The effect of implementing a dialysis start unit on modality decision among patients with unplanned start kidney replacement therapy.

INTRODUCTION: Many individuals start dialysis in an acute setting with suboptimal pre-dialysis education. These individuals are often treated with central venous catheter insertion and initiation of in-center hemodialysis and only a minority will transfer to a home-based therapy. The dialysis start unit is a program performing in-center hemodialysis in a separate space while providing support and education on chronic kidney disease and treatment options in the initial weeks of kidney replacement therapy. We aimed to assess the uptake of home dialysis therapies between 2013 and 2021 among patients who started acute inpatient hemodialysis at University Health Network, Toronto and underwent dialysis at the dialysis start unit. METHODS: This is a retrospective observational cohort study based on prospectively collected data. Patients' demographics were obtained from electronic charts. In the dialysis start unit, all patients received dialysis modality education by a nurse educator, dedicated home dialysis nurses, and the allied health care team. FINDINGS: During 2013-2021, 122 patients were dialyzed in the dialysis start unit and included in the study. Among those patients, 68 patients ultimately chose home dialysis (57 peritoneal dialysis and 11 home hemodialysis). Fifty-four patients continued in-center hemodialysis. Patients adopting home dialysis were less likely to have diabetes and hypertension as the etiology of kidney failure and more likely to have glomerulonephritis or vasculitis. DISCUSSION: Dialysis modality education is implementable in advanced chronic kidney disease. Individualized education and care after unplanned start dialysis can potentially enhance home dialysis choice and utilization.

Cerebrospinal Fluid and Serum Biomarker Insights in Aneurysmal Subarachnoid Haemorrhage: Navigating the Brain-Heart Interrelationship for Improved Patient Outcomes.

The pathophysiological mechanisms underlying severe cardiac dysfunction after aneurysmal subarachnoid haemorrhage (aSAH) remain poorly understood. In the present study, we focused on two categories of contributing factors describing the brain-heart relationship. The first group includes brain-specific cerebrospinal fluid (CSF) and serum biomarkers, as well as cardiac-specific biomarkers. The secondary category encompasses parameters associated with cerebral autoregulation and the autonomic nervous system. A group of 15 aSAH patients were included in the analysis. Severe cardiac complications were diagnosed in seven (47%) of patients. In the whole population, a significant correlation was observed between CSF S100 calcium-binding protein B (S100B) and brain natriuretic peptide (BNP) (rS = 0.62; p = 0.040). Additionally, we identified a significant correlation between CSF neuron-specific enolase (NSE) with cardiac troponin I (rS = 0.57; p = 0.025) and BNP (rS = 0.66; p = 0.029), as well as between CSF tau protein and BNP (rS = 0.78; p = 0.039). Patients experiencing severe cardiac complications exhibited notably higher levels of serum tau protein at day 1 (0.21 ± 0.23 [ng/mL]) compared to those without severe cardiac complications (0.03 ± 0.04 [ng/mL]); p = 0.009. Impaired cerebral autoregulation was noted in patients both with and without severe cardiac complications. Elevated serum NSE at day 1 was related to impaired cerebral autoregulation (rS = 0.90; p = 0.037). On the first day, a substantial, reciprocal correlation between heart rate variability low-to-high frequency ratio (HRV LF/HF) and both GFAP (rS = -0.83; p = 0.004) and S100B (rS = -0.83; p = 0.004) was observed. Cardiac and brain-specific biomarkers hold the potential to assist clinicians in providing timely insights into cardiac complications, and therefore they contribute to the prognosis of outcomes.

High Plasma Angiopoietin-2 Levels Predict the Need to Initiate Dialysis within Two Years in Patients with Chronic Kidney Disease.

