Transvenous lead extraction safety and efficacy in infected and noninfected patients using mechanical-only tools: Prospective registry from a high-volume center.

BACKGROUND: Transvenous lead extraction (TLE) is a well-established treatment option for patients with cardiac implantable electronic devices (CIED) complications. OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of TLE in CIED infection and non-CIED infection patients. METHODS: Consecutive patients who underwent TLE between 2016 and 2022 entered the EXTRACT Registry. Models of prediction were constructed for periprocedural clinical and procedural success and the incidence of major complications, including death in 30 days. RESULTS: The registry enrolled 504 patients (mean age 66.6 ± 12.8 years; 65.7% male). Complete procedural success was achieved in 474 patients (94.0%) and clinical success in 492 patients (97.6%). The total number of major and minor complications was 16 (3.2%) and 51 (10%), respectively. Three patients (0.6%) died during the procedure. New York Heart Association functional class IV and C-reactive protein levels defined before the procedure were independent predictors of any major complication, including death in 30 days in CIED infection patients. The time since the last preceding procedure and platelet count before the procedure were independent predictors of any major complication, including death in 30 days in non-CIED infection patients. CONCLUSIONS: TLE is safe and successfully performed in most patients, with a low major complication rate. CIED infection patients demonstrate better periprocedural clinical success and complete procedural success. However, CIED infection predicts higher 30-day mortality compared with non-CIED infection patients. Predictors of any major complication, including death in 30 days, differ between CIED infection and non-CIED infection patients.

General anaesthesia or sedation for percutaneous aortic valve implantation? The questionnaire results and authors' experience.

INTRODUCTION: Over the last two decades transcatheter aortic valve replacement (TAVR) has been approved for clinical use. The anaesthetic choice for this procedure is evolving. General anaesthesia was the predominant anaesthetic technique. Growing experience and advances in technology and economic considerations have led to an increasing interest in performing TAVR under monitored sedation. AIM: The assessment of monitored sedation, called cooperative sedation, involves pharmacologically mediated suppression of consciousness and preservation of verbal contact in response to stimulation as a safe method of anaesthesia for TAVR. MATERIAL AND METHODS: Sixty out of 63 TAVR patients with femoral access received monitored sedation. Dexmedetomidine was administered in most of such cases (46 patients). A questionnaire was also carried out by staff involved in performing TAVR procedures, with more than 5 years of experience in it, concerning the method of anaesthesia and perioperative care. RESULTS: Conversion to general anaesthesia was required in 10% of patients (6 cases), only one as a patient-related complication (hypercarbia). The questionnaire carried out showed that anaesthesia and postoperative care after TAVR are underestimated. CONCLUSIONS: The preliminary results regarding anaesthetic management in TAVR procedures demonstrate that monitored sedation is safe, provided that contraindications are observed.

Enhanced recovery after cardiac surgery.

The concept of early recovery after surgery (ERAS) consists of bundle interventions during the pre-, intra- and postoperative periods and team work. The ERAS, which is a multimodal strategy, enables one to limit the neurohumoral response to the surgery, maintain homeostasis, reduce the risk of complications, shorten the hospital stay, accelerate the return to everyday functioning, improve the patient's satisfaction, achieve a satisfactory quality of life and finally reduce the treatment costs and eliminate any redundant and ineffective practices. Almost every patient can be classified for the ERAS strategy except for patients undergoing urgent and emergency surgery. The necessity to give up ERAS can result from poor organisation and management. Moreover, the procedure itself can be the cause of the lack of adherence to the planned standard. It is necessary to use protocols and checklists. While fulfilling this doctrine, the anaesthesiologist becomes a perioperative specialist.

Can human myocardium be remotely preconditioned? The results of a randomized controlled trial.

