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  • 1.
    Appelblad, Micael
    et al.
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Fat content in pericardial suction blood and the efficacy of spontaneous density separation and surface adsorption in a prototype system for fat reduction.2007In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 134, no 2, p. 366-372Article in journal (Refereed)
  • 2.
    Boivie, Patrik
    et al.
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Edström, Cecilia
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Side differences in cerebrovascular accidents after cardiac surgery: a statistical analysis of neurologic symptoms and possible implications for anatomic mechanisms of aortic particle embolization.2005In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 129, no 3, p. 591-598Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Aortic manipulation and particle embolization have been identified to cause cerebrovascular accidents in cardiac surgery. Recent data suggest that left-hemispheric cerebrovascular accident (right-sided symptoms) is more common, and this has been interpreted as being caused by aortic cannula stream jets. Our aim was to evaluate symptoms of cerebrovascular accident and side differences from a retrospective statistical analysis. METHODS: During a 2-year period, 2641 consecutive cardiac surgery cases were analyzed. Patients positive for cerebrovascular accident were extracted from a database designed to monitor clinical symptoms. A protocol was used to confirm symptom data with the correct diagnosis in patient records. Patients were subdivided into 3 groups: control, immediate cerebrovascular accident, and delayed cerebrovascular accident. RESULTS: Among pooled patients, immediate and delayed cerebrovascular accidents were 3.0% and 0.9%, respectively. The expected predisposing factors behind immediate cerebrovascular accidents were significant, although the type of operation affected this search. Aortic quality was a strong predictor ( P < .001). The rate of delayed cerebrovascular accident was unaffected by surgery group. Left-sided symptoms of immediate cerebrovascular accident were approximately twice as frequent ( P = .016) as on the contralateral side. This phenomenon was observed for pooled patients and for isolated coronary bypass procedures (n = 1882; P = .025). CONCLUSIONS: Immediate cerebrovascular accident and aortic calcifications are linked. The predominance of left-sided symptoms may suggest that aortic manipulation and anatomic mechanisms in the aortic arch are more likely to cause cerebrovascular accidents than effects from cannula stream jets.

  • 3.
    Boivie, Patrik
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Hansson, Magnus
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Aortic plaque distribution in relation to cross-clamp and cannulation procedures during cardiac surgery2007In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 41, no 2, p. 120-125Article in journal (Other academic)
  • 4.
    Boivie, Patrik
    et al.
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Hansson, Magnus
    Umeå University, Faculty of Medicine, Medical Biosciences, Pathology.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Intraluminal aortic manipulation by means of intra-aortic filter, cannulation, and external clamp maneuvers evaluated versus dislodged embolic material.2006In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 131, no 2, p. 283-289Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Aortic atherosclerosis is an important risk factor for cerebrovascular accidents in cardiac surgery. An intra-aortic filter might reduce this risk. We aimed to analyze the risks for emboli associated with intraluminal aortic manipulation and intra-aortic filter handling in relation to cannulation and external clamp maneuvers. METHODS: A model was designed with a cadaver aorta and retrograde perfusion (n = 16). A crossclamp was positioned on the ascending aorta and repeatedly opened under pressure to collect aliquots with dislodged particles. Cannulation was performed after 10 clamp maneuvers, followed by positioning and removing the intra-aortic filter, with each step followed by a washout sequence to collect perfusate. The removed filter was also analyzed. Evaluation was by means of digital image analysis, with differentiation of particles into different spectra. RESULTS: Intra-aortic filter manipulation produced a significant washout of embolic particles; in particular, this was seen for the macroscopic cellular spectrum (P = .006 and P = .002 for filter insertion and removal, respectively). Particles were also found to be collected by the filter (P = .004). In addition, cannulation and aortic crossclamp manipulation generated a notable number of particles (P = .001 and P = .013, respectively). CONCLUSIONS: The intra-aortic filter collects material during aortic manipulation. However, intraluminal aortic manipulation from filter handling can also dislodge particles, possibly related to shedding of intimal debris. This is in addition to substantial amounts of particles that are generated by aortic cannulation and aortic crossclamping.

  • 5.
    Boivie, Patrik
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery.
    Hedberg, Magnus
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Size distribution of embolic material produced at aortic cross-clamp manipulation2010In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 44, no 6, p. 367-372Article in journal (Refereed)
    Abstract [en]

    Objectives: The association between aortic atherosclerosis and neurological damage during cardiac surgery is well recognized. The purpose was here to analyze the size distribution of particles produced at cross-clamp manipulation of the ascending aorta.

    Design: A human cadaveric aortic perfusion model of retrograde design was applied (n 27). With this model, washout samples were collected from the pressurized ascending aorta during cross clamp manipulation. Before the experiment, the aorta was flushed to remove debris and with a baseline sample collected. The cross-clamp was opened to collect ten repeated aliquots with dislodged particles. Collected washout samples were evaluated by digital image analysis and microscopy.

    Results: Cross-clamping produced a significant output of particles, which was seen for size intervals of 1 mm and smaller (p 0.002 to p 0.022). In all size intervals the particle output correlated with the degree of overall aortic calcification(p 0.002 to p 0.025). The model generated substantially more small-size particles than large debris (p 0.010).

    Conclusions: Aortic clamping was here verified to dislodge aortic debris which correlated with the degree of observed calcification. Macroscopic particles were few. In contrast, cross-clamping produced substantial numbers of small-size particles. These findings emphasize microembolic risks associated with cross-clamping of atherosclerotic vessels.

  • 6.
    Claesson Lingehall, Helena
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Cardiothoracic Surgery Division, Heart Center.
    Smulter, Nina
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Cardiothoracic Surgery Division, Heart Center.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Cardiothoracic Surgery Division, Heart Center.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing. Department of Nursing, The Strategic Research Programme in Care Sciences, Umeå University and Karolinska Institutet, Department of Surgical and Perioperative Science, Orthopedic Surgery, University of Umeå.
    Validation of the Swedish version of the Nursing Delirium Screening Scale used in patients 70 years and older undergoing cardiac surgery2013In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 22, no 19-20, p. 2858-2866Article in journal (Refereed)
    Abstract [en]

    AIMS AND OBJECTIVES: Validation of the Swedish version of the Nursing Delirium Screening Scale as a screening tool for nurses to use to detect postoperative delirium in patients 70 years and older undergoing cardiac surgery.

    BACKGROUND: Delirium is common among old patients after cardiac surgery. Underdiagnosis and poor documentation of postoperative delirium is problematic, and nurses often misread the signs.

    DESIGN: A prospective observational study.

    METHODS: Patients (n = 142) scheduled for cardiac surgery were assessed three times daily by the nursing staff using the Nursing Delirium Screening Scale. Nursing Delirium Screening Scale was compared with the Mini Mental State Examination and the Organic Brains Syndrome Scale, evaluated day one and day four postoperatively. Delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders - DSM-IV-TR criteria.

    RESULTS: A larger proportion of patients were diagnosed with delirium according to the Mini Mental State Examination and Organic Brains Syndrome Scale compared with the Nursing Delirium Screening Scale, both on day one and day four. The Nursing Delirium Screening Scale protocol identified the majority of hyperactive and mixed delirium patients, whereas several with hypoactive delirium were unrecognised.

    CONCLUSIONS: The Swedish version of the Nursing Delirium Screening Scale was easily incorporated into clinical care and showed high sensitivity in detecting hyperactive symptoms of delirium. However, in the routine use by nurses, the Nursing Delirium Screening Scale had low sensitivity in detecting hypoactive delirium, the most prevalent form of delirium after cardiac surgery. Nursing Delirium Screening Scale probably has to be combined with cognitive testing to detect hypoactive delirium.