Volume status, congestion, endothelial activation, and injury all play roles in glomerular filtration rate (GFR) decline. In this study, we aimed to determine whether the plasma endothelial and overhydration markers could serve as independent predictors for dialysis initiation in patients with chronic kidney disease (CKD) 3b-5 (GFR < 45 mL/min/1.72 m2) and preserved ejection fraction. A prospective, observational study in a single academic center was conducted from March 2019 to March 2022. Plasma levels of angiopoietin (Ang)-2, Vascular Endothelial Growth Factor-C (VEGF-C), Vascular Cell Adhesion Molecule-1 (VCAM-1), Copeptin (CPP), beta-trace protein (BTP), brain natriuretic peptide (BNP), and cardiac troponin I (cTnI) were all measured. Lung ultrasound (US) B-lines, bioimpedance, and echocardiography with global longitudinal strain (GLS) were recorded. The study outcome was the initiation of chronic dialysis (renal replacement therapy) during 24 months of follow-up. A total of 105 consecutive patients with a mean eGFR of 21.3 mL/min/1.73 m were recruited and finally analyzed. A positive correlation between Ang-2 and VCAM-1 and BTP was observed. Ang-2 correlated positively with BNP, cTnI, sCr, E/e', and the extracellular water (ECW)/intracellular water (ICW) ratio (ECW/ICW). After 24 months, a deterioration in renal function was observed in 47 patients (58%). In multivariate regression analysis, both VCAM-1 and Ang-2 showed independent influences on risk of renal replacement therapy initiation. In a Kaplan-Meier analysis, 72% of patients with Ang-2 concentrations below the median (3.15 ng/mL) survived without dialysis for two years. Such an impact was not observed for GFR, VCAM, CCP, VEGF-C, or BTP. Endothelial activation, quantified by plasma levels of Ang-2, may play a key role in GFR decline and the need for dialysis initiation in patients with CKD 3b, 4, and 5.

Association of arterial hemodynamics with left ventricular systolic function in hypertensive patients: A longitudinal study.

BACKGROUND: Left ventricular (LV) systolic impairment, particularly in the longitudinal direction, is considered an early and sensitive marker of hypertensive heart disease and increased cardiovascular risk. The evidence indicates that aortic stiffness and central hemodynamic factors are important determinants of LV performance, mediating the interaction between the heart and vascular load. Despite the existence of cross-sectional analyses linking central blood pressure (BP) parameters with LV mechanics, no longitudinal data are available which include serial measurements in the course of antihypertensive treatment. OBJECTIVES: To investigate the associations between changes in LV longitudinal and circumferential function with alterations in arterial hemodynamics and ventricular-arterial coupling (VAC) in patients with uncomplicated hypertension during a 12-month follow-up. MATERIAL AND METHODS: In this retrospective study, 216 patients (age 64.3 ±7.6 years) underwent echocardiography including left ventricular longitudinal (GLS) and circumferential strain (GCS) analysis, brachial BP measurements, VAC (combining echocardiography and brachial BP), and arterial hemodynamics using radial tonometry at baseline and after 12 months of antihypertensive therapy. Patients were grouped into 2 subsets: with improvement in GLS (n = 103) and with deterioration in GLS (n = 113). RESULTS: No significant differences were observed in the majority of cardiovascular, demographic or clinical characteristics between the groups. The subset with improvement in GLS demonstrated more favorable changes over follow-up in pulse wave velocity (p = 0.03), central augmentation pressure (p = 0.01) and ventricular-arterial coupling (p = 0.04) compared to patients showing deterioration in GLS. In the multivariable analysis, independent determinants of changes in GLS were: GLS at baseline (-0.48; p < 0.001), changes from baseline to follow-up in central augmentation pressure (-0.29; p = 0.002) and ventricular-arterial coupling (-0.25; p = 0.004). Independent determinants of analogous changes in GCS were: GCS at baseline (-0.46; p < 0.001) and changes in central augmentation pressure (-0.22; p = 0.02). CONCLUSIONS: Left ventricular longitudinal and circumferential functional remodeling over time in hypertensive patients is associated with arterial hemodynamics and ventricular-arterial coupling.

Comparison of left ventricular longitudinal systolic function parameters in the prediction of adverse outcome in heart failure with preserved ejection fraction.

