Long-term secondary cardiovascular prevention programme in patients subjected to coronary artery bypass surgery.

AIMS: Patients with coronary heart disease (CHD) are at very high risk of recurrent events. A strategy to reduce excess risk might be to deliver structured secondary prevention programmes, but their efficacy has been mostly evaluated in the short term and in experimental settings. This is a retrospective case-control study aimed at assessing, in the real world, the efficacy of a secondary prevention programme in reducing long-term coronary event recurrences after coronary artery bypass surgery (CABG). METHODS AND RESULTS: Programme participants (henceforth 'cases') were men and women aged <75 years subjected to CABG between 2002 and 2014, living within 100 km of the hospital. Key programme actions included optimization of treatments according to the most updated European preventive guidelines, surveillance of therapy adherence, and customized lifestyle counselling. Controls were analogous patients not involved in the programme because living farther than 100 km away, matched 1:1 with cases for gender, age at CABG, and year of CABG. Both groups (n = 1248) underwent usual periodic cardiology follow-up at our centre. Data on symptomatic or silent CHD recurrences were obtained from the hospital electronic health records. Cox analysis (adjusted for baseline differences between groups) shows that programme participation was associated with a significantly lower incidence throughout 5 years post-CABG of symptomatic [hazard ratio (95% confidence interval): 0.59 (0.38-0.94)] and silent [0.53 (0.31-0.89)] coronary recurrences. CONCLUSION: In a real-world setting, taking part in a structured longstanding secondary prevention programme, in addition to usual cardiology care, meaningfully lowers the risk of coronary recurrences.

Differences in Amino Acid Loss Between High-Efficiency Hemodialysis and Postdilution and Predilution Hemodiafiltration Using High Convection Volume Exchange-A New Metabolic Scenario? A Pilot Study.

OBJECTIVE: The objective of the study was to quantify the loss of total amino acids (TAAs), nonessential amino acids, essential amino acids, and branched chain amino acids (BCAAs) produced by high-efficiency hemodialysis (HEHD), postdilution hemodiafiltration (HDFpost), and predilution hemodiafiltration (HDFpre) using high ultrafiltration volumes; and to define the specific AA losses registered in HEHD, HDFpost, and HDFpre; to identify a potential metabolic and nutritional decline into protein energy wasting; to compare AA analysis of arterial blood samples taken from healthy controls and patients with end-stage renal disease undergoing hemodialysis. DESIGN AND METHODS: Identical dialysis monitors, membranes, and dialysate/infusate were used to homogenize extracorporeal body influence. Ten patients were recruited and randomized to receive treatment with HEHD, HDFpost, and HDFpre it was used on-line dialytic water methodologies (OL); patients' AA arterial concentrations were measured at the start and on completion of dialysis; TAA from the dialyzer filter was calculated, and baseline levels were subsequently compared with findings obtained 1 year later. Finally, the results obtained were compared with the data from a study of 8 healthy volunteers conducted using bioimpedance analysis and laboratory blood tests to assess nutritional status. RESULTS: A higher convective dose results in a higher weekly loss of TAA, nonessential AAs, essential AAs, and BCAAs (HEHD: 15.7 g; HDFpost-OL: 16.1 g; HDFpre-OL: 16.3 g, P < .01). After 12 months, the same hemodialys patients showed a reduced body and water intracellular mass and reduced phase angle. Arterial concentrations of TAAs and BCAAs were lower than those detected in healthy subjects (P < .01). CONCLUSION: The study shows that the AA losses in dialytic liquid are greater after high exchange volume HDF techniques, especially HDFpre. The AA losses are not metabolically compensated, so these increase the derangements of predialytic arterial plasma AA levels. Both AA losses and arterial AA perturbations further worsened body composition already after 12 months of additional dialysis.

Preoperative statin therapy is not associated with a decrease in the incidence of delirium after cardiac operations.

BACKGROUND: Delirium after cardiac operations is associated with significant morbidity and death. Statins have been recently suggested to exert protective cerebral effects. This study investigated whether preoperative statins were associated with decreased incidence of postoperative delirium in patients undergoing coronary artery bypass grafting. METHODS: The study enrolled 4,659 consecutive patients (21% women; age, 67.8±9.2 years) undergoing coronary artery bypass grafting. A propensity score-based optimal-matching algorithm was used to match 1,577 patients receiving preoperative statins with a control group (1:1). Patients were screened for delirium in the intensive care unit according to the Confusion Assessment Method for the intensive care unit. RESULTS: Delirium affected 89 patients (3%), and preoperative statin administration was not multivariably associated with a decreased incidence of delirium (odds ratio, 1.52; 95% confidence interval, 0.97 to 2.37; p=0.18) and was also unrelated to a delirium decrease in patient subgroups undergoing isolated coronary artery bypass grafting (odds ratio, 1.31; 95% confidence interval, 0.68 to 2.52; p=0.51) or combined valvular procedures (odds ratio, 1.72; 95% confidence interval, 0.96 to 3.07, p=0.08). Similar results were observed for age groups and cardiopulmonary bypass durations. Patients affected by postoperative delirium experienced a longer hospital stay (25th to 75th percentile) of 11 (7 to 18 days) vs 7 days (7 to 8 days, p<0.001) and 12% hospital mortality vs 1% (p<0.001). CONCLUSIONS: Preoperative statins were not associated with a decreased incidence of delirium in patients undergoing coronary revascularization.