    RELEVANCE TO CLINICAL PRACTICE: Nurses play a key role in detecting delirium. The Nursing Delirium Screening Scale was easy incorporated instrument for clinical practice and identified the majority of hyperactive and mixed delirium, but several of the patients with hypoactive delirium were unrecognised. Training of assessment and cognitive testing seems to be necessary to detect hypoactive delirium.

  • 7.
    Claesson Lingehall, Helena
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Smulter, Nina
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Lindahl, Elisabeth
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Dementia after postoperative delirium in older people who have undergone cardiac surgery: a longitudinal cohort studyManuscript (preprint) (Other academic)
  • 8.
    Claesson Lingehall, Helena
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Smulter, Nina
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. Cardiothoracic Surgery Division, Heart Center.
    Lindahl, Elisabeth
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lindkvist, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Gustavsson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Preoperative Cognitive Performance and Postoperative Delirium Are independently Associated With Future Dementia in Older People Who Have Undergone Cardiac Surgery: A Longitudinal Cohort Study2017In: Critical Care Medicine, ISSN 0090-3493, E-ISSN 1530-0293, Vol. 45, no 8, p. 1295-1303Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate if postoperative delirium was associated with the development of dementia within 5 years after cardiac surgery.

    Design: Longitudinal cohort study.

    Setting: Cardiothoracic Division, Umeå University Hospital, Sweden.

    Patients: Patients aged 70 years old or older (n = 114) scheduled for routine cardiac procedures with cardiopulmonary bypass without documented dementia were enrolled in 2009.

    Intervention: Structured assessments were performed preoperatively, 1 and 4 days after extubation, and 1, 3, and 5 years postoperatively.

    Measurements and Main Results: Patients were assessed comprehensively, including cognitive and physical function, coexisting medical conditions, demographic characteristics, and medications. Diagnoses of delirium, depression, and dementia were made according to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criteria. During the 5-year period, 30 of 114 participants (26.3%) developed dementia. Postoperative delirium had occurred in 87% of those who later developed dementia. A multivariable logistic regression model showed a lower preoperative Mini-Mental State Examination score (p < 0.001; odds ratio, 0.68; 95% CI, 0.54–0.84) and the occurrence of postoperative delirium (p = 0.002; odds ratio, 7.57; 95% CI, 2.15–26.65) were associated with dementia occurrence.

    Conclusions: Our findings suggest that older patients with reduced preoperative cognitive functions or who develop postoperative delirium are at risk of developing dementia within 5 years after cardiac surgery. Cognitive functions should be screened for preoperatively, those who develop postoperative delirium should be followed up to enable early detection of dementia symptoms, and management should be implemented.

  • 9. Engström, Karin
    et al.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Hazards with electrocautery-induced decomposition of fatty acids: in view of lipid embolization2010In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 44, no 5, p. 307-312Article in journal (Refereed)
    Abstract [en]

    Electrocautery induces a profound fatty-acid fragmentation to form short-chained compounds. The chemical and toxic nature of these compounds remains to be determined, including their clinical implications at blood recycling in cardiac surgery.

  • 10.
    Engström, Karl Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Angrén, John
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Björnstig, Ulf
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Saveman, Britt-Inger
    Umeå University, Faculty of Medicine, Department of Nursing.
    Mass casualty incidents in the underground mining industry: applying the Haddon Matrix on an integrative literature review2018In: Disaster Medicine and Public Health Preparedness, ISSN 1935-7893, E-ISSN 1938-744X, Vol. 12, no 1, p. 138-146Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Underground mining is associated with obvious risks that can lead to mass casualty incidents. Information about such incidents was analyzed in an integrated literature review.

    METHODS: A literature search (1980-2015) identified 564 modern-era underground mining reports from countries sharing similar occupational health legislation. These reports were condensed to 31 reports after consideration of quality grading and appropriateness to the aim. The Haddon matrix was used for structure, separating human factors from technical and environmental details, and timing.

    RESULTS: Most of the reports were descriptive regarding injury-creating technical and environmental factors. The influence of rock characteristics was an important pre-event environmental factor. The organic nature of coal adds risks not shared in hard-rock mines. A sequence of mechanisms is commonly described, often initiated by a human factor in interaction with technology and step-wise escalation to involve environmental circumstances. Socioeconomic factors introduce heterogeneity. In the Haddon matrix, emergency medical services are mainly a post-event environmental issue, which were not well described in the available literature. The US Quecreek Coal Mine incident of 2002 stands out as a well-planned rescue mission.

    CONCLUSION: Evaluation of the preparedness to handle underground mining incidents deserves further scientific attention. Preparedness must include the medical aspects of rescue operations.

  • 11.
    Engström, Karl-Gunnar
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Contaminating fat in pericardial suction blood: a clinical, thechnical and scientific challange2004In: Perfusion, Vol. 19, no 1, p. 21-31Article in journal (Refereed)
  • 12.
    Engström, Karl-Gunnar
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Particle contamination of salvage blood plasma in cardiac surgery2004In: Transfusion Medicine and Hemotherapy, Vol. 31, p. 204-212Article in journal (Refereed)
  • 13. Friberg, Örjan
    et al.
    Engström, Karl-Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Hentschel, Jan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Freter, Wolfgang
    Åberg, Bengt
    Dahlin, Lars-Göran
    Sandin, Mathias
    Näslund, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Carath -ett verksamhetsinitierat kvalitetsregister och processtöd: Ger toraxkirurgin bra möjlighet att följa vårdprocessen2011In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 108, no 26-28, p. 1365-1369Article in journal (Refereed)
    Abstract [en]

    Carath is the name of a database and outcomes registry for cardiovascular surgery used and developed by four Swedish cardiothoracic centres in cooperation. This report focuses on our experiences, positive and negative, of designing and implementing a “tailor made” database program for process control in mainly cardiac surgery. The system now provides valuable, and in some ways unique information on medical outcomes as well as administrative data. We have also become very aware of the difficulties involved in maintaining a good quality of data in multicentre medical registries. Several factors, not least the human factor, must be taken into account when building user friendly databases and quality registries. Variables must be well defined. Also, direct linking of data and outcomes directly from digitalised patient records has proved to be complicated - technically and due to the complexity of health care processes.

  • 14.
    Hedberg, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Boivie, Patrik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Edström, Cecilia
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Cerebrovascular accidents after cardiac surgery: an analysis of CT scans in relation to clinical symptoms2005In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 39, no 5, p. 299-305Article in journal (Refereed)
    Abstract [en]

    There is a link between aortic manipulation, particle embolization, and cerebrovascular accidents (CVA) in cardiac surgery. The present aim was to study hemispheric side differences of CVA. Cardiac-surgery patients with CVA and with computer tomography (CT) performed (n = 77) were analyzed within a total group of 2641 consecutive cases. CT data were reviewed for hemispheric and vascular distribution, and compared with CVA-symptom data of immediate and delayed type. Of the included patients, 66% had positive CT. In the group of 'cardiac-type' operations (e.g., routine clamping and cannulation) and having immediate CVA, right-hemispheric lesions were more frequent than of the contra-lateral side (p = 0.005). Patients with aortic dissections had strong dominance of bilateral findings, which was different from the unilateral pattern of 'cardiac-type' operations (p = 0.001). The middle-cerebral artery territory dominated, and when involved showed a significant (p = 0.022) right-sided distribution. Both CT and clinical symptoms confirmed that CVA after cardiac surgery has a right-hemispheric predominance. These observations may imply that aortic manipulation directs embolic material towards the brachiocephalic trunk.

  • 15.
    Hedberg, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Boivie, Patrik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Early and delayed stroke after coronary surgery: an analysis of risk factors and the impact on short- and long-term survival2011In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 40, no 2, p. 379-387Article in journal (Refereed)
    Abstract [en]

    Objective: Stroke is a serious complication to cardiac surgery, and is generally considered as a uniform disease regardless of its temporal relationship to surgery. Our hypothesis suggests that stroke, in association with surgery, reflects other characteristics than stroke occurring with a free interval. This issue was here explored for risk factors and survival effects.