AIMS: Several different diagnostic parameters can be used to assess left ventricular (LV) longitudinal systolic function, but no studies comparing their predictive value have been conducted. We sought to compare the prognostic value of LV long-axis function parameters at rest and exercise using the population with heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS: Clinical and biochemical variables were collected at baseline in 201 patients with HFpEF. Echocardiography was performed at rest and immediately after exercise, with measurement of mitral annular plane systolic excursion, systolic tissue velocity (s'), global longitudinal strain (GLS), and global longitudinal strain rate (GLSR). Participants were followed for 48 (24-60) months for heart failure hospitalization and cardiovascular death. Seventy-four patients (36.8%) met the study endpoint. Cox regression analysis revealed that after adjustment for Meta-Analysis Global Group in Chronic Heart Failure risk score, brain natriuretic peptide (BNP), and peak VO2 , heart failure hospitalization and cardiovascular death were significantly associated with GLS at rest [hazard ratio (HR) 0.91; 95% confidence interval (CI) 0.84-0.98; P = 0.016], GLS after exercise (HR 0.84; 95% CI 0.77-0.91; P < 0.001), and GLSR after exercise (HR 0.13; 95% CI 0.04-0.48; P = 0.002). The addition of each of the following: exercise GLS and GLSR and resting GLS to the base model including Meta-Analysis Global Group in Chronic Heart Failure, BNP, and peak VO2 improved predictive power for the study endpoint [net reclassification improvement (NRI) = 49%, P < 0.001; NRI = 42%, P = 0.004; and NRI = 38%, P = 0.009, respectively]. Exercise GLS was the only longitudinal parameter significantly improving c-statistics of the base model (0.68 vs. 0.73; P = 0.047). CONCLUSIONS: Echocardiographic parameters of LV longitudinal function are not equipotential in predicting adverse outcomes in HFpEF. LV deformation indices, especially assessed with exercise, show the highest predictive utility independent from and incremental to clinical data and BNP.

Prediction of AF in Heart Failure With Preserved Ejection Fraction: Incremental Value of Left Atrial Strain.

OBJECTIVES: This study sought to identify the factors associated with incident atrial fibrillation (AF) in a well-characterized heart failure with preserved ejection fraction (HFpEF) population, with special focus on left atrial (LA) strain. BACKGROUND: AF is associated with HFpEF, with adverse consequences. Effective risk evaluation might allow the initiation of protective strategies. METHODS: Clinical evaluation and echocardiography, including measurements of peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and LA volume index (LAVI), were obtained in 170 patients with symptomatic HFpEF (mean age, 65 ± 8 years), free of baseline AF. AF was identified by standard 12-lead electrocardiogram, review of relevant medical records (including Holter documentation), and surveillance with a portable single-lead electrocardiogram device over 2 weeks. Results were validated in the 103 patients with HFpEF from the Karolinska-Rennes (KaRen) study. RESULTS: Over a median follow-up of 49 months, incident AF was identified in 39 patients (23%). Patients who developed AF were older; had higher clinical risk scores, brain natriuretic peptide, creatinine, LAVI, and LV mass; lower LA strain and exercise capacity; and more impaired LV diastolic function. PACS, PALS, and LAVI were the most predictive parameters for AF (area under receiver-operating characteristic curve: 0.76 for PACS, 0.71 for PALS, and 0.72 for LAVI). Nested Cox regression models showed that the predictive value of PACS and PALS was independent from and incremental to clinical data, LAVI, and E/e' ratio. Classification and regression trees analysis identified PACS ≤12.7%, PALS ≤29.4%, and LAVI >34.3 ml/m2 as discriminatory nodes for AF, with a 33-fold greater hazard of AF (p < 0.001) in patients categorized as high risk. The classification and regression trees algorithm discriminated high and low AF risk in the validation cohort. CONCLUSIONS: PACS and PALS provide incremental predictive information about incident AF in HFpEF. The inclusion of these LA strain components to the diagnostic algorithm may help guide screening and further monitoring for AF risk in this population.

Dialysis Catheter Insertion with Extended Ultrasound Monitoring.

