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BACKGROUND: Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (antegrade cerebral perfusion [ACP]), or retrograde. In recent years nadir temperature progressively increased to 26°C-28°C (moderately hypothermic circulatory arrest [MHCA]), adding ACP. Aim of this multicentric study is to evaluate early results of aortic arch surgery and if DHCA with 10 min of cold reperfusion at the same nadir temperature of the CA before rewarming (delayed rewarming [DR]) can provide a neuroprotection and a lower body protection similar to that provided by MHCA + ACP. METHODS: A total of 210 patients were included in the study. DHCA + DR was used in 59 patients and MHCA + ACP in 151. Primary endpoints were death, neurologic event (NE), temporary (TNE), or permanent (permanent neurologic deficit [PND]), and need of renal replacement therapy (RRT). RESULTS: Operative mortality occurred in 14 patients (6.7%), NEs in 17 (8.1%), and PNDs in 10 (4.8%). A total of 23 patients (10.9%) needed RRT. Death + PND occurred in 21 patients (10%) and composite endpoint in 35 (19.2%). Intergroup weighed logistic regression analysis showed similar prevalence of deaths, NDs, and death + PND, but need of RRT (odds ratio [OR]: 7.39, confidence interval [CI]: 1.37-79.1) and composite endpoint (OR: 8.97, CI: 1.95-35.3) were significantly lower in DHCA + DR group compared with MHCA + ACP group. CONCLUSIONS: The results of our study demonstrate that DHCA + DR has the same prevalence of operative mortality, NE and association of death+PND than MHCA + ACP. However, the data suggests that DHCA + DR when compared with MHCA + ACP provides better renal protection and reduced prevalence of composite endpoint.
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Aorta Torácica , Parada Circulatória Induzida por Hipotermia Profunda , Humanos , Aorta Torácica/cirurgia , Resultado do Tratamento , Parada Circulatória Induzida por Hipotermia Profunda/métodos , Encéfalo , Ponte Cardiopulmonar/métodos , Perfusão/métodos , Circulação Cerebrovascular , Estudos RetrospectivosRESUMO
Left atrial intramural hematoma (LAIH) is an uncommon entity for which a timely diagnosis is critical for decision making. Cardiac surgical or catheter-based procedures are potential causing factors. Though cardiac computerized tomography and magnetic resonance are highly accurate diagnostic modalities, their role is limited by the lack of widespread availability. The present clinical case illustrates the diagnostic features of LAIH that can be obtained using echocardiography at the bedside in critically ill patients. We report a case of LAIH, that followed a catheter ablation procedure and was complicated by cardiac and cerebral ischemia. Cardiac surgical management was required.
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Apêndice Atrial , Ablação por Cateter , Ecocardiografia , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/cirurgia , Hematoma/diagnóstico por imagem , Hematoma/cirurgia , HumanosRESUMO
BACKGROUND: The aim of this multicenter prospective study was to evaluate the prognostic weight of preoperative right ventricular assessment on early mortality in cardiac surgery. METHODS: This is a multicenter prospective observational study performed by the Italian Group of Research for Outcome in Cardiac Surgery (GIROC) including 11 centers. From October 2017 to March 2019, out of 923 patients undergoing cardiac surgery, 28 patients with some missing data were excluded and 895 patients were enrolled in the study right ventricular dilatation was defined as a basal end-diastolic diameter >42 mm. The right ventricle (RV) function was assessed using the combination of three parameters: fractional area changing (FAC), tricuspid annular plane systolic excursion (TAPSE), and S'-wave using tissue Doppler imaging (TDI-S'); RV dysfunction was defined as the presence of at least two of the following cutoffs: FAC <35%, TAPSE <17 mm, and TDI S' <9.5 mm RESULTS: Among the entire cohort, 624 (70%) showed normal RV, 92 (10%) isolated RV dilatation, 154 (17%) isolated RV dysfunction, and 25 (3%) both RV dilatation and dysfunction. Non-surviving patients showed a significantly higher rate of RV alteration at multivariable analysis, RV status was found to be an independent predictor for higher in-hospital mortality beside Euroscore II. CONCLUSIONS: This prospective multicenter observation study shows the importance to assess RV preoperatively and to include both RV function and dimension in a risk score model such as Euroscore II to implement its predictivity, since PH cannot always mirror the status of the right ventricle.