    Methods: Data were collected from 7839 procedures of isolated coronary artery bypass grafting (CABG), 297 off-pump CABG, and 986 combined CABG and valve procedures. Records of patients with any signs of neurological complications were reviewed to extract 149 subjects with stroke at extubation (early, 1.6%) versus 99 patients having a free interval (delayed, 1.1%). Survival data were complete, with a median follow-up time of 9.3 years (maximum 16.3 years). Independent risk factors were analyzed by logistic regression and survival by Cox regression.

    Results: Risk factors for early stroke were advanced age, high preoperative creatinine level, extent of aortic atherosclerosis, and long cardiopulmonary bypass time (all P<0.001). Factors associated with delayed stroke were female gender (P<0.001), unstable angina (P=0.003), previous cerebrovascular disease (P=0.009), inotropic support requirement (P<0.001), and postoperative atrial fibrillation (P<0.001). Stroke explained mortality not only in the early postoperative period (P<0.001), but also at long-term follow-up (P<0.001). Early and delayed stroke were associated with mortality hazard ratios (HRs) of 1.44 and 1.85 (P=0.008, P<0.001), respectively. However, for patients surviving their first postoperative year, early stroke did not influence long-term mortality (HR 1.07, P=0.695). This was in contrast to delayed stroke (HR 1.71, P=0.001).

    Conclusions: Early and delayed stroke differed in their related risk factors. The influence of stroke on short-term mortality was obvious and devastating. Mortality in association with early stroke mainly presented itself in the acute period, whereas for delayed stroke survival continued to be impaired also in the long-term perspective. Our report emphasizes that early and delayed stroke should be considered as two separate entities.

  • 16.
    Hedberg, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Boivie, Patrik
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Early and delayed stroke after coronary surgery: an analysis of risk factors and the impact on short and long-term survivalManuscript (preprint) (Other academic)
  • 17.
    Hedberg, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Hemispheric distribution of stroke after cardiac surgery: patient characteristics and survival impactManuscript (preprint) (Other academic)
  • 18.
    Hedberg, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Stroke after cardiac surgery - hemispheric distribution and survival2013In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 47, no 3, p. 136-144Article in journal (Refereed)
    Abstract [en]

    Objectives. Stroke following cardiac surgery may occur either in association with surgery (early) or occur postoperatively (delayed). The hemispheric distribution of lesions may provide information about embolic routes, which was analyzed here. Design. In 10,809 patients undergoing cardiac surgery, early (n = 223) and delayed stroke (n = 116) were explored. Symptoms and computed tomography findings were evaluated to categorize hemispheric distributions. This was compared with pre- and intra-operative characteristics and survival, using logistic regression and Kaplan-Meier statistics. Results. Early stroke had preponderance for the right rather than the left hemisphere (P = 0.009), whereas delayed stroke had a uniform distribution. Several intraoperative variables predicted the development of bilateral stroke compared with its unilateral counterpart. At multivariable analysis, the use of tranexamic acid was associated with bilateral stroke (P = 0.017), but was also associated with right rather than left-hemispheric stroke (P = 0.001). Bilateral lesions dramatically impaired survival versus those with unilateral lesions (P < 0.001). There was no survival difference between left and right-hemispheric stroke. Conclusions. When stroke, after cardiac surgery, is subdivided into early and delayed forms, it becomes evident that early, but not delayed stroke, demonstrates a hemispheric side difference. The preponderance for right-hemispheric lesions may indicate embolic mechanisms routed via the brachiocephalic trunk.

  • 19.
    Hedberg, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Funck, Bertil
    Swedish National Food Administration, Food Control Department, Meat Inspection Division, Luleå, Sweden.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Cannulation of the noncalcified aorta generates particles of microembolic nature: an experimental study using pig aorta2008In: Journal of cardiac surgery, ISSN 0886-0440, E-ISSN 1540-8191, Vol. 23, no 1, p. 39-43Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND AIM OF THE STUDY: Aortic cannulation during cardiac surgery is a potential etiological factor for perioperative stroke. Cannulae may dislodge aortic-wall calcifications. In addition, the sharp edge of the cannula-tip may shear off vessel-wall tissue, which can be expelled into the lumen. This hypothesis concerning source of emboli was tested in a noncalcified aortic perfusion model.

    METHODS: Pig aortas were pressurized and cannulated. Washout samples were collected before and after cannulation (n = 40). Particles were deposited onto a 10-microm filter and evaluated by microscopy and digital image analysis.

    RESULTS: A higher incidence of particles generated by cannulation was noted as compared to before the maneuver (p < 0.001). This increase included small (<0.1 mm, p < 0.001) and intermediate-size particles (0.1-0.5 mm, p < 0.001). Particles above 0.5 mm were few and were not associated with cannulation.

    CONCLUSIONS: Cannulation was a source of embolic material in the noncalcified aortic model. However, these particles were less than 0.5 mm in diameter and may contribute to neurocognitive decline after cardiac surgery.

  • 20.
    Janson, Veronica
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry. Klinisk kemi.
    Andersson, Britta
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Behnam-Motlagh, Parviz
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Engström, Karl-Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Henriksson, Roger
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Grankvist, Kjell
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry. Klinisk kemi.
    Acquisition of Cisplatin-resistance in Malignant Mesothelioma Cells Abrogates Na,K(+),2Cl(-;)-cotransport Activity and Cisplatin-induced Early Membrane Blebbing.2008In: Cell Physiol Biochem, ISSN 1421-9778, Vol. 22, no 1-4, p. 45-56Article in journal (Refereed)
    Abstract [en]

    AIMS:

    Resistance mechanisms are important limiting factors in the treatment of solid malignancies with cis-diamminedichloroplatinum(II) (cisplatin). To gain further understanding of the effects of acquired cisplatin-resistance, we compared a human malignant pleural mesothelioma cell line (p31) to a sub-line (p31res1.2) with acquired cisplatin-resistance.

    METHODS AND RESULTS:

    The role of Na(+),K(+),2Cl(-)-cotransport (NKCC1) activity in cisplatin-induced morphological changes and acquired cisplatin-resistance was investigated in a time-resolved manner. Acquisition of cisplatin-resistance resulted in markedly reduced NKCC1 activity, absence of cisplatin-induced early membrane blebbing, and increased basal caspase-3 activity. At equitoxic cisplatin concentrations, P31res1.2 cells had a faster activation of caspase-3 than P31 cells, but the end-stage cytotoxicity and number of cells with DNA fragmentation was similar. Bumetanide inhibition of NKCC1 activity in P31 cells repressed cisplatin-induced early-phase membrane blebbing but did not increase P31 cell resistance to cisplatin.

    CONCLUSIONS:

    Together, these results suggest that active NKCC1 was necessary for cisplatin-induced early membrane blebbing of P31 cells, but not for cisplatin-resistance. Thus, acquisition of cisplatin-resistance can affect mechanisms that have profound effects on cisplatin-induced morphological changes but are not necessary for the subsequent progression to apoptosis.