Transcatheter vs. surgical aortic valve replacement: a retrospective analysis assessing clinical effectiveness and safety.

OBJECTIVE: To compare, in terms of clinical effectiveness and safety, patients who underwent transcatheter aortic valve implantation (TAVI) with those who underwent surgical aortic valve replacement (S-AVR) for the treatment of severe aortic stenosis during the same period. METHODS: One hundred and eighty-seven consecutive patients were included: 81 with S-AVR and 106 with TAVI. Primary and secondary outcomes were reported in accordance with published reporting guidelines for valve surgery. A propensity matching model was computed in the attempt to reduce confounding effects of covariates. RESULTS: Thirty-day mortality and morbidity, as well as follow-up events, did not differ between the two therapeutic options, except for ICU stay, in favor of TAVI, and occurrence of pleural effusions, in favor of S-AVR. TAVI accomplished significant mean aortic gradient reduction (better than S-AVR in the immediate postoperative and at least comparable at follow-up) and improvement in valve area and functional class (always higher than S-AVR). Although for the first year, survival was at least comparable between TAVI and S-AVR (both whole and matched groups); at later times, TAVI all-cause and noncardiac mortality was higher in the whole sample, as expected from age and comorbidities of TAVI patients. At later follow-up, in the matched subsamples, 1-year mortality rates were replicated, with a significantly higher incidence of cardiac deaths in S-AVR patients. CONCLUSION: TAVI morbidity and mortality registered in this series are lower than those estimated for conventional surgery in high-risk patients and compare to those associated with S-AVR in good surgical candidates.

Risk factors for perioperative acute kidney injury after adult cardiac surgery: role of perioperative management.

BACKGROUND: The development of acute kidney injury (AKI) after adult cardiac surgery is associated with increased morbidity and mortality. Our aim was to assess the risk factors for postoperative AKI and whether the addition of perioperative management variables can improve AKI prediction. METHODS: We studied 3,219 patients operated from January 2006 to December 2009. The AKI was defined as proposed by the Acute Kidney Injury Network. Patient preoperative characteristics, as well as intraoperative, cardiopulmonary bypass (CPB), and postoperative management variables, were evaluated for association with AKI with logistic regression analysis. The model including all variables was assessed first, then separate models including only preoperative variables followed by the sequential addition of intraoperative, CPB, and postoperative management variables were tested; receiver operating characteristic analysis was used to evaluate and compare models' discriminatory power. RESULTS: The AKI occurred in 288 of 3,219 patients (8.9%). Logistic regression analysis identified 15 predictors of AKI; 4 were preoperative (age, diabetes, smoking, and serum creatinine), 4 intraoperative (inotropes, erythrocytes transfusion, cross-clamp time, and need of a new pump run), 2 CPB-related (urine output and furosemide administration during CPB), and 5 postoperative (erythrocytes transfusion, administration of vasoconstrictors, inotropes, diuretics, and antiarrhythmics). Model-discrimination performance improved from an area under the curve of 0.830 (95% confidence interval 0.807 to 0.854) for the model including only preoperative variables to an area under the curve of 0.904 (95% confidence interval 0.886 to 0.921) for the model including all variables (p<0.001). CONCLUSIONS: Several factors influence AKI development after cardiac surgery and perioperative patient management significantly affects AKI occurrence. Predictive models can be sensibly improved by the addition of these variables.

Determinants of pericardial drainage for cardiac tamponade following cardiac surgery.

OBJECTIVE: We aimed to identify independent risk factors predisposing toward postoperative surgical or percutaneous pericardial drainage following cardiac surgery, and to assess late survival. METHODS: A retrospective review of preoperative, intra-operative and postoperative variables was conducted in 5818 patients, who underwent adult heart surgery in a 7-year time span (2002-2009). Pericardial drainage was performed in 117 patients (2%), of whom 52 (44%) were evacuated by surgical drainage and 65 (56%) by echocardiographic-guided pericardiocentesis. Patients were divided in two groups: patients with two-dimensional (2D) echocardiographic evidence of cardiac tamponade, who underwent pericardial surgical or percutaneous drainage (group I: 117 patients); and patients without cardiac tamponade (group II: 5701 patients), who served as the control group. RESULTS: The two groups were compared with univariate analysis, and variables significantly (p ≤ 0.05) or possibly (p ≤ 0.2) associated with pericardial drainage were entered into multivariable logistic regression analysis models assessing the role of pre-, intra- and postoperative variables together or separately. Pericardial drainage was more likely to occur in patients undergoing combined procedures such as double/triple valves or surgery on ascending aorta, in patients with higher EuroSCORE (European System for Cardiac Operative Risk Evaluation) levels, whereas patients receiving aspirin treatment before surgery had a lower risk of this complication. In addition, postoperative blood product transfusion and the occurrence of renal failure after surgery increased the risk of this complication. CONCLUSIONS: Postoperative pericardial drainage is an uncommon complication after heart surgery, mainly managed percutaneously. Our study has identified different independent causative factors for cardiac tamponade requiring pericardiocentesis. The identification of preoperative and postoperative risk factors may be useful to adopt strategies to further reduce the incidence of pericardial tamponade requiring drainage.

