/CK-MB levels were significantly higher in group 1 than in groups 2 and 3 at 12 and 24 h after aortic unclamping (P<0.0001). Receiver operating characteristic and multivariable logistic regression analyses indicated cTnI as the best discriminator between PMI 'in general' and 'inherent' release of cTnI after CABG with a cut-off value of 10.5 ng/mL and between graft-related and non-graft-related PMI with a cut-off value of 35.5 ng/mL. CONCLUSION: Perioperative cTnI elevation after CABG separates among patients with graft-related, non-graft-related, and without PMI, however, not earlier than 12 h after surgery.
Aged↗
Efficiency comparisons of rank and permutation tests.
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Efficiency↗
Two-part permutation tests for DNA methylation and microarray data.
BACKGROUND: One important application of microarray experiments is to identify differentially expressed genes. Often, small and negative expression levels were clipped-off to be equal to an arbitrarily chosen cutoff value before a statistical test is carried out. Then, there are two types of data: truncated values and original observations. The truncated values are not just another point on the continuum of possible values and, therefore, it is appropriate to combine two statistical tests in a two-part model rather than using standard statistical methods. A similar situation occurs when DNA methylation data are investigated. In that case, there are null values (undetectable methylation) and observed positive values. For these data, we propose a two-part permutation test. RESULTS: The proposed permutation test leads to smaller p-values in comparison to the original two-part test. We found this for both DNA methylation data and microarray data. With a simulation study we confirmed this result and could show that the two-part permutation test is, on average, more powerful. The new test also reduces, without any loss of power, to a standard test when there are no null or truncated values. CONCLUSION: The two-part permutation test can be used in routine analyses since it reduces to a standard test when there are positive values only. Further advantages of the new test are that it opens the possibility to use other test statistics to construct the two-part test and that it avoids the use of any asymptotic distribution. The latter advantage is particularly important for the analysis of microarrays since sample sizes are usually small.
Algorithms↗
Risk stratification with cardiac troponin I in patients undergoing elective coronary artery bypass surgery.
OBJECTIVE: Cardiac troponin I (cTnI) is a highly sensitive and specific marker for postoperative prediction of patients outcome after coronary artery bypass surgery (CABG). Whether preoperatively elevated cTnI levels similarly predict the outcome in patients scheduled for elective CABG is currently unknown. METHODS: Therefore, a possible correlation between preoperative cTnI levels and perioperative major adverse events and in-hospital mortality after CABG was investigated. CTnI was measured within 24h before surgery in 1405 out of 3124 consecutive elective CABG patients. Out of these patients, 1178 had a preoperative cTnI level below 0.1ng/ml (group 1), 163 patients had a cTnI level between 0.11 and 1.5ng/ml (group 2), and 64 patients had a cTnI level above 1.5ng/ml (group 3). CTnI levels, electrocardiograms, clinical data, adverse events and in-hospital mortality were recorded prospectively. Patients with ST-elevation myocardial infarction less than 7 days before surgery were excluded from the study. RESULTS: Perioperative myocardial infarction (PMI) occurred in 69/1178 patients (5.9%) in group 1, 14/163 patients (8.6%; odds ratio (OR) 1.5, 95% confidence interval (CI): 0.8-2.8) in group 2, and 11/64 patients (17.2%; OR 3.3, CI: 1.6-7.0) in group 3 (overall: P<0.001, Cochran-Armitage trend test). Low cardiac output syndrome (LCOS) occurred in 19/1178 patients (1.6%), 9/163 (5.5%; OR 3.6, CI: 1.5-8.5), and 7/64 patients (10.9%; OR 7.5, CI: 2.7-19.8) (overall: P<0.001, group 1 vs. group 2: P<0.002), respectively. In-hospital mortality was 1.7% in group 1 and 3.1% in group 2, but 6.3% (OR 3.9, CI: 1.1-12.5) in group 3 (overall: P<0.01, group 1 vs. group 2: P=NS). Intensive care and hospital stay were significantly longer in group 3 compared to groups 1 and 2. Univariate and multivariate logistic regression analysis confirmed the statistically significant relationship between cTnI and PMI, LCOS and in-hospital mortality, respectively (P<0.001). CONCLUSIONS: Risk stratification by measurement of cTnI levels within 24h before elective CABG clearly identifies a subgroup of patients with increased risk for postoperative adverse outcome and in-hospital mortality.
Aged↗
Prognostic value of preoperative cardiac troponin I in patients with non-ST-segment elevation acute coronary syndromes undergoing coronary artery bypass surgery.
STUDY OBJECTIVES: Elevated levels of cardiac troponin I (cTnI) have been associated with adverse short-term and long-term outcomes in acute coronary syndrome (ACS) patients and in patients who underwent coronary artery bypass grafting (CABG); however, the prognostic implications of preoperative cTnI determination have not been investigated so far. DESIGN AND SETTING: Retrospective study in a department of cardiothoracic surgery of a university hospital. PATIENTS AND METHODS: A possible correlation between preoperative cTnI levels and major adverse cardiac events (MACE) and in-hospital mortality in CABG patients with non-ST-segment elevation ACS (NSTE-ACS) was investigated. cTnI was determined in 1,978 of 3,124 consecutive CABG patients. Among these, 1,592 patients had preoperative cTnI levels < 0.1 ng/mL and therefore served as control subjects (group 1), 265 patients had NSTE-ACS with cTnI levels from 0.11 to 1.5 ng/mL (group 2), and 121 patients had NSTE-ACS with cTnI levels > 1.5 ng/mL (group 3). cTnI levels, clinical data, MACE, and in-hospital mortality were recorded prospectively. Logistic regression and receiver operating characteristic analyses were applied to determine prognostic cutoff values of cTnI. RESULTS: Perioperative myocardial infarction was found in 5.8% of the patients in group 1, 8.3% of the patients in group 2 (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.9 to 2.5), and 18.2% patients in group 3 (OR, 3.6; 95% CI, 2.1 to 6.2; p < 0.0001, Cochran-Armitage trend test). Low cardiac output syndrome occurred in 1.5% of patients in group 1, 4.2% of patients in group 2 (OR, 2.8; 95% CI, 1.3 to 6.1), and 10.9% patients in group 3 (OR, 6.5; 95% CI, 2.9 to 14.4; p < 0.0001). In-hospital mortality was 1.5% in group 1, 3.0% in group 2 (OR, 2.0; 95% CI, 0.8 to 4.8), but 6.6% in group 3 (OR, 4.6; 95% CI, 1.9 to 11.1; p < 0.0001). Univariate and multivariate logistic regression analyses identified cTnI as the strongest preoperative predictor for MACE and in-hospital mortality, respectively. CONCLUSIONS: Preoperative cTnI measurement before CABG appears as a powerful and independent determinant of short-term surgical risk in patients with NSTE-ACS.
Aged↗