  • 21.
    Janson, Veronica
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Behnam-Motlagh, Parviz
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry. Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Henriksson, Roger
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Hörstedt, Per
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Grankvist, Kjell
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Phase-contrast microscopy studies of early Cisplatin-induced morphological changes of malignant mesothelioma cells and the correspondence to induced apoptosis.2008In: Experimental Lung Research, ISSN 0190-2148, E-ISSN 1521-0499, Vol. 34, no 2, p. 49-67Article in journal (Refereed)
    Abstract [en]

    Cisplatin treatment efficacy of malignant pleural mesothelioma (MPM) is aggravated by resistance and adverse effects. In P31 MPM cells, cisplatin induces morphological changes and apoptosis. To determine if very early (10 minutes) morphological responses corresponded to apoptosis-induction, cisplatin effects on P31 morphology were examined with phase-contrast microscopy (PCM), scanning electron microscopy (SEM), and flow cytometry (fluorescence-activated cell sorting [FACS]), and compared to apoptosis-induction over time. Increased membrane protrusions were identified with PCM and SEM, but these were not consistent with the induction of apoptosis. The authors concluded that very early morphological changes can be determined with PCM in MPM, but they did not convincingly correspond to apoptosis induction.

  • 22.
    Johansson, Bengt
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Engström, Karl-Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Dellborg, M.
    Kronvall, T.
    Kvidal, P.
    Mattsson, E.
    Thilen, U.
    Functional class, symptoms, medications, arrhythmia devices and quality of life in adults with congenital aortic valve disease. Data from the national registry of congenital heart disease2013In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 34, no Supplement: 1, p. 375-375Article in journal (Other academic)
    Abstract [en]

    Purpose: Despite the relative high prevalence of congenital aorticvalve disease, the outcome in contemporary cohorts of adults is not well established. In the present study, we have analysed data in the National Registry on Adult Congenital Heart Disease in order to elucidate the long-term outcome regarding functional class,symptoms, quality of life, medications and need for arrhythmiadevices in this cohort.

    Methods: Six hundred fifty-one adult patients with isolated congenitalaortic valve disease met the criteria and were grouped according to: if their first aortic valve intervention was < 18 years (group 1) (n=152), first aortic valve intervention > 18 years (group 2) (n=129) or no aorticvalve intervention (group 0) (n=370).

    Results: 92% of the patients were in NYHA I. Symptoms were reportedin 12.7% but more commonly in group 2 compared with group 1 (20.7% vs. 9.6%, p = 0.039). The overall quality of life assessed with EQ-VAS was 90% and equal between groups. The use of cardiovascularmedications, anticoagulation excluded, was higher in group 2 than ingroups 0 and 1 (29.1% vs. 9.1% and 11.6%, p = 0.001, p < 0.001). Warfarin was prescribed in 55.3% of the patients in group 2, in 34.5% ingroup 1 and 1.7% in group 0 (p < 0.001 for all comparisons) whichindicates that non-mechanical valve prostheses or other alternatives are common in group 1 and 2. Implanted arrhythmia devices were more common in group 2 compared with group 0 (5.1 vs. 0.6%, p = 0.01).

    Conclusion: Functional status and quality of life is generally goodand not obviously related to previous interventions. Symptoms, cardiovascular medications, including warfarin, and anti-arrhythmiadevices were more common in patients with their initial valveintervention in adult age. Many patients with a previous intervention have alternatives to mechanical heart valve prostheses and may thus need future re-interventions.

  • 23.
    Johansson, Bengt
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Holmgren, Anders
    Hedström, Magnus
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Engström-Laurent, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Evaluation of hyaluronan and calcifications in stenotic and regurgitant aortic valves.2011In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 39, no 1, p. 27-32Article in journal (Refereed)
    Abstract [en]

    Objective: Hyaluronan (HA) is a major component of the interstitium and has been observed in normal heart valves. The function of HA in heart valves is unknown but contribution to biomechanical function has been proposed. The purpose of this investigation was to study the distribution of HA in relation to calcifications in diseased human aortic valves. Methods: Human aortic valves were collected at aortic valve replacement, of whom nine patients had regurgitation and 13 stenotic disease. The valves were decalcified and stained for the visualisation of HA. The specimens were macroscopically evaluated for magnitude of calcification using image analysis. The microscopic amount and distribution of HA and calcifications were semiquantitatively evaluated using histochemistry. Results: The overall HA staining showed an inverse relationship against the magnitude of observed valve calcifications (p<0.001) and type of disease (p=0.014). Multiple-group comparison revealed regionally reduced HA staining in diffuse and heavy calcified regions inside the valve (both p<0.001) compared with normal-structured parts of the valve. HA was concentrated on the ventricular side of the valve (p=0.002). Conclusions: The content of HA was reduced in calcified aortic valves and had a heterogeneous distribution, potentially contributing to poor valve function. HA may also be involved in the pathophysiological process in degenerative aortic stenosis.

  • 24.
    KARLSSON, SOFIA
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    GYLLENCREUTZ, LINA
    Umeå University, Faculty of Medicine, Department of Nursing.
    ENGSTRÖM, GUNNAR
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    BJÖRNSTIG, ULF
    Saveman, Britt-Inger
    Umeå University, Faculty of Medicine, Department of Nursing.
    PREPAREDNESS FOR MINING INJURY INCIDENTS: INTERVIEWS WITH SWEDISH RESCUERS2017In: Safety Science Monitor, ISSN 1443-8844Article in journal (Refereed)
    Abstract [en]

    Objectives. To explore the perceptions and experiences of mining-, rescue service- (RS), and emergency medical service (EMS) personnel regarding how to handle incidents in an underground mine.Methods. Six focus-group interviews and 10 individual interviews were carried out with groups of mining-, RS and EMS personnel, who served the underground mining industry located in small municipalities in a sparsely populated area of northern Sweden. The transcripts of the interviews were analysed using qualitative content analysis.Results. The three groups mostly described experiences of minor incidents and announced a limited preparedness for handling major mining incidents. Collaboration was described as being difficult because of limited knowledge about the others’ responsibilities and capacities. Few non-mining personnel were trained, or prepared to fulfil their tasks in an underground environment, and some expressed that they would even refuse to go underground because of concerns for their own safety.Conclusions. There is a need for more collaboration and joint practices between and among the groups involved in rescue operations. Collaboration between mine- and RS personnel exists, but the EMS personnel is largely excluded from this interaction. Therefore, the EMS personnel are insecure about how to handle underground mining incidents. A closer collaboration between all organizations in preparing for mining incidents is emphasized, and would have positive effects on the rescue operation. Some experiences may also be used under similar circumstances, such as incidents in railway and road tunnels.

  • 25.
    Lindholm, Lena
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Heart Centre, Cardiothoracic Surgery, Umeå.
    Engström, Karl-Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Heart Centre, Cardiothoracic Surgery, Umeå.
    Endogenous gas formation of carbon dioxide used for wound flooding: an experimental study with implications regarding gas microembolism during cardiopulmonary bypass2014In: Perfusion, ISSN 0267-6591, E-ISSN 1477-111X, Vol. 29, no 3, p. 242-248Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Gas microembolisation is an identified risk in cardiac surgery. Flooding the wound with carbon dioxide is a method proposed to reduce this problem. The high solubility of carbon dioxide is beneficial, but may also cause problems. The gas solubility diminishes at warming and endogenous bubbles are formed when cold blood saturated with carbon dioxide is returned by cardiotomy suction.

    METHODS: The release of endogenous gas was measured at high resolution in an experimental digital model. A medium (water or blood) was incubated and equilibrated with gas (100% carbon dioxide or air) at a low temperature (10°C or 23°C). The temperature was increased to 37°C and the gas release was measured, at rest and at fluid motion.

    RESULTS: The amount of carbon dioxide released at warming was substantial for both water and blood (both p=0.005). The effect was more pronounced when the temperature differential increased (p=0.005). However, blood and water differed in these terms: with water, the release of carbon-dioxide started instantly at warming; with blood, carbon dioxide remained dissolved and was released at fluid motion. When blood was warmed from 10°C to 37°C, the gas release corresponded to 44.4% (40.6/46.5) of the medium volume (median with quartile range).