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Procedimentos Cirúrgicos Cardíacos/mortalidade , Ventrículos do Coração/patologia , Avaliação de Resultados em Cuidados de Saúde/métodos , Projetos de Pesquisa , Função Ventricular Direita , Adulto , Idoso , Idoso de 80 Anos ou mais , Dilatação Patológica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Prognóstico , Estudos Prospectivos , Risco , Disfunção Ventricular Direita , Adulto JovemRESUMO
The association of Standford type A acute aortic dissection with situs inversus totalis (SIT) is extremely rare and only a few cases are reported in the literature to date. Due to the particular rarity, this unusual condition, if not diagnosed quickly and correctly, can generate both clinical and surgical difficulties. Case presentation: We describe the case of a male Caucasian patient with SIT and aortic dissection type A, who occurred to our Emergency Department with a severe clinical condition of shock. Using the fast diagnostic approach with chest X-Ray and echocardiography followed by computed tomography investigation, a Standford type A acute aortic dissection and the presence of SIT were detected. The patient was subjected to surgical treatment with optimal results in a short time. Clinical discussion and conclusion: The event of aortic dissection is an extremely serious condition and the simultaneous presence of a critical clinical presentation with an unusual congenital anomaly could condition a correct and rapid diagnostic process. Only an accurate diagnostic investigation can give a quick diagnosis and useful elements for a correct therapeutic approach.
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BACKGROUND: Infective endocarditis (IE) is a serious disease, and in many cases, surgery is necessary. Whether the type of prosthesis implanted for aortic valve replacement (AVR) for IE impacts patient survival is a matter of debate. The aim of the present study is to quantify differences in long-term survival and recurrence of endocarditis AVR for IE according to prosthesis type among patients aged 40 to 65 years. METHODS: This was an analysis of the INFECT-REGISTRY. Trends in proportion to the use of mechanical prostheses versus biological ones over time were tested by applying the sieve bootstrapped t-test. Confounders were adjusted using the optimal full-matching propensity score. The difference in overall survival was compared using the Cox model, whereas the differences in recurrence of endocarditis were evaluated using the Gray test. RESULTS: Overall, 4365 patients were diagnosed and operated on for IE from 2000 to 2021. Of these, 549, aged between 40 and 65 years, underwent AVR. A total of 268 (48.8%) received mechanical prostheses, and 281 (51.2%) received biological ones. A significant trend in the reduction of implantation of mechanical vs. biological prostheses was observed during the study period (p < 0.0001). Long-term survival was significantly higher among patients receiving a mechanical prosthesis than those receiving a biological prosthesis (hazard ratio [HR] 0.546, 95% CI: 0.322-0.926, p = 0.025). Mechanical prostheses were associated with significantly less recurrent endocarditis after AVR than biological prostheses (HR 0.268, 95%CI: 0.077-0.933, p = 0.039). CONCLUSIONS: The present analysis of the INFECT-REGISTRY shows increased survival and reduced recurrence of endocarditis after a mechanical aortic valve prosthesis implant for IE in middle-aged patients.
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Thoracic aortic aneurysms represent a potentially life-threatening disease with increasing prevalence, probably related to the increasing mean age of the global population; the complications of thoracic aortic aneurysms can show multiple modes of presentation in the acute phase based on various factors, including the involvement of the structures with which the aneurysm is in close anatomical relationship. With this case report we want to show how it is possible that a complicated ascending aortic aneurysm can mimic an acute pulmonary embolism/acute cor pulmonale in the acute phase; the earliest possible differential diagnosis between pulmonary embolism and acute aortic disease is of crucial importance due to the opposite implications that the treatment of these two diseases have.