INTRODUCTION: Dialysis catheter insertion is a routine procedure performed when there is necessity of urgent renal replacement therapy initiation. Due to limited access, higher costs, and long waiting times for fluoroscopy, alternative visualization methods are introduced into clinical practice. One of the most promising is transthoracic echocardiographic monitoring of guide-wire introduction. OBJECTIVE: The feasibility of the technique was verified by nephrologists inserting dialysis catheters. METHODS: A single center prospective trial was performed (NCT03727581). Introduction of guide-wire was monitored with ultrasound to confirm correct position of the wire in the inferior vena cava (IVC) or right atrium (RA). The study group included 30 patients, 19 males and 11 females, 25-83 years old. RESULTS: It was possible to obtain a good picture of IVC in the majority of patients. In 20 (66.7%) cases, IVC view was excellent; in 9 (30%) cases, was fair; and in 1 (3.3%) patient, we failed to visualize IVC. The guide-wire was identified in IVC in 12 (42.8%) patients, in another 9 (32.1%) patients guide-wire was visible in IVC after withdrawing and advancing it, and in RA in 6 (21.4%) patients. Catheters were successfully placed in 29 (96.7%) patients. CONCLUSIONS: Detection of the guide-wire confirms correct course of the procedure and increases the safety of catheter insertion without fluoroscopy.

Application of strain and other echocardiographic parameters in the evaluation of early and long-term clinical outcomes after cardiac surgery revascularization.

BACKGROUND: Coronary artery bypass graft (CABG) surgery is an effective therapeutic strategy for coronary heart disease (CHD). Myocardial longitudinal strain echocardiography with 2D speckle tracking could obtain ventricular function with better accuracy and reliability than the left ventricular ejection fraction. The aim of the study was to assess changes in left ventricular function in patients before and after surgical revascularization for a 24-month period of observation, using echocardiography with speckle tracking strain imaging. We searched for echocardiographic predictors of poor early and long-term outcome after CABG. METHODS: We enrolled 69 patients scheduled for elective coronary bypass grafting. Patients were divided into groups based on pre-operative systolic and diastolic parameters, depending on the GLS value and the E' Lat and E/E' value. The correlation between these parameters and early and long-term outcomes was analyzed. RESULTS: Preoperative EF was preserved in 86, 95% (60) patients. Pre-operative reduced GLS was observed in 73.91% (51) of patients and severely reduced in 31.88% (22). In the first post-operative 6-month period, we observed a significant decrease in the GLS. The GLS was a predictor of early postoperative outcome for intubation time, the inotropes use and length of ICU stay. Diastolic dysfunction was a predictor of the greater inotrope requirements. CONCLUSIONS: Global longitudinal strain and diastolic dysfunction parameters are a good predictors of worse early outcome after CABG.

Echocardiographic evaluation of left ventricular strain in severe aortic stenosis with therapeutic implications and risk stratification.

Degenerative aortic stenosis (AS) is an increasingly common acquired valvular heart disease in adults due to the extension of life expectancy in the population of developing countries. The occurrence of calcifications and associated severe aortic stenosis (SAS) increases with age and affects approx. 3-5% of people over 75 years of age. The basis for the decision on the date and type of therapy is echocardiographic evaluation of the severity of the AS and left ventricular (LV) function as well as clinical signs. It appears that the use of newer, more precise methods in echocardiography, especially in patients with preserved ejection fraction (pEF), may change our management in qualifying for valve replacement, especially in asymptomatic patients with SAS. The aim of this review study is echocardiographic strain analysis and evaluation of strain of LV myocardial fibers in patients with SAS, using the speckle tracking echocardiography (STE). This evaluation allows for risk stratification of a valve disease and the choice of the appropriate therapy method.

Aortic root dilation in kidney transplant recipients.