    CONCLUSION: Gas dissolved in a medium becomes released at warming, as confirmed here. Blood exposed to carbon dioxide became heavily oversaturated at warming, with the gas instantly released at fluid motion. The amount of contained gas increased with a higher temperature differential. Our study has relevance to wound flushing, using carbon dioxide, in cardiac surgery. The clinical consequences of these findings remain to be answered.

  • 26.
    Ljungberg, Johan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Albertsson, Elin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Holmer, Paul
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bergdahl, Ingvar A.
    Umeå University, Faculty of Medicine, Department of Biobank Research.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Traditional Cardiovascular Risk Factors and Their Relation to Future Surgery for Valvular Heart Disease or Ascending Aortic Disease: A Case-Referent Study2017In: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, ISSN 2047-9980, E-ISSN 2047-9980, Vol. 6, no 5, article id e005133Article in journal (Refereed)
    Abstract [en]

    Background: Risk factors for developing heart valve and ascending aortic disease are based mainly on retrospective data. To elucidate these factors in a prospective manner, we have performed a nested case-referent study using data from large, population-based surveys. Methods and Results: A total of 777 patients operated for heart valve disease or disease of the ascending aorta had previously participated in population-based health surveys in Northern Sweden. Median time (interquartile range) from survey to surgery was 10.5 (9.0) years. Primary indications for surgery were aortic stenosis (41%), aortic regurgitation (12%), mitral regurgitation (23%), and dilatation/dissection of the ascending aorta (17%). For each case, referents were allocated, matched for age, sex, and geographical area. In multivariable models, surgery for aortic stenosis was predicted by hypertension, high cholesterol levels, diabetes mellitus, and active smoking. Surgery for aortic regurgitation was associated with a low cholesterol level, whereas a high cholesterol level predicted surgery for mitral regurgitation. Hypertension, blood pressure, and previous smoking predicted surgery for disease of the ascending aorta whereas diabetes mellitus was associated with reduced risk. After exclusion of cases with coronary atherosclerosis, only the inverse associations between cholesterol and aortic regurgitation and between diabetes mellitus and disease of the ascending aorta remained. Conclusions: This is the first truly prospective study of traditional cardiovascular risk factors and their association with valvular heart disease and disease of the ascending aorta. We confirm the strong association between traditional risk factors and aortic stenosis, but only in patients with concomitant coronary artery disease. In isolated valvular heart disease, the impact of traditional risk factors is varying.

  • 27.
    Ljungberg, Johan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Bergdahl, Ingvar A.
    Umeå University, Faculty of Medicine, Department of Biobank Research.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Arterial hypertension and elevated diastolic blood pressure is associated with developing aortic stenosis requiring surgery in persons less than 60 years of ageManuscript (preprint) (Other academic)
    Abstract [en]

    Background:  Due to age-related differences in aortic valve structure, it is likely that the pathophysiology of aortic stenosis and associated risk factors differ between age groups. Here we prospectively studied the influence of traditional cardiovascular risk factors on aortic stenosis development among patients without concomitant coronary artery disease, and stratified for age. 

    Methods: This study included 131 patients from previous population-based surveys, who underwent surgery for aortic stenosis and had no visible coronary arteriosclerosis upon preoperative coronary angiogram. The younger group included 49 patients of <60 years old at surgery: median age, 54.4 years; median follow-up, 8.7 years. The older group included 82 patients of ≥60 years old at surgery: median age, 71.3 years; median follow-up, 11.0 years. For each case, we selected four referents matched for age, gender, and geographic area. To identify predictors for surgery, we used multivariable conditional logistic regression with a model including arterial hypertension, cholesterol levels, diabetes, BMI, and smoking. 

    Results:  Future surgery for aortic stenosis was associated with arterial hypertension and elevated levels of diastolic blood pressure in the younger group (odds ratio, 3.40; 95% confidence interval, 1.45–7.93, and odds ratio 1,60; 95% confidence interval, 1.09–2.37, respectively), and with only impaired fasting glucose tolerance in the older group (odds ratio, 3.22; 95% confidence interval, 1.19–8.76). 

    Conclusion: Arterial hypertension and elevated diastolic blood pressure are associated with a risk for aortic stenosis development in subjects below 60 years of age. Strict blood pressure control in this group are strongly advocated to avoid other cardiovascular diseases correlated to hypertension. If hypertension and elevated diastolic blood pressure are risk for developing aortic stenosis need further investigations. Notably, elevated fasting glucose levels were related to aortic stenosis in older adults without concomitant coronary artery disease. 

  • 28.
    Mariscalco, Giovanni
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Are current smokers paradoxically protected against atrial fibrillation after cardiac surgery?2009In: Nicotine & tobacco research, ISSN 1462-2203, E-ISSN 1469-994X, Vol. 11, no 1, p. 58-63Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The hyperadrenergic condition following surgical stress and inotropic drugs have been identified as leading causes for postoperative atrial fibrillation (AF). Smokers are characterized by higher catecholamine levels and tolerance. We tested the hypothesis that smoking patients are less prone to develop postoperative AF. METHODS: A total of 3,245 coronary artery bypass and valvular procedures were reviewed. Predictors of AF and interaction between variables were explored by multivariable logistic regression. AF-predictive scores were created and validated for goodness of fit, and receiver operating characteristic curves were created. RESULTS: Postoperative AF occurred in 26% of patients. Smokers accounted for 15% of the study population and demonstrated a reduced incidence of postoperative AF compared with nonsmoking individuals (20% vs. 27%, p < .001). Multivariate analysis revealed a significant interaction between smoking status and inotropic support requirement. The AF-protective effect of smoking was confounded by inotropic drugs. However, when we excluded from analysis the patients with inotropic support, smoking conferred a 46% risk reduction of AF (odds ratio [OR] = 0.54, 95% CI = 0.34-0.87, p = .011). In addition, age, valvular surgery, and hypertension were independently associated with AF. Postoperative AF increased the length of hospitalization, without affecting hospital mortality. AF was associated with an increased 1-year mortality (p = .002). DISCUSSION: Current smokers are less prone to develop AF after cardiac surgery. Our data support the hypothesis that hyperadrenergic state and catecholamines are key mechanisms in the pathophysiology of postoperative AF.

  • 29.
    Mariscalco, Giovanni
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Atrial fibrillation after cardiac surgery: risk factors and their temporal relationship in prophylactic drug strategy decision2007In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 129, no 3, p. 354-362Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Postoperative atrial fibrillation (AF) is a vexing problem in cardiac surgery. Our aim was to identify risk factors between surgical procedures, all having cardiopulmonary bypass (CPB) in common, and how AF contributes to early and late mortality.

    METHODS: Patients were reviewed during a 10-year period, comprising coronary artery bypass grafting (CABG, n=7056), aortic valve replacement (AVR, n=690) and their combination (COMB, n=688). The study assessed 43 variables of which pre-/intraoperative data were evaluated for uni/multivariate analysis in relation to AF and type of surgery. Data were reviewed versus hospital and 1-year mortality; the latter being obtained from the Swedish population registry.

    RESULTS: The surgery subgroups exhibited obvious differences. The overall incidence of AF was 25.6%, ranging from 22.7% for CABG to 44.0% for COMB procedures. Numerous interaction patterns were seen among the analyzed parameters. In multivariate fashion, age was encountered in all groups, whereas coronary disease superimposed risk factors with reference to myocardial conditions at CPB weaning. Postoperative AF increased the length of hospitalization, whereas it did not affect hospital mortality. In CABG patients only, AF gave rise to increased 1-year mortality (p<0.001).

    CONCLUSIONS: In addition to the accepted risk factors of AF, primarily age, we emphasize the importance of considering details at CPB weaning, a correlation that was coronary specific. The weaning period hides valuable information that can be useful for more specific AF-prophylactic strategies. The AF-related increase in late mortality after CABG but not after valve procedures is intriguing, and draws attention to possible AF recurrence during patient follow-up and management.

