Do women benefit more than men from off-pump coronary artery bypass grafting?

OBJECTIVES: Outcomes after coronary artery bypass grafting (CABG) are worse in women than in men. This study aims to investigate whether off-pump coronary artery bypass (OPCAB) surgery improves the outcomes in women by comparing different outcome measures in both genders. METHODS: Patients who underwent isolated CABG, either on-pump (ONCAB) or OPCAB, between January 1998 and June 2017 were included. Primary endpoints were 30-day and 120-day mortality. Logistic regression models were constructed to evaluate the effect of the CABG technique on important outcomes such as mortality and the need for blood transfusion. RESULTS: The data of 17,052 patients were analysed, 3,684 of whom were women (414 OPCAB) and 13,368 men (1,483 OPCAB). The mean number of grafts was lower in the OPCAB group of both genders (p < 0.001). Postoperatively, both men and women undergoing OPCAB surgery received fewer red blood cell transfusions (p < 0.001) and had higher postoperative haemoglobin levels (p < 0.001) than those undergoing ONCAB. Early mortality occurred less frequently after OPCAB surgery in both genders, although the difference was not significant. However, 120-day mortality was significantly lower after OPCAB surgery in women, even after correction for preoperative risk factors [odds ratio (OR) = 0.356, 95% confidence interval (CI) 0.144-0.882, p = 0.026]. The difference in 120-day mortality was not significant in men (OR = 0.787, 95% CI 0.498-1.246, p = 0.307). CONCLUSIONS: Women undergoing CABG benefit more from OPCAB surgery than from ONCAB surgery in terms of 120-day mortality. This difference was not found in men in our patient population.

The Hemodynamic Effects of Different Pacing Modalities After Cardiopulmonary Bypass in Patients With Reduced Left Ventricular Function.

OBJECTIVES: Patients with decreased left ventricular function undergoing cardiac surgery have a greater chance of difficult weaning from cardiopulmonary bypass and a poorer clinical outcome. Directly after weaning, interventricular dyssynchrony, paradoxical septal motion, and even temporary bundle-branch block might be observed. In this study, the authors measured arterial dP/dtmax, mean arterial pressure (MAP), and cardiac index using transpulmonary thermodilution, pulse contour analysis, and femoral artery catheter and compared the effects between right ventricular (A-RV) and biventricular (A-BiV) pacing on these parameters. DESIGN: Prospective study. SETTING: Single-center study. PARTICIPANTS: The study comprised 17 patients with a normal or prolonged QRS duration and a left ventricular ejection fraction ≤35% who underwent coronary artery bypass grafting with or without valve replacement. INTERVENTIONS: Temporary pacing wires were placed on the right atrium and both ventricles. Different pacing modalities were used in a standardized order. MEASUREMENTS AND MAIN RESULTS: A-BiV pacing compared with A-RV pacing demonstrated higher arterial dP/dtmax values (846 ± 646 mmHg/s v 800 ± 587 mmHg/s, p = 0.023) and higher MAP values (77 ± 19 mmHg v 71 ± 18 mmHg, p = 0.036). CONCLUSION: In patients with preoperative decreased left ventricular function undergoing coronary artery bypass grafting, A-BiV pacing improve the arterial dP/dtmax and MAP in patients with both normal and prolonged QRS duration compared with standard A-RV pacing. In addition, arterial dP/dtmax and MAP can be used to evaluate the effect of intraoperative pacing. In contrast to previous studies using more invasive techniques, transpulmonary thermodilution is easy to apply in the perioperative clinical setting.

Is there an alternative treatment for patients intolerant to antiplatelet therapy if percutaneous left atrial appendage closure is considered?