INTRODUCTION Aortic root (AoR) dilation is associated with cardiac damage and higher cardiovascular risk. Cardiovascular disease is the most common cause of death in patients after kidney transplantation (KTx ). OBJECTIVES The aim of this study was to assess the prevalence of enlarged AoR diameter in KTx recipients. Patients with bicuspid aortic valve, significant valvular disease, or evidence of connective tissue disorder were excluded. PATIENTS AND METHODS A total of 87 KTx recipients were divided into 2 groups depending on immunosuppressive regimen: 41 patients receiving mammalian target of rapamycin inhibitors (mTORi) and 46 patients treated with calcineurin inhibitors (CNIs). In all patients, echocardiography was performed, laboratory and clinical markers of cardiovascular risk were assessed, and the AoR diameter was calculated. RESULTS There were no differences between groups in age, sex, body surface area, body mass index, frequency of diabetes, hypertension, dyslipidemia, time after replacement therapy, creatinine levels, and estimated glomerular filtration rate. In the CNI group, the observed and calculated AoR diameters were similar (P = 0.8). In the mTORi group, the observed AoR diameter was higher than the calculated one (P = 0.002). The concentric and eccentric left ventricular hypertrophy was similar in both groups (P = 0.12 and P = 0.69, respectively). In the stepwise regression analysis, the AoR diameter was associated with body surface area and mTORi treatment. CONCLUSIONS KTx recipients have a high prevalence of AoR dilation. Immunosuppressive regimen based on mTORi increases the incidence of AoR enlargement.

The combined impact of mechanical factors on the wall stress of the human ascending aorta - a finite elements study.

BACKGROUND: Biomechanical factors influence stress in the aortic wall. The aim of this study was to assess how the diameter and shape of the vessel, blood pressure and longitudinal systolic aortic stretching (SAS) caused by the contraction of the myocardium influence stress in the aortic wall. METHODS: Three computational models of the non-dilated aorta and aneurysms of the ascending aorta and aortic root were created. Then, finite elements analyses were carried out. The models were subjected to blood pressure (120 mmHg and 160 mmHg) and longitudinal systolic aortic stretching (0 mm, 5 mm, 10 mm and 15 mm). The influence of wall elasticity was examined too. RESULTS: Blood pressure had a smaller impact on the stress than the SAS. An increase in blood pressure from120 mmHg to 160 mmHg increased the peak wall stress (PWS) on average by 0.1 MPa in all models. A 5 mm SAS caused a 0.1­0. 2 MPa increase in PWS in all the models. The increase in PWS caused by a 10mm and 15mmSAS was 0.2 MPa and 0. 4 MPa in the non-dilated aorta, 0.2­0.3 MPa and 0.3­0.5 MPa in the aneurysm of the ascending aorta, and 0.1­0.2 MPa and 0.2­0.3 MPa in the aortic root aneurysm model, respectively. The loss of elasticity of the aneurysmal wall resulted in an increase of PWS by 0.1­0.2 MPa. CONCLUSIONS: Aortic geometry, wall stiffness, blood pressure and SAS have an impact on PWS. However, SAS had the biggest impact on wall stress. The results of this study may be useful in future patient-specific computational models used to assess the risk of aortic complications.

Preoperative thromboelastometry for the prediction of increased chest tube output in cardiac surgery: A retrospective study.

Bleeding following cardiac surgery is a serious event with potentially life-threatening consequences. Preoperative recognition of coagulation abnormalities and detection of cardiopulmonary bypass (CPB) related coagulopathy could aid in the start of preventive treatment strategies that minimize perioperative blood loss. Most algorithms that analyze thromboelastometry coagulation tests in elective cardiac surgery do not include test results performed before surgery. We evaluated preoperative rotational thromboelastometry test results for their ability to predict blood loss during and after cardiac surgery.A total of 114 adult patients undergoing cardiac surgery with CPB were included in this retrospective analysis. Each patient had thromboelastometry tests done twice: preoperatively, before the induction of anesthesia and postoperatively, 10 minutes after heparin reversal with protamine after decannulation.Patients were placed into 1 of 2 groups depending on whether preoperative thromboelastometry parameters deviated from reference ranges: Group 1 [N = 29; extrinsically activated test (EXTEM) or INTEM results out of normal range] or Group 2 (N = 85; EXTEM and INTEM results within the normal range). We observed that the total amount of chest tube output was significantly greater in Group 1 than in Group 2 (700 mL vs 570 mL, P = .03). At the same time, the preoperative values of standard coagulation tests such as platelet count, aPTT, and INR did not indicate any abnormalities of coagulation.Preoperative coagulation abnormalities diagnosed with thromboelastometry can predict increased chest tube output in the early postoperative period in elective adult cardiac surgery. Monitoring of the coagulation system with thromboelastometry allows rapid diagnosis of coagulation abnormalities even before the start of the surgery. These abnormalities could not always be detected with routine coagulation tests.