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OBJECTIVES: We described clinical-epidemiological features of prosthetic valve endocarditis (PVE) and assessed the determinants of early surgical outcomes in multicentre design. METHODS: Data regarding 2823 patients undergoing surgery for endocarditis at 19 Italian Centers between 1979 and 2015 were collected in a database. Of them, 582 had PVE: in this group, the determinants of early mortality and complications were assessed, also taking into account the different chronological eras encompassed by the study. RESULTS: Overall hospital (30-day) mortality was 19.2% (112 patients). Postoperative complications of any type occurred in 256 patients (44%). Across 3 eras (1980-2000, 2001-08 and 2009-14), early mortality did not significantly change (20.4%, 17.1%, 20.5%, respectively, P = 0.60), whereas complication rate increased (18.5%, 38.2%, 52.8%, P < 0.001), consistent with increasing mean patient age (56 ± 14, 64 ± 15, 65 ± 14 years, respectively, P < 0.001) and median logistic EuroSCORE (14%, 21%, 23%, P = 0.025). Older age, female sex, preoperative serum creatinine >-2 mg/dl, chronic pulmonary disease, low ejection fraction, non-streptococcal aetiology, active endocarditis, preoperative intubation, preoperative shock and triple valve surgery were significantly associated with mortality. In multivariable analysis, age (OR = 1.02; P = 0.03), renal insufficiency (OR = 2.1; P = 0.05), triple valve surgery (OR = 6.9; P = 0.004) and shock (OR = 4.5; P < 0.001) were independently associated with mortality, while streptococcal aetiology, healed endocarditis and ejection fraction with survival. Adjusting for study era, preoperative shock (OR = 3; P < 0.001), Enterococcus (OR = 2.3; P = 0.01) and female sex (OR = 1.5; P = 0.03) independently predicted complications, whereas ejection fraction was protective. CONCLUSIONS: PVE surgery remains a high-risk one. The strongest predictors of early outcome of PVE surgery are related to patient's haemodynamic status and microbiological factors.
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Procedimentos Cirúrgicos Cardíacos/métodos , Endocardite Bacteriana/cirurgia , Próteses Valvulares Cardíacas/efeitos adversos , Infecções Relacionadas à Prótese/cirurgia , Sistema de Registros , Medição de Risco , Idoso , Endocardite Bacteriana/epidemiologia , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Infecções Relacionadas à Prótese/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de TempoAssuntos
Cardiopatias Congênitas , Doenças das Valvas Cardíacas , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral , Cardiopatias Congênitas/diagnóstico por imagem , Cardiopatias Congênitas/cirurgia , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/cirurgiaRESUMO
OBJECTIVE: To verify the rate of thromboembolic and hemorrhagic complications during the first 6 months after mitral valve repair and to assess whether the type of antithrombotic therapy influenced clinical outcome. METHODS: Retrospective data were retrieved from 19 centers. Inclusion criteria were isolated mitral valve repair with ring implantation. Exclusion criteria were ongoing or past atrial fibrillation and any combined intraoperative surgical procedures. The study cohort consisted of 1882 patients (aged 58 ± 15 years; 36% women), and included 1517 treated with an oral anticoagulant (VKA group) and 365 with antiplatelet drugs (APLT group). Primary efficacy outcome was the incidence of arterial thromboembolic events within 6 months and primary safety outcome was the incidence of major bleeding within 6 months. Propensity matching was performed to obtain 2 comparable cohorts (858 vs 286). RESULTS: No differences were detected for arterial embolic complications in matched cohort (1.6% VKA vs 2.1% APLT; P = .50). Conversely, patients in the APLT group showed lower incidence of major bleeding complications (3.9% vs 0.7%; P = .01). Six-month mortality rate was significantly higher in the VKA group (2.7% vs 0.3%; P = .02). Multivariable analysis in the matched cohort found VKA as independent predictor of major bleeding complications and mortality at 6 months. CONCLUSIONS: Vitamin K antagonist therapy was not superior to antiplatelet therapy to prevent thromboembolic complications after mitral valve repair. Our data suggest that oral anticoagulation may carry a higher bleeding risk compared with antiplatelet therapy, although these results should be confirmed in an adequately powered randomized controlled trial.