Cardiopulmonary bypass duration is an independent predictor of morbidity and mortality after cardiac surgery.

OBJECTIVE: The aim of this study was to determine if there is a direct relationship between the duration of cardiopulmonary bypass (CPB time [CPBT]) and postoperative morbidity and mortality in patients undergoing cardiac surgery. DESIGN: Retrospective study. SETTING: Cardiac surgery unit, university hospital. PARTICIPANTS: Five thousand six patients, New York Heart Association classes 1 through 4, who underwent cardiac surgery between January 2002 and March 2008. INTERVENTIONS: All patients were subjected to CPB. MEASUREMENTS AND MAIN RESULTS: The mean CPBT was 115 minutes (median 106). One hundred thirty-one patients (2.6%) died during the same hospitalization. The postoperative median blood loss was 600 mL. Reoperations for bleeding occurred in 193 patients (3.9%), and 1,001 patients received 3 or more units of red blood cells. There were 108 patients (2.2%) with neurologic sequelae, 391 patients (7.8%) with renal complications, 37 patients (0.7%) with abdominal complications, and 184 patients (3.7%) with respiratory complications. Seventy-two patients (1.4%) had an infective complication, and 80 patients (1.6%) had a postoperative multiorgan failure. The multivariate analysis confirmed the role of CPBT, considered in 30-minute increments, as an independent risk factor for postoperative death (odds ratio [OR] = 1.57, p < 0.0001), pulmonary (OR = 1.17, p < 0.0001), renal (OR 1.31, p < 0.0001), and neurologic complications (OR = 1.28, p < 0.0001), multiorgan failure (OR = 1.21, p < 0.0001), reoperation for bleeding (OR = 1.1, p = 0.0165), and multiple blood transfusions (OR = 1.58, p < 0.0001). CONCLUSIONS: Prolonged CPB duration independently predicts postoperative morbidity and mortality after cardiac surgery.

Effects of combined deferiprone and desferrioxamine iron chelating therapy in beta-thalassemia major end-stage heart failure: a case report.

Despite usual iron chelating therapy based on desferrioxamine, patients affected by beta-thalassemia major (beta-TM) often develop progressive heart failure caused by myocardial iron overload, which is the leading cause of mortality within the third decade of life. Heart transplantation is a limited therapeutic option, as very often these patients have multi-organ iron deposits and infective complications (particularly hepatitis C), secondary to frequent blood transfusions. We report the case of a 26-year-old male affected by beta-TM with end-stage heart failure, who showed a dramatic improvement in symptoms and myocardial function when a new oral iron chelating agent, deferiprone, was added to standard therapy with desferrioxamine.

High thoracic epidural anesthesia for off-pump coronary artery bypass surgery.

OBJECTIVE: To assess the feasibility of high thoracic epidural anesthesia combined with sevoflurane for off-pump coronary artery bypass surgery and to evaluate the postoperative pain control, side effects, and perioperative hemodynamics. DESIGN: Retrospective review of prospectively collected data. SETTING: A university teaching hospital. PARTICIPANTS: One hundred six consecutive patients receiving thoracic epidural combined with sevoflurane. INTERVENTION: From November 1999, the patients undergoing off-pump coronary artery bypass grafting were offered the epidural-inhalation anesthetic approach. MEASUREMENTS AND MAIN RESULTS: Insertion of the epidural catheter was successful in all but 2 patients; 1 bloody tap occurred and the dura was never punctured, although 1 patient presented with postoperative paraplegia. An emergency spinal cord nuclear magnetic resonance excluded signs of medullary compression caused by epidural or spinal hematoma. Visual analog scale scores for pain during the first 24-hour period were < 2 in all patients. Mean time to extubation was 4.6 +/- 2.9 hours. The average intensive care unit stay was 1.5 +/- 0.8 days. Incidences of perioperative myocardial infarction, myocardial ischemia, and atrial fibrillation were 2.8%, 7.5%, and 10.6%, respectively. Two patients died: 1 from multiorgan failure and the other from myocardial infarction. Heart rate, mean arterial pressure, cardiac index, and systemic vascular resistance were not affected by thoracic epidural alone. Mean arterial pressure and cardiac index decreased (p < 0.05) when general anesthesia was induced and remained stable thereafter. Neither heart rate nor systemic vascular resistance changed from baseline during operation. CONCLUSIONS: Thoracic epidural as an adjunct to general anesthesia is a feasible technique in off-pump coronary artery bypass surgery. It induces intense postoperative analgesia and does not compromise central hemodynamics.