  • 30.
    Mariscalco, Giovanni
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Postoperative atrial fibrillation is associated with late mortality after coronary surgery, but not after valvular surgery2009In: Annals of Thoracic Surgery, ISSN 0003-4975, E-ISSN 1552-6259, Vol. 88, no 6, p. 1871-1876Article in journal (Refereed)
    Abstract [en]

    Postoperative AF increases late mortality after isolated CABG surgery only. This finding was not statistically confirmed after isolated or combined valvular procedures. Our results draw the attention to possible AF recurrence after hospital discharge, indicating a strict postoperative surveillance.

  • 31. Mariscalco, Giovanni
    et al.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Ferrarese, Sandro
    Cozzi, Giuseppe
    Bruno, Vito Domenico
    Sessa, Fausto
    Sala, Andrea
    Relationship between atrial histopathology and atrial fibrillation after coronary bypass surgery2006In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 131, no 6, p. 1364-1372Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Postoperative atrial fibrillation is common after coronary surgery. The cellular condition of atrial myocytes might play a part in the postoperative development of atrial fibrillation. Our study aimed to investigate whether patients in whom postoperative atrial fibrillation develops show pre-existent alterations in histopathology of the right atrium and how such changes are expressed in relation to the use of cardiopulmonary bypass.

    METHODS: Seventy patients undergoing elective coronary revascularization were prospectively randomized to on-pump conventional surgery (conventional coronary artery bypass grafting, n = 35) or off-pump surgery on the beating heart (off-pump coronary artery bypass grafting, n = 35). Samples from the right atrial appendage were immediately collected after opening the pericardium. In the on-pump group samples were also taken after weaning from cardiopulmonary bypass. Focusing on degenerative alterations, histology was studied by means of light microscopy and for confirmation of particular findings by means of electronic microscopy.

    RESULTS: Twenty-two (31%) patients had postoperative atrial fibrillation, with the rate not being different between the off-pump coronary artery bypass grafting and conventional coronary artery bypass grafting groups (P = .797). Left atrial enlargement and inotropic requirement were related to atrial fibrillation. Interstitial fibrosis, vacuolization, and nuclear derangement of myocytes were the histologic abnormalities associated with the development of postoperative atrial fibrillation. However, in multivariate analysis fibrosis was confounded by myocyte vacuolization (P = .002) and nuclear derangement (P = .016), representing independent atrial fibrillation predictors. As expected, the conventional coronary artery bypass grafting and off-pump coronary artery bypass grafting groups showed similar histology, but more importantly, no atrial changes were detected in relation to cardiopulmonary bypass exposure in the conventional coronary artery bypass grafting group. Atrial histology showed degenerative changes that correlated with advanced age and left atrial enlargement.

    CONCLUSIONS: Our study supports the contention that atrial fibrillation after coronary surgery is associated with pre-existing histopathologic changes of the right atrium. Patients randomly allocated to off-pump coronary artery bypass grafting procedures showed a similar rate of atrial fibrillation and a similar relationship to atrial histology as did those exposed to cardiopulmonary bypass. Cardiopulmonary bypass did not cause additional changes in tested histology variables.

  • 32.
    Rinnström, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Engström, Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Heart centre, Umeå university.
    Ugander, Martin
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Factors associated with left ventricular hypertrophy in adults with surgically repaired coarctation of the aorta2013In: International Cardiovascular Forum Journal, ISSN 2410-2636, Vol. 1, no 2, p. 79-83Article in journal (Refereed)
    Abstract [en]

    Introduction: Most patients with repaired coarctation of the aorta (CoA) live normal lives and have good physical performance. However, even after a successful surgical intervention, long-term cardiovascular risks including left ventricular hypertrophy remain. The aim of the study was to identify factors associated with increased left ventricular mass (LVM) in patients with surgically repaired CoA.

    Methods: Consecutive cardiovascular magnetic resonance investigations in 51 patients with surgically repaired CoA (age 37+/-15 years, age at intervention 9.7 ± 6.8 years, 45% female) were reviewed. LVM was measured and indexed to body surface area. The association between increased LVM index and clinical, anatomic and functional variables was investigated with logistic regression analysis.

    Results: In this population, 14/51 (27%) patients had a LVM index above normal limits. Factors associated with an increased LVM index in univariate analysis were higher systolic blood pressure (odds ratio (OR) = 1.04, 95 % confidence interval(CI) 1.00-1.08, p = 0.03), descending aortic diameter (OR = 1.48, CI 1.14-1.90, p = 0.003) and more than mild aortic valve disease or previous aortic valve intervention (OR = 15.1, CI 2.50-48.4, p=0.002), but not diastolic blood pressure, diameter of ascending aorta, diameter or ratio of CoA, velocity in descending aorta, smoking or bicuspid aortic valve (p > 0.05 for all). In multivariate analysis, only systolic blood pressure (p = 0.05) and aortic valve disease (p = 0.006) remained significant, yielding R2 = 0.47, p = 0.002 for the model.

    Conclusion: Increased LVM is a common late finding after surgically repaired CoA. This study showed that LVM was associated with modifiable factors; systolic blood pressure and aortic valve disease. As most patients are young, and increased LVM will eventually affect ventricular function, close attention to blood pressure optimization may be of particular importance in the surgically repaired CoA population.

  • 33.
    Rinnström, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Heart Centre, Umeå.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Cardiothoracic Surgery, Heart Centre.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Heart Centre, Umeå.
    Subtypes of bicuspid aortic valves in coarctation of the aorta2014In: Heart and Vessels, ISSN 0910-8327, E-ISSN 1615-2573, Vol. 29, no 3, p. 354-363Article in journal (Refereed)
    Abstract [en]

    Bicuspid aortic valves (BAVs) represent a wide morphologic and functional spectrum. In coarctation of the aorta, BAVs are common, but the proportion of BAV subtypes and their relation to aortic dimensions and development of late valve dysfunction are unknown. Sixty-two cardiovascular magnetic resonance investigations of patients with coarctation of the aorta were reviewed with respect to aortic valve morphology, aortic valve function, and aortic dimensions. BAVs were identified in 45 patients (72.6 %), of which 13 (20.9 %) were type-0 (two commissures), 28 (45.1 %) type-1 (three commissures but fusion of one commissure with a raphe) and 4 (6.5 %) valves were bicuspid but not possible to classify further. Patients with BAVs type-0 had larger dimensions in their sinus of Valsalva (35.5 ± 6.8 vs. 29.7 ± 2.7 mm, p = 0.002), ascending aorta (33.1 ± 6.2 vs. 26.0 ± 4.3 mm, p = 0.005) and sino-tubular junction (29.3 ± 7.4 vs. 24.2 ± 3.5 mm, p = 0.040) compared with tricuspid aortic valves (TAVs). Moderate and severe aortic valve disease was more common in BAV type-0 compared with BAV type-1 (p = 0.030) and TAV (p = 0.016). In a multivariate linear regression model BAV type-0 (p = 0.005), BAV type-1 (p = 0.011), age (p < 0.001), patient height (p = 0.009), and aortic valve disease (p = 0.035) were independently associated with increased diameter of the ascending aorta (R (2) of the model 0.54, p < 0.001). BAV type-0 is relatively common in coarctation of the aorta. Both BAV type-0 and type-1 are associated with increased diameter of the ascending aorta but this association is stronger for BAV type-0. Development of aortic valve disease is more common in BAV type-0 than in BAV type-1. Discrimination between BAV subtypes may potentially provide clinical and prognostic information in patients with coarctation of the aorta.