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Anticoagulantes/administração & dosagem , Implante de Prótese de Valva Cardíaca/efeitos adversos , Hemorragia/prevenção & controle , Insuficiência da Valva Mitral/cirurgia , Inibidores da Agregação Plaquetária/administração & dosagem , Tromboembolia/prevenção & controle , Administração Oral , Adulto , Fatores Etários , Idoso , Anticoagulantes/efeitos adversos , Estudos de Coortes , Bases de Dados Factuais , Feminino , Seguimentos , Implante de Prótese de Valva Cardíaca/métodos , Hemorragia/induzido quimicamente , Humanos , Injeções Subcutâneas , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico por imagem , Análise Multivariada , Inibidores da Agregação Plaquetária/efeitos adversos , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/prevenção & controle , Valor Preditivo dos Testes , Curva ROC , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Estatísticas não Paramétricas , Taxa de Sobrevida , Tromboembolia/tratamento farmacológico , Resultado do Tratamento , Ultrassonografia , Vitamina K/administração & dosagem , Vitamina K/antagonistas & inibidoresRESUMO
OBJECTIVES: The study objective was to evaluate the effects on early outcome and midterm survival of performing coronary artery bypass grafting with the off-pump technique in comparison with cardiopulmonary bypass (on-pump) in patients with preoperative anemia. METHODS: Consecutive adult anemic patients (preoperative hemoglobin <13.0 g/dL in men and <12.0 g/dL in women) resident in Puglia region who underwent isolated coronary artery bypass grafting between January 2011 and November 2013 were considered. Vital status was ascertained from the date of surgery to December 31, 2013. Odds ratio and hazard ratio (HR) were estimated. Propensity score methods were used to control for confounders. RESULTS: Of 939 anemic patients (234 female, aged 71 ± 9 years), 361 underwent operation with the off-pump technique and 578 underwent operation with the on-pump technique. Patients undergoing off-pump coronary artery bypass had a shorter intensive care unit length of stay, lower blood transfusion rate, and postoperative reduction in creatinine clearance. During a median follow-up of 18 months, 126 patients died: 46 in hospital (35 on-pump) and 80 after discharge (33 on-pump). In comparison with the off-pump technique, the on-pump technique had greater hospital mortality (odds ratio, 2.57; P = .028) and 30-day incidence of fatal events (HR, 2.67; P = .026). After a period without risk differences between groups (1-6 months; HR, 0.79; P = .618), a lower mortality in those undergoing the on-pump technique was detected (after 6 months HR, 0.35; P = .014). All results were confirmed in the 157 pairs of patients matched for propensity score, anemia grade, and surgery center. CONCLUSIONS: In patients with low levels of preoperative hemoglobin, off-pump coronary artery bypass was associated with lower early morbidity and mortality but a greater risk of mortality during follow-up compared with on-pump coronary artery bypass.
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Anemia/complicações , Ponte Cardiopulmonar , Ponte de Artéria Coronária sem Circulação Extracorpórea , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Idoso , Idoso de 80 Anos ou mais , Anemia/sangue , Anemia/diagnóstico , Anemia/mortalidade , Biomarcadores/sangue , Transfusão de Sangue , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/mortalidade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/mortalidade , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Feminino , Hemoglobinas/análise , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Itália , Estimativa de Kaplan-Meier , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Modelos de Riscos Proporcionais , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Little is known about ivabradine in cardiac rehabilitation in patients with coronary artery bypass graft (CABG). METHODS: In this prospective, randomized study, suitable patients admitted for cardiac rehabilitation after recent CABG were randomized to ivabradine 5 mg twice a day + standard medical therapy including bisoprolol 1.25 mg once daily (group I-BB, n = 38) or standard medical therapy including bisoprolol 2.5 to 3.75 mg once daily (group BB, n = 43). Patients were evaluated at admission, discharge, and 3 months. The primary end point was improvement in functional status, and other end points were improvement in diastolic function and recovery of systolic function. End points were assessed by distance covered in 6-minute walking test (6MWT), percentage with normal diastolic function, and percentage increase in left ventricular ejection fraction (LVEF). RESULTS: Cardiac rehabilitation improved functional capacity in both groups. In group BB, distances covered in the 6MWT at admission, discharge, and 3 months were 215 ± 53, 314 ± 32, and 347 ± 42 m, respectively. Corresponding distances in group I-BB were 180 ± 91, 311 ± 58, and 370 ± 55 m. Normal diastolic function was restored in I-BB patients, increasing from 24% at admission to 50% and 79% at discharge and 3 months; in BB patients, it decreased from 23% to 19% and 16%. The LVEF improved in I-BB patients, from 57% ± 3% at admission to 62% ± 4% at discharge and 66% ± 3% at 3 months, while remaining unchanged in BB patients (57% ± 3%, 59% ± 4%, and 59% ± 3%). CONCLUSION: Adding ivabradine to low-dose bisoprolol during cardiac rehabilitation in patients with CABG improved functional capacity, enhanced recovery of systolic function, and reduced diastolic dysfunction.