Prolonged Cardiopulmonary Bypass is a Risk Factor for Intestinal Ischaemic Damage and Endotoxaemia.

BACKGROUND: Intestinal ischaemia-reperfusion, a frequent occurrence during cardiac surgery with cardiopulmonary bypass (CPB) induces a systemic inflammatory reaction. We hypothesised that ischaemia-reperfusion following prolonged CPB could increase intestinal permeability and thus, lead to endotoxin translocation from the intestine to the bloodstream. MATERIAL AND METHODS: Patients subjected to coronary artery bypass grafting with CPB were included: Group 1 (CPB ≥90minutes) or Group 2 (CPB <90minutes). Intestinal Fatty Acid Binding Protein (I-FABP), TNF alpha, IL6, IL8, and endotoxin levels were measured before the induction of general anaesthesia (T1), at 6 (T2), and 24hours (T3) after surgery. RESULTS: The low level of I-FABP at T1 increased for every patient in Group 1 at T2 (from 1015.5pg/mL to 2608.5pg/mL, p=0.02) and in Group 2 (from 1123.5pg/ml to 2284.0pg/ml, p<0.001). Furthermore, at T3, the I-FABP level was over three times higher in Group 1 than in Group 2 (2178pg/mL vs 615pg/mL; p<0.001). I-FABP correlated with CPB time (R=0.6, p<0.001) at T3. After surgery, endotoxins were elevated in 73% of patients in Group 1 and in 32% in Group 2 and correlated with CPB time (at T2, R=0.5, p=0.002; at T3, R=0.4, p=0.016). CONCLUSIONS: The duration of CPB is linked to the release of biomarkers that indicate ischaemic-reperfusion damage to the gastrointestinal mucosa and endotoxaemia. I-FABP assay may help to identify patients presenting with intestinal damage, who are at risk of bacterial translocation.

Beneficial effect of bilateral native nephrectomy as complete denervation on left ventricular mass and function in renal transplant recipients.

INTRODUCTION: Left ventricular hypertrophy (LVH) is a risk factor for cardiovascular morbidity and mortality in renal transplant recipients. The development of LVH is connected with excessive activation of the sympathetic nervous system. A bilateral nephrectomy is an example of complete renal denervation. OBJECTIVES: The aim of this study was to evaluate the effect of pretransplant bilateral native nephrectomy on left ventricular mass and function during a long-term follow-up of patients after kidney transplantation. PATIENTS AND METHODS: The study group consisted of 32 renal transplant recipients who had previously undergone pretransplant bilateral native nephrectomy. The control group involved 32 recipients with preserved native kidneys, matched for age, sex, creatinine levels, estimated glomerular filtration rate, immunosuppressive treatment, and the time of renal replacement therapy. All patients were evaluated by echocardiography, and 16 patients--by cardiac magnetic resonance (CMR). In addition, all patients had their arterial blood pressure (BP) and metabolic markers measured. RESULTS: In comparison with controls, the study group had lower systolic BP (P = 0.048) and received a lower number of antihypertensive agents (P = 0.001). Lipid and hemoglobin levels were similar in both groups. The study group had a lower left ventricular mass index (LVMI; P = 0.001) and left atrial volume index (LAVI; P = 0.004). The left ventricular mass evaluated by CMR was also lower in the study group (P <0.001). Mild left ventricular diastolic dysfunction (LVDD) was more frequent in the study group compared with the control group ( P <0.001). CONCLUSIONS: In a long-term follow-up of patients after kidney transplantation, the bilateral native nephrectomy before transplantation was associated with a lower LVMI and LAVI as well as a lower grade of LVDD. These patients had lower systolic BP and used fewer antihypertensive drugs.