  • 34.
    Rinnström, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Umeå Heart Centre.
    Engström, Karl-Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Ugander, M.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Umeå Heart Centre.
    Factors associated with left ventricular hypertrophy in adults with surgically repaired coarctation of the aorta2013In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 34, no Supplement: 1, p. 322-322Article in journal (Other academic)
    Abstract [en]

    Purpose: Most patients with repaired coarctation of the aorta live normal lives and have good physical performance. However, even after surgical intervention, there are long-term cardiovascular risks including arterial hypertension and left ventricular hypertrophy.

    Methods: Fifty-one cardiovascular magnetic resonance investigations inadult patients with repaired coarctation of the aorta were reviewed and left ventricular mass was calculated. Using binary logistic regression, factors associated with left ventricular mass index abovethe reference limit were analysed among clinical, anatomic and functional variables.

    Results: In this population, 14 (27.5%) of the patients had leftventricular mass index above the upper reference limit. Higher systolic blood pressure (OR=1.042, p=0.028), > mild aortic valve disease/previous aortic valve intervention (OR=1.042, p=0.002), and diameter of the descending aorta (OR=1.475, p=0.003) wereindependently associated with left ventricular mass index above theupper reference limit. In a post hoc model where systolic blood pressure was categorised in four levels, only high systolic blood pressure (>160 mmHg) (OR=31.913, p=0.020), together with > mild aortic valve disease or previous aortic valve intervention (OR=25.493, p=0.002) remainedindependently associated with left ventricular mass index above theupper reference limit.

    Conclusion: Increased left ventricular mass is a common finding late after repair in coarctation of the aorta and is associated with themodifiable factors blood pressure and aortic valve disease. As most patients are young, and increased mass will affect the left ventricle over decades, attention to blood pressure is important in this population.

  • 35.
    Sandberg, Camilla
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Dellborg, Mikael
    Thilén, Ulf
    Wadell, Karin
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Heart Centre, Umeå.
    The level of physical exercise is associated with self-reported health status (EQ-5D) in adults with congenital heart disease2015In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 22, no 2, p. 240-248Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The prognosis in adults with congenital aortic valve disease is usually favourable; nevertheless, a number of medical and social factors might hamper long-term prognosis and quality of life. With a focus on physical exercise level, data from the Swedish National Registry on Congenital Heart Disease (SWEDCON) were analysed and variables associated with health-related quality of life in adults with congenital aortic valve disease were identified.

    METHODS: In this registry study, SWEDCON was searched for adult patients with isolated congenital aortic valve disease and valid EuroQol-5Dimensions health questionnaire (EQ-5D) data.

    RESULTS: This study identified 315 patients. The majority (n = 202, 64%) reported best possible health status (EQ-5Dindex = 1) whereas 113 (35%) reported some impairment (EQ-5Dindex < 1) with mean EQ-5Dindex 0.73 ± 0.17. In a multivariate logistic regression model, self-reported physical exercise > 3 h/week was independently associated with best possible health status (EQ-5Dindex = 1; p = 0.013). Moreover presence of cardiovascular symptoms (p < 0.001), active smoking (p = 0.002), history of valve surgery (p = 0.017), low educational level (p = 0.022), and higher systolic blood pressure (p = 0.029) were independently associated with impaired health status (EQ-5Dindex < 1).

    CONCLUSIONS: Physical exercise >3 h/week was, as a single variable, associated with best possible health status in adults with congenital aortic valve disease. In contrast, a number of medical and social factors are associated with worse self-reported health status. Among these, symptoms, smoking, and educational level are potential targets for modification and intervention. There is a need for studies investigating the effect of increased level of physical exercise in patients with congenital aortic valve disease.

  • 36.
    Sandberg, Camilla
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Umeå Heart Centre.
    Thilen, U.
    Wadell, Karin
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Engström, Karl-Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Umeå Heart Centre.
    Complex adult congenital heart disease is associated with impaired skeletal muscle function2013In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 34, no Supplement: 1, p. 383-383Article in journal (Refereed)
    Abstract [en]

    Purpose: Complex congenital heart disease is often associatedwith impaired physical functioning, usually measured as peak oxygen uptake in an exercise test. Skeletal muscle function is, however, less studied in these patients.

    Methods: Unilateral isotonic shoulder flexion was tested in 79 adultpatients (mean age 36.6±14.8 years, 31 females) with congenital heartdisease, classed as either "complex" (n=41, 51.9%) or "simple" (n=38, 48.1%). The patients were sitting comfortably in a chair with their back touching the wall and holding a weight (2 kg for women and 3 kg for men) in the hand of the tested side. The patients were asked to elevate the arm, from 0 to 90 degrees flexion, as many times as possible. The pace of 20 contractions per minute was held using a metronome.

    Results: Patients with complex lesions performed less shoulder flexions compared with patients with simple lesions (29.2±10.0 vs. 54.6±25.8, p<0.001). In univariate analysis including a number of demographic and clinical variables, only complexity of cardiac lesion (p<0.001) and on-going cardiac medications (p=0.012) were associated with shouldermuscle function, of which complexity (p<0.001) remained significant in multivariate analysis.

    Conclusion: There is a marked difference in shoulder muscle functionbetween patients with complex and simple congenital heart disease. Such differences might affect ability to perform daily activities and contribute to impaired overall physical functioning. Rehabilitation targeting muscle function may be indicated in patients with complexcongenital heart disease.

  • 37.
    Sandberg, Camilla
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Umeå Heart Centre.
    Wadell, Karin
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Gradmark, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Umeå Heart Centre.
    Thilen, U.
    Engström, Karl-Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology. Umeå Heart Centre.
    Physical activity level in adults with congenital heart disease: effects of gender and complexity of heart lesion2013In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 34, no Supplement: 1, p. 382-383Article in journal (Refereed)
    Abstract [en]

    Purpose: Many adults with congenital heart disease have reduced exercise capacity but only little is known about habitual physical activityin this group. The aim of this study was to investigate habitual physicalactivity level in a cohort of adults with congenital heart disease.

    Methods: Seventy-five adult patients (29 females) aged 37.2±15.1 yearswith congenital heart disease classed as either simple or complex were studied with a combined accelerometer and heart rate monitor (Actiheart). The patients carried the Actiheart during 5 consecutive days, and where encouraged to proceed with their usual daily activities. Data was analysed with the Actiheart Software version 2.2. A mean ofPhysical Activity Level (PAL) (PAL=Total Energy Expenditure/Resting Energy Expenditure) over 4 days was calculated. PAL < 1.45 was categorised as low, 1.45-1.6 as moderate and >1.6 as high.

    Results: Forty-three patients (57,3%) had low PAL, 18 (24%) moderate PAL and 14 (16,7%) high PAL. PAL was lower in women compared to men (1.32±0.10 vs. 1.52±0.18, p < 0.001). PAL was higher in patients withsimple compared with complex congenital heart disease (1.50±0.21 vs. 1.39±0.14, p = 0.019). Among men, active smoking (p=0.015) and lower age (p=0.04) were independently associated with higher PAL, whereas no such associations were observed among women.

    Conclusion: The majority of the observed patients had low PAL and women had lower PAL compared to men. PAL was related to complexity ofheart lesion. Efforts to increase habitual physical activity may beindicated in this population, especially in women and patients withcomplex congenital heart disease.

  • 38.
    Smulter, Nina
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Cardiothoracic Division, Department of Surgery and Perioperative Science, Umeå University.
    Claesson Lingehall, Helena
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. Cardiothoracic Division, Department of Surgery and Perioperative Science, Umeå University.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Cardiothoracic Division, Department of Surgery and Perioperative Science, Umeå University.
    Delirium after cardiac surgery: incidence and risk factors2013In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 17, no 5, p. 790-796Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Delirium after cardiac surgery is a problem with consequences for patients and healthcare. Preventive strategies from known risk factors may reduce the incidence and severity of delirium. The present aim was to explore risk factors behind delirium in older patients undergoing cardiac surgery with cardiopulmonary bypass.