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Benzazepinas/uso terapêutico , Cardiotônicos/uso terapêutico , Ponte de Artéria Coronária/reabilitação , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Bisoprolol/uso terapêutico , Quimioterapia Combinada , Ecocardiografia , Determinação de Ponto Final , Feminino , Testes de Função Cardíaca , Humanos , Ivabradina , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Volume Sistólico , CaminhadaRESUMO
Floating thrombus in a non-aneurysmal and non-atherosclerotic thoracic aorta is a rare event with potentially catastrophic complications. Especially younger patients have a higher risk of embolization. Transesophageal echocardiography is the diagnostic method of choice. However, the treatment of this pathology is still controversial and includes both medical and surgical options. We report our experience with a 43-year-old patient and a review of the literature, and make a proposal for therapeutic interventions.
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Anticoagulantes/uso terapêutico , Doenças da Aorta/tratamento farmacológico , Heparina/uso terapêutico , Trombose/tratamento farmacológico , Varfarina/uso terapêutico , Adulto , Aorta Torácica , Doenças da Aorta/diagnóstico por imagem , Ecocardiografia Transesofagiana , Eletrocardiografia , Humanos , Masculino , Trombose/diagnóstico por imagemRESUMO
OBJECTIVE: Myocardial damage occurs after valve surgery, but its prognostic implication has not been evaluated. The aim of the present study was to assess the influence of myocardial damage on mortality and morbidity in patients undergoing aortic surgery (AVS) and mitral valve surgery (MVS). METHODS: In a prospective multicenter study from the cardiac surgery registry of the Puglia region, cardiac troponin I (cTnI) was measured immediately after and the morning after the intervention in consecutive patients undergoing AVS or MVS. The percentile ranks of the cTnI peak values within each center were analyzed. RESULTS: Of 965 patients (age, 67±12 years; 45.5% women), 579 had undergone AVS and 386 MVS. cTnI release was significantly greater in the MVS group than in the AVS group and in the nonsurvivors than in the survivors in both groups. The cTnI cutoff with the greatest sensitivity and specificity (60th percentile for AVS and 91st for MVS) in predicting hospital mortality (2.6%) was also associated with a greater rate of postoperative complications and mortality within 3 months postoperatively (multivariate hazard ratio, 3.38; P=.005). Compared with the reference model, which included the multivariate predictors of hospital mortality (active endocarditis, New York Heart Association class III-IV, left ventricular ejection fraction≤30%, and cardiopulmonary bypass duration), the addition of cTnI greater than the cutoffs showed significant improvement in model performance (likelihood ratio test, P=.009; net reclassification improvement, 0.751; P<.001; integrated discrimination improvement, 0.048; P=.002; c-index 0.832 vs 0.838). CONCLUSIONS: An elevated postoperative cTnI level was an independent risk factor for mortality and morbidity. Measurement of the cTnI level improved the risk reclassification of patients undergoing AVS or MVS.
