Renal function is associated with risk of atrial fibrillation after cardiac surgery.

BACKGROUND: Atrial fibrillation (AF) frequently occurs after cardiac surgery and is responsible for increased morbidity and resource use. The aim of the present study was to evaluate the association of impaired renal function and the development of postoperative AF. METHODS AND RESULTS: Patients undergoing elective cardiac surgery in the absence of significant left ventricular dysfunction (n=253; average age 65+/-11 years) were recruited to the present prospective study. Ninety-nine patients (39.1%) developed AF during the postoperative period. Creatinine clearance, estimated by the calculated glomerular filtration rate (GFR), was prospectively assessed to determine the association of baseline renal function and the development of postoperative AF. Baseline calculated GFR was assessed as a continuous and a categorical variable (normal: greater than 90 mL/min/1.73 m(2); mildly decreased: 60 mL/min/1.73 m(2) to 89 mL/min/1.73 m(2); and moderately to severely decreased: less than 60 mL/min/1.73 m(2)). Baseline creatinine clearance was 72+/-22.2 mL/min/1.73 m(2) and 78.8+/-23.5 mL/min/1.73 m(2) in patients with and without postoperative AF, respectively (P=0.02). There was an independent association between decreasing calculated GFR and the development of postoperative AF (OR for 10 mL decrease in calculated GFR: 1.21, 95% CI 1.02 to 1.39). In addition to calculated GFR, surgery for valvular heart disease (versus coronary artery bypass grafting [OR 2.23, 95% CI 1.09 to 3.14; P<0.01]), age (OR per 10-year increase in age 1.92, 1.18 to 2.59) and perioperative nonuse of beta-adrenergic blockers (OR 1.62, 95% CI 1.12 to 3.55; P<0.01) were identified as independent predictors of postoperative AF. CONCLUSIONS: In the setting of cardiac surgery, impaired calculated GFR is associated with an increased risk for the development of postoperative AF. These data provide additional evidence supporting the association between renal dysfunction and adverse cardiovascular outcomes.

A comparison between oral antiarrhythmic drugs in the prevention of atrial fibrillation after cardiac surgery: the pilot study of prevention of postoperative atrial fibrillation (SPPAF), a randomized, placebo-controlled trial.

BACKGROUND: Atrial fibrillation (AF) frequently occurs after cardiac surgical procedures, and beta-blockers, sotalol, and amiodarone may reduce the frequency of AF after open heart surgery. This pilot trial was designed to test whether each of the active oral drug regimens is superior to placebo for prevention of postoperative AF and whether there are differences in favor of 1 of the preventive strategies. METHODS AND RESULTS: We conducted a randomized, double-blinded, placebo-controlled trial in which patients undergoing cardiac surgery in the absence of heart failure and without significant left ventricular dysfunction (n = 253; average age, 65 +/- 11 years) received oral amiodarone plus metoprolol (n = 63), metoprolol alone (n = 62), sotalol (n = 63), or placebo (n = 65). Patients receiving combination therapy (amiodarone plus metoprolol) and those receiving sotalol had a significantly lower frequency of AF (30.2% and 31.7%; absolute difference, 23.6% and 22.1%; odds ratios [OR], 0.37 [95% CI, 0.18 to 0.77, P <.01 vs placebo] and 0.40 [0.19 to 0.82, P =.01 vs placebo]) compared with patients receiving placebo (53.8%). Treatment with metoprolol was associated with a 13.5% absolute reduction of AF (P =.16; OR, 0.58 [0.29 to 1.17]. Treatment effects did not differ significantly between active drug groups. Adverse events including cerebrovascular accident, postoperative ventricular tachycardia, nausea, and dyspepsia, in hospital death, postoperative infections, and hypotension, were similar among the groups. Bradycardia necessitating dose reduction or drug withdrawal occurred in 3.1% (placebo), 3.2% (combined amiodarone and metoprolol; P =.65 vs placebo), 12.7% (sotalol; P <.05 vs placebo), and 16.1% (metoprolol; P <.05 vs placebo). Patients in the placebo group had a nonsignificantly longer length of hospital stay as compared with the active treatment groups (13.1 +/- 8.9 days vs 11.3 +/- 7; P =.10), with no significant difference between the active treatment groups. CONCLUSIONS: Oral active prophylaxis with either sotalol or amiodarone plus metoprolol may reduce the rate of AF after cardiac surgery in a population at high risk for postoperative AF. Treatment with metoprolol alone resulted in a trend to a lower risk for postoperative AF.

Unusual cause of dyspnoea: a case presentation of an echocardiographic pitfall.