Does the Stage of Chronic Kidney Failure Influence the Outcome in Cardiac Surgery?

BACKGROUND: The number of patients with chronic kidney failure requiring cardiac surgery is continuously increasing. Additionally, significant worsening in the overall risk profile of this group of patients is noted. OBJECTIVES: To investigate the effect of chronic renal dysfunction both in non-dialysis-dependent renal failure and end-stage renal failure patients, on early mortality--morbidity and late survival in a series of cardiac surgery patients at our institution. MATERIAL AND METHODS: 1344 patients who had open heart surgery at our university hospital between 2010 and 2013 were retrospectively reviewed. Chronic renal dysfunction was defined according to preoperative glomerular filtration rate. Patients selection (n=80). Group 1 mild--(GRF 59-30 mL/min), Group 2 moderate--(GFR 29-15 mL/min), Group 3 end stage--(GFR<15 mL/min) renal failure. RESULTS: Chronic renal dysfunction was present in 5.95% of all patients studied. Group 1--55 (68.75%), Group 2--16 (20%), Group 3--9 (11.25%). No difference between the groups in the need for heart inotropic support was noted; however the use of these medications was necessary in 60.6% of all studied patients. Forty nine percent in Group 1, 87.5% in Group 2 and 77% in Group 3, respectively. Renal replacement therapy in the early postoperative period was needed in 12 patients, with significance between the groups (p = 0.001). The overall hospital mortality was 2.5%. Follow-up was completed with a mean of 1.4 years (range 2 months to 4 years). There were 6 (7.5%) late deaths. CONCLUSIONS: Our observations do not exhibit large variations in postoperative complications and deaths in patients with chronic renal failure, depending on the degree of preoperative renal function impairment. It seems that renal failure regardless of the degree of impairment is a factor aggravating the intra and post-operative course in cardiac surgery patients.

Long-term efficacy of surgical ablation of atrial fibrillation in a low-volume centre.

Surgical ablation is a recommended procedure for patients with atrial fibrillation (AF) undergoing a cardiac surgery operation. However, the procedure is associated with significant risk of late recurrence of AF. The aim of the study was to assess the long-term efficacy of the procedure with respect to the comorbidities. The study group consisted of 22 patients: 9 women and 13 men, who underwent surgical AF ablation in the 2008-2013 period. The patients were interviewed by telephone and were asked to send their recently performed 12-lead electrocardiography (ECG). The semi-structured interview consisted of 25 items regarding the history of AF, concomitant comorbidities, lifelong syncopal history, smoking, family history of premature cardiovascular diseases, and current medical treatment. Furthermore, the Epworth test was performed to measure the daytime sleepiness, which in turn is related to the presence of obstructive sleep apnoea. On the basis of the obtained data, the CHADS2, and Epworth scale scores were calculated for each patient. As a result of the study six patients (27%) had sinus rhythm or paced dual chamber rhythm, and 16 patients had atrial fibrillation. The multivariate analysis revealed that Epworth scale scoring > 9, CHADS2 score > 0, and persistent type of AF were related to poor outcome of surgical ablation procedure. In conclusion, patients with AF treated with surgical ablation have similar prognosis of sinus rhythm maintenance to those treated with radiofrequency ablation. Moreover, the same predisposing factors play a significant role in AF recurrence both in surgical patients and in patients treated with radiofrequency ablation.

Unchanged plasma levels of the soluble urokinase plasminogen activator receptor in elective coronary artery bypass graft surgery patients and cardiopulmonary bypass use.