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Valva Aórtica/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cardiopatias/etiologia , Doenças das Valvas Cardíacas/cirurgia , Valva Mitral/cirurgia , Miocárdio/patologia , Idoso , Biomarcadores/sangue , Procedimentos Cirúrgicos Cardíacos/mortalidade , Distribuição de Qui-Quadrado , Intervalo Livre de Doença , Feminino , Cardiopatias/sangue , Cardiopatias/mortalidade , Cardiopatias/patologia , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/mortalidade , Mortalidade Hospitalar , Humanos , Itália , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Miocárdio/metabolismo , Razão de Chances , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Troponina I/sangueRESUMO
BACKGROUND: Acute Kidney Injury (AKI) after cardiac surgery is a complication influencing postoperative outcome. Preoperative hemoglobin is a predictor of postoperative AKI. We aimed to identify preoperative predictors of Renal Replacement Therapy (RRT) and to develop a new risk-scoring system including hemoglobin to better stratify the risk of events. METHODS: We evaluated 3288 consecutive patients of the Regional Cardiac Surgery Registry of Puglia operated in 2011-2012. Chronic dialysis and renal transplantation patients were excluded. Primary outcome was post-operative RRT incidence. RESULTS: The study sample was divided in two cohorts: 1642 patients (70 RRT) operated during the year 2011 as derivation cohort and 1646 patients (69 RRT) of the year 2012 as validation. In a multivariable logistic regression model using a stepwise method, six preoperative risk factors were associated with RRT in the derivation cohort: creatinine clearance, preoperative hemoglobin, neurological dysfunction, left ventricular ejection fraction, urgency and combined procedures (discrimination c-index 0.844 and 0.818 in the validation cohort). Scoring system included risk factors obtained from derivation cohort adjusting their relative weight with updated rounded coefficients in the validation cohort: creatinine clearance<50ml/min (1 point), hemoglobin≤12.5g/dl (1 point), left ventricular ejection fraction≤30% (1 point), urgent operation (1 point), emergency-salvage surgery (2 points), and combined procedures (1 point). In both cohorts, outcomes were strongly correlated with score points. CONCLUSIONS: Our simple bedside prognostic score demonstrates good performance in predicting RRT. Hemoglobin plays an important role and future studies will clarify if preoperative anemia correction will lead to decreased RRT risk.
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Ponte Cardiopulmonar/efeitos adversos , Hemoglobinas/metabolismo , Complicações Pós-Operatórias/sangue , Sistema de Registros , Terapia de Substituição Renal , Índice de Gravidade de Doença , Idoso , Idoso de 80 Anos ou mais , Ponte Cardiopulmonar/tendências , Estudos de Coortes , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Valor Preditivo dos Testes , Estudos Prospectivos , Terapia de Substituição Renal/tendênciasRESUMO
BACKGROUND: Anemia is a risk factor for adverse events after cardiac operations. We evaluated the incremental value of preoperative anemia over the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II to predict hospital death after cardiac operations. METHODS: Data for 4,594 consecutive adults (1,548 women [33.7%]), aged 67 ± 11 years, who underwent cardiac operations from January 2011 to July 2013 were extracted from the Regional Cardiac Surgery Registry of Puglia. The last preoperative hemoglobin value was used, according to World Health Organization criteria, to classify anemia as mild (hemoglobin 11.0 to 12.9 g/dL in men and 11.0 to 11.9 g/dL in women) in 1,021 patients (22.2%) and as moderate to severe (hemoglobin <11.0 g/dL) in 593 patients (12.9%). The EuroSCORE II was used to evaluate predicted hospital death after operations. Logistic regression analysis for in-hospital death was performed including EuroSCORE II risk factors and anemia, with model discrimination quantified by C statistic and risk classification by the use of net reclassification improvement (NRI). RESULTS: Overall expected and observed mortality rates were 4.4% and 5.9%. Anemia was significantly associated with a mortality rate of 3.4% in patients without anemia, 7.7% in mild anemia, and 15.7% in moderate to severe anemia (p < 0.001) and also at multivariate analysis correcting for EuroSCORE II (p < 0.001). When anemia was analyzed with EuroSCORE II, the model improved in discrimination (C statistic = 0.852 vs 0.860; p = 0.007) and reclassification (category free-NRI, 0.592; p < 0.001), preserving the calibration with good concordance between predicted probabilities and outcome. CONCLUSIONS: Preoperative anemia has strong association with operative death in cardiac surgical patients. Anemia provides significant incremental value over the EuroSCORE II and should be considered for assessment of cardiac surgical risk.
