No abstract

Objective-To investigate the value of the Parsonnet score (PS) in identifying preoperatively patients that are likely to spend < 24 hours on the intensive care unit (ICU) following cardiac surgery. Method-Prospectively collected data on 5591 patients were analysed. PS, mortality, the length of stay on the ICU (ICU-LOS), number of patients with clinical evidence of stroke, need for haemofiltration, resternotomy for bleeding, tracheostomy, and use of intra-aortic balloon pump were documented as outcomes. A receiver operating characteristic (ROC) curve constructed using PS as a predictor of ICU stay < 24 hours identified a PS of 10 as the best cut oV point that would predict ICU-LOS < 24 hours. The patients were therefore stratified by PS into two groups, those with a PS of 0 to 9 (PS 0-9) and those with a PS of 10 and above (PS 10+). Results-The ROC curve constructed using PS as a predictor of ICU stay < 24 hours had an area under the curve of 0.70 (0.01). The maximum eYciency of the test was at a sensitivity of 0.68. This corresponded to PS 10. The positive predictive value of the test at this score was 90.5%. Patients with PS 0-9 had a mean ICU stay of 1.49 days, while patients with PS 10+ had a mean ICU stay of 2.89 days (p = 0.01). The risk of stroke, use of intra-aortic balloon pump, requirement for haemofiltration, need for tracheostomy, and risk of resternotomy for bleeding were each significantly less in patients with PS 0-9 versus those with a score of PS 10+ (p < 0.01 in all cases). The risk of a single complication was 4.7% (PS 0-9) v 15.2% (PS 10+) (p < 0.01). Conclusion-PS is an impartial and objective method of predicting postoperative complications and ICU stay < 24 hours. This is of value in selecting a cohort of patients likely to maintain a smooth flow of patients through the cardiothoracic unit when resources are limited to a few free ICU beds. (Heart 2000;83:429-432)

With appropriate case selection, trainees in cardiac surgery can achieve good results. As training changes in the UK, trainees should receive increased supervised exposure to a wider range of procedure to compensate for a lower volume of workload.

Three cases of post‐traumatic intrahepatic cutaneous biliary fistulas are presented, and some of the techniques available for the surgical management of persistent fistulas are described: simple suture, fistulo‐jejunostomy and fistulo‐cholecystostomy. All 3 patients achieved good clinical and biochemical results from their operations.

After cardiac surgery transoesophageal echocardiography showed a large thrombus compressing the right atrium in 'three hypotensive patients. No satisfactory images were obtained by transthoracic imaging, which is often difficult in ventilated patients after cardiac surgery. Transoesophageal echocardiography, however, provided rapid diagnostic information and permitted prompt surgical intervention.In patients who become hypotensive after major cardiac surgery it is often not easy to make the differential diagnosis between left ventricular dysfunction, prosthetic valve dysfunction, sepsis, cardiac tamponade, and intrathoracic bleeding. Echocardiography can provide additional information about the contractile state of the left ventricle and the function of prosthetic valves but transthoracic imaging in a ventilated patient after cardiac surgery is difficult. Transoesophageal echocardiography provides rapid, real time high resolution imaging of the heart and surrounding structures that is valuable in the management of these patients.We describe three patients in whom compression of the right atrium by localised haematoma formation presented as either an early or late postoperative complication of valve surgery and in whom transoesophageal echocardiography was of primary diagnostic importance. 1). Colour Doppler flow mapping showed that the right atrial cavity was less than 1 cm in diameter. The right ventricle and the left heart were underfilled and the mitral valve prosthesis seemed to be functioning normally. At reoperation the transoesophageal echocardiographic findings were confirmed and direct left atrial puncture showed a left atrial pressure of 5 mm Hg. The large haematoma was removed and haemostasis secured. The patient subsequently made an uneventful postoperative recovery. CASE 2A 66 year old man who had had a CarpentierEdwards aortic valve replacement for aortic regurgitation and dilatation of the ascending aorta 10 years previously had the prosthetic valve replaced by a number 12 Starr-Edwards valve. The operative procedure was uncomplicated and the patient had an uneventful postoperative course. He was discharged seven days after operation. He was readmitted three days later with a history of increasing shortness of breath, a heart rate of 120 beats/ min, and a systolic blood pressure of 70-80 mm Hg. There were no clinical signs of valve dysfunction or chest infection. The electrocardiogram showed atrial fibrillation with a rapid ventricular response and the chest x ray showed some cardiomegaly but clear lung fields. Echocardiography showed a large haematoma surrounding and compressing the right atrium, like that in patient 1. At reoperation there was a large clot compressing the right atrium contained by a partially obliterated pericardium. The source