OBJECTIVES: No experimental study has shown that the myocardium of a remotely preconditioned patient is more resistant to a standardized ischaemic/hypoxic insult. METHODS: This was a single-centre randomized (1:1), double-blinded, sham-controlled, parallel-group study. Patients referred for elective coronary bypass surgery were allocated to either remote ischaemic preconditioning (3 cycles of 5-min ischaemia/5-min reperfusion of the right arm using a blood pressure cuff inflated to 200 mmHg) or sham intervention. One hundred and thirty-four patients were recruited, of whom 10 dropped out, and 4 were excluded from the per-protocol analysis. The right atrial trabecula harvested on cannulation for cardiopulmonary bypass was subjected to 60 min of simulated ischaemia and 120 min of reoxygenation in an isolated organ experiment. Postoperative troponin T release and haemodynamics were assessed in an in vivo study. RESULTS: The atrial trabeculae obtained from remotely preconditioned patients recovered 41.9% (36.3-48.3) of the initial contraction force, whereas those from non-preconditioned patients recovered 45.9% (39.1-53.7) (P = 0.399). Overall, the content of cleaved poly (ADP ribose) polymerase in the right atrial muscle increased from 9.4% (6.0-13.5) to 19.1% (13.2-23.8) (P < 0.001) after 1 h of ischaemia and 2 h of reperfusion in vitro. The amount of activated Caspase 3 and the number of terminal deoxynucleotidyl transferase dUTP nick end labeling-positive cells also significantly increased. No difference was observed between the remotely preconditioned and sham-treated myocardium. In the in vivo trial, the area under the curve for postoperative concentration of troponin T over 72 h was 16.4 ng⋅h/ml (95% confidence interval 14.2-18.9) for the remote ischaemic preconditioning and 15.5 ng⋅h/ml (13.4-17.9) for the control group in the intention-to-treat analysis. This translated into an area under the curve ratio of 1.06 (0.86-1.30; P = 0.586). CONCLUSIONS: Remote ischaemic preconditioning with 3 cycles of 5-min ischaemia/reperfusion of the upper limb before cardiac surgery does not make human myocardium more resistant to ischaemia/reperfusion injury. CLINICAL TRIAL REGISTRATION NUMBER: NCT01994707.

Remote Ischaemic PrEconditioning of Human Myocardium (RIPE): study protocol for a double-blinded randomised controlled trial.

BACKGROUND: Remote preconditioning has been shown to be a potent protective phenomenon in many animals. Several studies aimed to demonstrate it was feasible in humans by trying to show its protective effect during cardiac surgery. Of these, some small studies and one larger trial were positive while two other bigger studies showed no effectiveness of remote preconditioning as assessed by levels of postoperatively released cardiac markers. Recently, two large clinical trials also failed to prove the benefit of remote preconditioning in cardiac surgery. No study showed that remote preconditioning actually increases resistance of human myocardium to standardised ischaemic and reperfusion stimulus in experimental settings. In animal studies, remote preconditioning was shown to improve mitochondrial function and structure, but such data on human myocardium are scarce. AIM: The aim of the study is to determine whether remote preconditioning protects human myocardium against ischaemia-reperfusion injury in both in vivo and in vitro conditions. METHODS: The trial is designed as a single-centre, double-blinded, sham-controlled trial of 120 patients. We randomise (1:1) patients referred for coronary artery bypass grafting for stable coronary artery disease to remote preconditioning or "sham" intervention. The remote preconditioning is obtained by three cycles of 5 min inflation and 5 min deflation of a blood pressure cuff on the right arm. Postoperative course including myocardial enzymes profile will be analysed. Moreover, in the in-vitro arm the clinically preconditioned myocardium will be assessed for function, mitochondria structure, and mitochondria-dependent apoptosis. The informed consent of all patients is obtained before enrolment into the study by the investigator. The study conforms to the spirit and the letter of the declaration of Helsinki. RESULTS AND CONCLUSIONS: In case the effect of remote preconditioning is not measurable in ex-vivo assessment, any future attempt at implementing this phenomenon in clinical practice may be futile and should not be continued until the effect can be confirmed in a controlled experimental setting. The study might therefore indicate future directions in trials of clinical implementation of remote preconditioning. TRIAL REGISTRATION: Clinical Trials Register (Clinicaltrials.gov) identifier: NCT01994707. The study was approved by Institutional Review Board of the Medical University of Silesia (KNW/0022/KB1/160/12).