OBJECTIVE AND DESIGN: The soluble urokinase plasminogen activator receptor (suPAR) has been recently recognized as a potential biological marker of various disease states, but the impact of a major surgical intervention on the suPAR level has not yet been established. The aim of our study was to investigate if the induction of a systemic inflammatory reaction in response to cardiopulmonary bypass would be accompanied by an increase in the plasma suPAR level. METHODS AND SUBJECTS: Patients undergoing coronary artery bypass grafting under cardiopulmonary bypass (CPB) were added. Based on the baseline suPAR level, patients were divided into group 1 (suPAR within normal range) or group 2 (suPAR above range). Blood was collected before the induction of anesthesia and 6 and 24 hours after surgery. Plasma suPAR, IL-6, IL-8, TNF-α, troponin I, NT-proBNP, and NGAL were quantified to assess the impact of surgical trauma on these markers. RESULTS: The baseline suPAR level was within the normal range in 31 patients (3.3 ng/mL), and elevated in 29 (5.1 ng/mL) (p<0.001). Baseline mediators of systemic inflammatory reaction concentrations (IL-6, TNF-α, and IL-8) and organ injury indices (troponin I, NT-proBNP, and NGAL) were low and increased after surgery in all patients (p<0.05). The surgery did not cause significant changes in the suPAR level either at 6 or 24 hours after, however the difference between groups observed at baseline remained substantial during the postoperative period. CONCLUSIONS: There was no change in the suPAR level observed in patients subjected to elective cardiac coronary artery bypass surgery and CPB, despite activation of a systemic inflammatory reaction.

Applying the PARiHS framework in a knowledge dissemination initiative.

This paper describes the process of facilitating knowledge dissemination using the Promoting Action on Research Implementation in Health Services (PARiHS) framework, including articulation of findings, barriers, implications, and recommendations. Advanced practice nurses (APNs) are in a unique position to facilitate the dissemination of evidence-based knowledge to front-line staff in health care organizations. At a community acute care hospital in Toronto, Ontario, the collaborative competency of an APN was used to develop partnerships with three units in order to implement interprofessional knowledge dissemination via education sessions. The goal was to increase nurses' knowledge of best practices and, consequently, improve outcomes for nephrology patients under their care. The PARiHS framework was used to facilitate the process of knowledge dissemination. The framework consists of three elements: evidence, context, and facilitation. In order for the implementation of a project to be successful, it is necessary to understand the context of the organization. Implications and recommendations for advance practice nurses will be described.

Temporary resolution of chronic atrial fibrillation after cardiac surgery and the prolongation of ventricular repolarization.

BACKGROUND: Chronic atrial fibrillation may temporarily resolve after cardiac surgery. Prolongation of the ventricular repolarization period may be the electrophysiological background for this phenomenon. OBJECTIVES: The aim of the study was to assess the association between resolution of atrial fibrillation and changes in the duration of the ventricular repolarization period in patients with pre-operative chronic atrial fibrillation who underwent cardiac surgery. MATERIAL AND METHODS: A retrospective analysis of the medical recordings of patients with chronic atrial fibrillation who underwent cardiac surgery was performed. After exclusions the study group comprised 51 patients with chronic atrial fibrillation who underwent surgery in the Cardiac Surgery Department of Wroclaw Medical University in 2008 and 2009. The 12-lead EKGs performed before and after the surgery were assessed and the QT and R-R intervals were measured. The patients were divided into Group 1, in whom atrial fibrillation persisted after the cardiac surgery, and Group 2, whose atrial fibrillation resolved after the surgery. RESULTS: In 31 patients (60.8%) atrial fibrillation disappeared during the first 24 hours after cardiac surgery. A significant prolongation of the QT interval after the surgery was found in Group 2 that was not observed in Group 1. Multiple regression analysis revealed that QT interval duration after surgery is related to the resolution of atrial fibrillation independently from the duration of the R-R interval duration and the need for cardiac pacing. CONCLUSIONS: Spontaneous temporary resolution of atrial fibrillation is a common finding after cardiac surgery in patients with chronic atrial fibrillation. This phenomenon is related to a prolonged QT interval, therefore it may have an electrophysiological basis rather than a hemodynamic background. Further studies are required to assess the clinical importance of the prolongation of the QT interval after cardiac surgery.