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Anemia/complicações , Procedimentos Cirúrgicos Cardíacos/mortalidade , Mortalidade Hospitalar , Modelos Estatísticos , Medição de Risco/métodos , Idoso , Feminino , Humanos , Masculino , Estudos ProspectivosRESUMO
OBJECTIVES: To evaluate performance of the European System for Cardiac Operation Risk Evaluation (EuroSCORE II), to assess the influence of model updating and to derive a hierarchical tree for modelling the relationship between EuroSCORE II risk factors and hospital mortality after cardiac surgery in a large prospective contemporary cohort of consecutive adult patients. METHODS: Data on consecutive patients, who underwent on-pump cardiac surgery or off-pump coronary artery bypass graft intervention, were retrieved from Puglia Adult Cardiac Surgery Registry. Discrimination, calibration, re-estimation of EuroSCORE II coefficients and hierarchical tree analysis of risk factors were assessed. RESULTS: Out 6293 procedures, 6191 (98.4%) had complete data for EuroSCORE II assessment with a hospital mortality rate of 4.85% and EuroSCORE II of 4.40 ± 7.04%. The area under the receiver operator characteristic curve (0.830) showed good discriminative ability of EuroSCORE II in distinguishing patients who died and those who survived. Calibration of EuroSCORE II was preserved with lower predicted than observed risk in the highest EuroSCORE II deciles. At logistic regression analysis, the complete revision of the model had most of re-estimated regression coefficients not statistically different from those in the original EuroSCORE II model. When missing values were replaced with the mean EuroSCORE II value according to urgency and weight of intervention, the risk score confirmed discrimination and calibration obtained over the entire sample. A recursive tree-building algorithm of EuroSCORE II variables identified three large groups (55.1, 17.1 and 18.1% of procedures) with low-to-moderate risk (observed mortality of 1.5, 3.2 and 6.4%) and two groups (3.8 and 5.9% of procedures) at high risk (mortality of 14.6 and 32.2%). Patients with low-to-moderate risk had good agreement between observed events and predicted frequencies by EuroSCORE II, whereas those at greater risk showed an underestimation of expected mortality. CONCLUSIONS: This study demonstrates that EuroSCORE II is a good predictor of hospital mortality after cardiac surgery in an external validation cohort of contemporary patients from a multicentre prospective regional registry. The EuroSCORE II predicts hospital mortality with a slight underestimation in high-risk patients that should be further and better evaluated. The EuroSCORE II variables as a risk tree provides clinicians and surgeons a practical bedside tool for mortality risk stratification of patients at low, intermediate and high risk for hospital mortality after cardiac surgery.
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Procedimentos Cirúrgicos Cardíacos/mortalidade , Idoso , Feminino , Indicadores Básicos de Saúde , Mortalidade Hospitalar , Humanos , Itália/epidemiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Estudos Prospectivos , Sistema de Registros , Medição de Risco , Análise de SobrevidaRESUMO
AIMS: To evaluate the feasibility of a cardiac surgery registry and to describe patients' characteristics, type of procedures performed, incidence of postoperative complications with short and middle-term mortality. METHODS: A database with clinical information and details on cardiac surgical operations was implemented by Puglia Health Regional Agency to collect data of each cardiac surgery procedure performed in the seven adult cardiac surgery centres of the region. Health regional agency personnel guaranteed data accuracy and quality control procedures. Mortality after the discharge was evaluated for residents in Puglia by linking clinical data to the Health Information System. RESULTS: From January 2011 to December 2012, 6429 operations were performed. All operations were included in the registry with very high completeness of collected data (95.3% per patient). The majority of the operations performed were coronary artery bypass graft alone (41.1%), valve surgery alone (26.2%), coronary artery bypass graft and valve surgery (11.4%), or valve with other surgery (11.8%). During a median follow-up of 12 months (interquartile range 6-18 months), 211 deaths were detected after the discharge. Overall, cumulative mortality from the operation was 8.2% at 6 months and 9.5% at 12 months. CONCLUSION: Implementation of a regional clinical registry of cardiac surgery is feasible with a great level of accuracy and the evaluation of mid-term mortality overcomes the limited value of hospital mortality. An accurate cardiac surgery registry elicits epidemiologic evaluations, comparisons between expected and observed mortality, incidence of postoperative complications and encourages a reliable public reporting.