Congenital or acquired communication between the left ventricle and the right atrium is known as the Gerbode defect, which is rarely diagnosed since the defect is very unusual and for this reason often misinterpreted as an eccentric tricuspid regurgitation jet. The entity and reason of the defect is unknown to many physicians, so that profound knowledge and a careful and meticulous echocardiogram are necessary in order to prevent misinterpretation of this defect as a pulmonary hypertension. We report the case of a 76-year-old Austrian woman who developed such a Gerbode defect after a recent bioprosthetic aortic valve replacement.

Unstable angina early after aortic valve replacement surgery in a female patient with normal coronary arteries preoperatively--a case report.

BACKGROUND: Angina pectoris early after aortic valve replacement surgery in patients with previously normal coronary arteries may be life threatening and has to be assessed immediately. CASE REPORT: 12 weeks after aortic valve replacement surgery, a 60-year-old female patient was referred for evaluation of recent onset of severe chest pain on mild exertion and at rest. Coronary angiography showed severe stenosis involving the left coronary ostium and the left main stem. The patient was urgently referred for bypass surgery and had an uneventful postoperative recovery. CONCLUSION: A high degree of suspicion is needed for early recognition and aggressive management of this rare but serious complication.

Self-retaining pledgeted suture as retractor for mitral procedure.

A simple reliable maneuver to optimize exposure of the left atrium for mitral valve operations is described. It offers more space to mobilize the valvular structure, facilitating complicated reconstruction in the posteromedial commisural area.

Intracoronary air embolism in open heart surgery--an uncommon source of myocardial ischaemia.

We report a case of air embolism detected by transesophageal echocardiography in a patient undergoing open heart surgery for acute mitral regurgitation. Intraoperative transesophageal echocardiography revealed an increased brightness of the apical wall and a severely compromised left ventricular myocardium with severe diffuse hypokinesis after removal of the aortic cross clamps and spontaneous resolution in the control echocardiography.

A head-to-head comparison of infusion and bolus doses of adenosine for stress myocardial contrast echocardiography.

BACKGROUND: This study was a head-to-head, intraindividual comparison of the diagnostic accuracy and side effect profile of bolus and infusion administration of adenosine for stress myocardial contrast echocardiography (MCE). METHODS: Adenosine MCE was performed in 64 subjects, referred for stress thallium-201 single-photon emission computed tomography (SPECT) for known or suspected CAD. Each patient received adenosine by multiple boluses (6-12 mg/bolus) and infusion (140 mug/kg per min for 6 min) forms in random order, given at least 20 minutes apart. RESULTS: No prolonged or serious adverse events occurred during either adenosine bolus or infusion. Compared to SPECT imaging, the sensitivity, specificity, and concordance for the diagnosis of CAD were 77%, 87%, and 82% for adenosine infusion MCE and 81%, 90%, and 86% for adenosine bolus MCE, respectively. CONCLUSIONS: Both adenosine infusion and adenosine bolus protocols are safe for MCE in humans and can be used for the diagnosis of CAD.

Risk factors of postoperative atrial fibrillation after cardiac surgery.

BACKGROUND: Postoperative atrial fibrillation (AF) occurs in up to 50% of cardiac surgery patients and represents the most common postoperative arrhythmic complication. The etiology of AF after open-heart surgery is incompletely understood and its prevention remains suboptimal. Identification of patients vulnerable for postoperative AF would allow targeting of those most likely to benefit from aggressive prophylactic intervention. The aim of the present study was to evaluate clinical predictors of postoperative AF. METHODS AND RESULTS: Patients undergoing elective cardiac surgery in the absence of significant left ventricular dysfunction (n = 253; average age 65 +/- 11 years) were recruited to the present prospective study. Ninety-nine patients (39.1%) of the total study population developed AF during the postoperative period. The median age for patients with postoperative AF was 69 years compared with 64 years for patients without (p < 0.001). In addition to advanced age, AF patients were more likely to have surgery for valvular heart disease and less likely to have preoperative beta-adrenergic blockers than patients without AF. Multivariate logistic regression analysis (odds ratio, +/-95% CI, p value) was used to identify the following independent clinical predictors of postoperative AF: increasing age (above vs. below median [OR = 2.6; CI, 1.2 to 3.9; p < 0.01]), and surgery for valvular heart disease (vs. coronary artery bypass grafting [OR 2.8; CI, 1.1 to 3.5; p < 0.01)]). Additionally, postoperative complications (stroke, infections, unstable hemodynamics [OR = 1.9; CI, 1.0 to 7.5; p < 0.05]), and preoperative nonuse of beta-adrenergic blockers (OR = 1.7; CI, 1.1 to 4.9; p < 0.05) were associated with increased risk for postoperative AF. Both, patients with and without AF had similar body mass index, preoperative heart rate, preoperative blood pressure, and duration of surgery. Male sex did not identify patients at high risk for development of AF after cardiac surgery. CONCLUSIONS: Postoperative AF remains the most common complication after cardiac surgery. A combination of advanced age and type of surgery identifies patients at high risk for development of AF after cardiac surgery.