[Pulmonary embolism in a patient with unstable angina treated with surgical revascularisation--a case report]. / Zator tetnicy plucnej w niestabilnej dlawicy piersiowej poddanej chirurgicznej rewaskularyzacji.

A case of a 58-year-old female patient with unstable angina is presented. Two weeks earlier the patient suffered from acute myocardial infarction treated with thrombolysis. The patient underwent surgical revascularisation which was complicated by acute pulmonary embolism. Repeated surgery and inspection of pulmonary arteries revealed the presence of thrombus which was successfully removed. The post-operative course was uneventful. The causes and treatment of pulmonary embolism complicating coronary artery by-pass grafting are discussed.

Diagnostic accuracy of pre-operative NT-proBNP level in predicting short-term outcomes in coronary surgery: a pilot study.

BACKGROUND: B-type natriuretic peptides (BNP) are acknowledged markers of acute and chronic heart failure. Insufficient data exist, however, regarding their diagnostic usefulness in cardiac surgery, particularly in coronary patients. AIM: To assess diagnostic accuracy of preoperative value of NT-proBNP level as a predictor of short-term postoperative complications in subjects undergoing coronary artery bypass grafting (CABG). METHODS: This pilot study included 100 consecutive patients scheduled for elective CABG, including 24 females and 76 males (mean age 65.9 ± 9.1 years). Exclusion criteria were: significant valvular disorders, off-pump procedure, renal failure (GFR < 60 mL/min/1.73 m2), low ejection fraction (< 30%), intra-aortic balloon pump counterpulsation (IABP), use of inotropic agents, atrial fibrillation (AF), and implanted pacemaker or defibrillator. The NT-proBNP level was measured on the day of the surgery before induction of anaesthesia. We investigated short-term postoperative complications, defined as those occurring within 30 days or before hospital discharge. RESULTS: Median NT-proBNP concentration was 526.0 pg/mL (IQR 156.0-1150.0). None of patients died postoperatively. Excessive drainage (> 850 mL) was found in 13 (13%) patients and 22 (22%) subjects required transfusions. Prolonged mechanical ventilation (> 12 h) was necessary in 15 (15%) patients and respiratory failure occurred in 2 (2%) of them. Postoperative AF was present in 34 (34%) subjects. Perioperative myocardial infarction was diagnosed in 2 (2%) persons. Low cardiac output was present in 9 (9%) patients. Haemodynamic support with the use of IABP was necessary in 7 (7%) patients and inotropic drugs were used in 61 (61%) subjects. Stroke or delirium was diagnosed in 1 (1%) subject. The NT-proBNP level correlated with the operative risk estimated by logistic and additive EuroSCORE: r = 0.558 (95% CI 0.406-0.680; p < 0.001) and r = 0.551 (95% CI 0.397-0.674; p < 0.001), respectively. The NT-proBNP level correlated significantly with the length of Intensive Care Unit (ICU) stay and hospital stay: r = 0.412 (95% CI 0.238-0.566; p < 0.001) and r = 0.547 (95% CI 0.393-0.672; p < 0.001), respectively. The NT-proBNP level was a predictor of postoperative prolonged mechanical ventilation, respiratory failure, AF, IABP use, inotropic support and postoperative platelet transfusions (p < 0.05 for all). However, good or very good diagnostic accuracy was found only in relation to mechanical ventilation (AUROC = 0.854), respiratory insufficiency (AUROC = 0.867), IABP use (AUROC = 0.889), and milrinone use (AUROC = 0.929). CONCLUSIONS: Preoperative assessment of NT-proBNP level in CABG patients could be a valuable diagnostic method for predicting several postoperative complications, especially pulmonary outcomes and requirement for haemodynamic support, and it correlated with the length of ICU stay and hospital stay.