    METHODS: Patients (≥70 years) scheduled for routine cardiac surgery were included (n = 142). The patients were assessed and monitored pre-/postoperatively, and delirium was diagnosed from repeated assessments with the Mini-Mental State Examination and the Organic Brain Syndrome Scale, using the DSM-IV-TR criteria. Variables were analysed by uni-/multivariable logistic regression, including both preoperative variables (predisposing) and those extracted during surgery and in the early postoperative period (precipitating).

    RESULTS: Delirium was diagnosed in 78 patients (54.9%). Delirium was independently associated with both predisposing and precipitating factors (P-value, odds ratio, upper/lower confidence interval): age (0.036, 1.1, 1.0/1.2), diabetes (0.032, 3.5, 1.1/11.0), gastritis/ulcer problems (0.050, 4.0, 1.0/16.1), volume load during operation (0.001, 2.8, 1.5/5.1), ventilator time in ICU (0.042, 1.2, 1.0/1.4), highest temperature recorded in ICU (0.044, 2.2, 1.0/4.8) and sodium concentration in ICU (0.038, 1.2, 1.0/1.4).

    CONCLUSIONS: Delirium was common among older patients undergoing cardiac surgery. Both predisposing and precipitating factors contributed to delirium. When combined, the predictive strength of the model improved. Preventive strategies may be considered, in particular among the precipitating factors. Of interest, delirium was strongly associated with an increased volume load during surgery.

  • 39.
    Smulter, Nina
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Claesson Lingehall, Helena
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    The use of a screening scale improves the recognition of delirium in older patients after cardiac surgery: a retrospective observational studyManuscript (preprint) (Other academic)
  • 40.
    Smulter, Nina
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Claesson Lingehall, Helena
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Validation of the confusion assessment method in detecting postoperative delirium in cardiac surgery patients2015In: American Journal of Critical Care, ISSN 1062-3264, E-ISSN 1937-710X, Vol. 24, no 6, p. 480-487Article in journal (Refereed)
    Abstract [en]

    Background: Early detection, prevention, and treatment of delirium after cardiac surgery are important for quick postoperative recovery. The Confusion Assessment Method (CAM) may be an easy-to-use instrument for detecting delirium in clinical practice.

    Objectives: To compare the congruent validity of the CAM with the results from repeated assessments by using a combination of the Organic Brain Syndrome Scale and the Mini-Mental State Examination according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) criteria for delirium.

    Methods: Patients aged 70 years or older undergoing cardiac surgery were assessed on postoperative days 1 and 4, and the 2 diagnostic methods were compared. The sensitivity and specificity of the CAM were examined. The reference method allowed categorization of delirium into subgroups of psychomotor activities and psychiatric symptom profiles, which were compared with the CAM results.

    Results: Postoperative delirium was diagnosed in 78 of 141 patients (55.3%). According to the CAM, 59 patients (41.8%) were categorized as delirious, 53 correctly. Thus, the sensitivity was 68% and the specificity was 90%, indicating false-negative rather than false-positive observations.

    Conclusion: Patients with psychomotor hyperactivity and mixed psychotic-emotional symptoms were more likely to have delirium detected via the CAM than were patients with less obvious clinical manifestations of delirium. Repetitive cognitive testing and psychogeriatric experience are probably necessary to improve the results obtained with the CAM.

  • 41.
    Smulter, Nina
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Hentschel, Jan
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    The association between delirium symptoms according to the Nursing Delirium Screening Scale and hospitalization costs after cardiac surgeryManuscript (preprint) (Other academic)
  • 42.
    Smulter, Nina
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences. Umeå University, Faculty of Medicine, Department of Nursing. Cardiothoracic Surgery Division, Heart Center.
    Lingehall, Helena Claesson
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Appelblad, Micael
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Svenmarker, Staffan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Disturbances in Oxygen Balance During Cardiopulmonary Bypass: A Risk Factor for Postoperative Delirium2018In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 32, no 2, p. 684-690Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to determine risk factors for postoperative delirium after cardiac surgery, specifically associated with the conduct of cardiopulmonary bypass (CPB).

    Design: Prospective observational study.

    Setting: Heart Centre, University Hospital.

    Participants: The study included 142 patients aged 70 years and older scheduled for elective cardiac surgery with CPB.

    Interventions: Risk factor analysis comprised information collected from the hospital clinical and CPB dedicated databases in addition to the medical chart. Delirium was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criterion using the Mini Mental State Examination and the Organic Brain Syndrome scale.

    Measurements and Main Results: Assessments of delirium diagnosis were executed preoperatively and on the following first and fourth postoperative days. Delirium occurred in 55% (78/142) of the patients. Patients with delirium were identified with significantly higher body weight and body surface area preoperatively, accompanied with longer CPB time, higher positive fluid balance per CPB, and lower systemic pump flow related to body surface area. Furthermore, the duration of the mixed venous oxygen saturation (SvO2) below 75% was significantly longer during CPB. The result from the multivariable logistic regression analysis included the duration of SvO2 below 75%, fluid balance per CPB and patient age as independent risk factors for postoperative delirium.

    Conclusions: The influence of the SvO2 level during CPB, fluid balance, and patient age should be recognized as risk factors for postoperative delirium after cardiac surgery in patients 70 years and older.

  • 43.
    Svenmarker, Staffan
    et al.
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Karlsson, T
    Jansson, E
    Lindholm, R
    Aberg, Torkel
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Influence of pericardial suction blood retransfusion on memory function and release of protein S100B.2004In: Perfusion, ISSN 0267-6591, Vol. 19, no 6, p. 337-43Article in journal (Refereed)
  • 44.
    Wikstrand, Victoria
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Linder, Nadja
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Evaluation of the Doppler technique for fat emboli detection in an experimental flow model2008In: The Journal of extra-corporeal technology, ISSN 0022-1058, Vol. 40, no 3, p. 175-183Article in journal (Refereed)
    Abstract [en]

    Pericardial suction blood (PSB) is known to be contaminated with fat droplets, which may cause embolic brain damage during cardiopulmonary bypass (CPB). This study aimed to investigate the possibility to detect fat emboli by a Doppler technique. An in vitro flow model was designed, with a main pump, a filter, a reservoir, and an injector. A Hatteland Doppler probe was attached to the circulation loop to monitor particle counts and their size distribution. Suspended soya oil or heat-extracted human wound fat was analyzed in the model. The concentrations of these fat emboli were calibrated to simulate clinical conditions with either a continuous return of PSB to the systemic circulation or when PSB was collected for rapid infusion at CPB weaning. For validation purpose, air and solid emboli were also analyzed. Digital image analysis was performed to characterize the nature of the tested emboli. With soya suspension, there was an apparent dose response between Doppler counts and the nominal fat concentration. This pattern was seen for computed Doppler output (p = .037) but not for Doppler raw counts (p = .434). No correlation was seen when human fat suspensions were tested. Conversely, the image analysis showed an obvious relationship between microscopy particle count and the nominal fat concentration (p < .001). However, the scatter plot between image analysis counting and Doppler recordings showed a random distribution (p = .873). It was evident that the Doppler heavily underestimated the true number of injected fat emboli. When the image analysis data were subdivided into diameter intervals, it was discovered that the few large-size droplets accounted for a majority of total fat volume compared with the numerous small-size particles (< 10 microm). Our findings strongly suggest that the echogenecity of fat droplets is insufficient for detection by means of the tested Doppler method.

  • 45.
    Åberg, Torkel
    et al.
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Hentschel, J
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Nio års registrering vid hjärtcentrum visar att medicinska resultat förbättrats2004In: Läkartidningen, Vol. 102, p. 26-29Article in journal (Refereed)
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