INTRODUCTION: Left atrial appendage (LAA) closure has become of major interest for patients with atrial fibrillation intolerant to oral anticoagulation therapy (OAC). Patients with a contraindication to both OAC and antiplatelet therapy are not eligible for percutaneous LAA closure. We aimed to find an alternative treatment for these specific patients. METHODS: From March 2014 until December 2015 five patients were referred for percutaneous LAA closure. Alternative treatment was necessary due to an absolute contraindication to OAC and antiplatelet therapy (n = 4) or after previous failed percutaneous device implantation (n = 1). A stand-alone full thoracoscopic closure of the LAA using the Atriclip PRO device (AtriCure Inc., Dayton, OH, USA) was performed under guidance of transoesophageal echocardiography (TEE). After three months all patients underwent a computed tomography scan. Mean follow-up was 7.2 months [range 4.5-9.8 months]. RESULTS: All procedures were achieved without the occurrence of complications. Complete LAA closure was obtained in all patients without any residual flow confirmed by TEE. Postoperative computed tomography confirmed persisting adequate clip positioning with complete LAA closure and absence of intracardial thrombi. During follow-up no thromboembolic events occurred. CONCLUSION: For atrial fibrillation patients with an absolute contraindication to OAC and antiplatelet therapy a stand-alone, minimally invasive thoracoscopic closure of the LAA is a safe and feasible alternative treatment. This might be a solution to avoid serious bleeding complications while eliminating the thromboembolic risk originating from the LAA in patients who are not eligible for percutaneous LAA closure.

Intermittent warm blood versus cold crystalloid cardioplegia for myocardial protection: a propensity score-matched analysis of 12-year single-center experience.

OBJECTIVES: This study analyzes the efficacy in myocardial protection of two types of cardioplegia solutions, namely, blood and crystalloid cardioplegia, both given intermittently in patients undergoing coronary artery bypass grafting (CABG). METHODS: Adult patients undergoing primary isolated coronary artery bypass grafting between January 1998 and January 2011 with cardiopulmonary bypass, using either blood or crystalloid cardioplegia, were identified in our database. Propensity score matching was performed to create comparable patient groups. Multivariate logistic regression analysis was performed to identify independent risk factors for perioperative myocardial damage. The primary endpoint of the study was the maximum creatine kinase-MB (CK-MB) value within 5 days postoperatively with a cut-off point of 100 U/L. Early mortality and perioperative low cardiac output syndrome in both groups were compared. RESULTS: The study included 7138 CABG patients: 3369 patients using crystalloid cardioplegia and 3769 using blood cardioplegia. After propensity score matching, 2585 patients per study group remained for the analysis. Wilcoxon signed-rank test revealed significantly higher CK-MB levels in patients operated with the use of blood cardioplegia. Multivariate regression analysis identified blood cardioplegia as an independent risk factor for elevated CK-MB levels. However, it was associated with lower aspartate aminotransferase (AST) levels. The type of cardioplegia had no influence on early mortality, postoperative low cardiac output syndrome or intensive care unit stay. CONCLUSIONS: Blood cardioplegia was identified as an independent risk factor for elevated levels of CK-MB after CABG, but was associated with lower AST levels. The authors conclude that the type of cardioplegia had no significant influence on clinical outcome.

Reducing the immediate availability of red blood cells in cardiac surgery, a single-centre experience.

BACKGROUND: In our institution, we have redefined our criteria for direct availability of red blood cell (RBC) units in the operation room. In this study, we sought to evaluate the safety of applying this new logistical policy of blood transfusion in the first preliminary group of patients. METHODS: In March 2010, we started a new policy concerning the elective availability of RBC units in the operation room. This policy was called: No Elective Red Cells (NERC) program. The program was applied for patients undergoing primary isolated coronary artery bypass grafting (CABG) or single valve surgery. No elective RBC units were preoperatively ordered for these patients. In case of urgent need, blood was delivered to the operating room within 20 min. The present study includes the first 500 patients who were managed according to this policy. Logistic regression analyses were performed to investigate the impact of biomedical variables on fulfilling this NERC program. RESULTS: The majority of patients (n = 409, 81 %) did not receive any RBCs during the hospital stay. In patients who did receive RBCs (n = 91, 19 %), 11 patients (2.2 %) received RBCs after 24 h postoperatively. Female gender, left ventricular ejection fraction (LVEF) and EuroSCORE were significant predictors for the need of blood transfusion (OR = 3.12; 2.79; 1.17 respectively). CONCLUSION: In a selected group of patients, it is safe to perform cardiac surgery without the immediate availability of RBCs in the operating room. Transfusion was avoided in 81 % of these patients. Female gender, LVEF and EuroSCORE were associated with blood transfusion.

Evolution of cerebral perfusion techniques in type a aortic dissection surgery: a single center experience.

BACKGROUND: The purpose of this study was to investigate the effect of using antegrade selective cerebral perfusion (ASCP) with moderate hypothermia on hospital mortality after surgery for acute type A aortic dissection (AAAD). METHODS: Between January 1998 and December 2008, 142 consecutive patients were operated on for AAAD. Patients were divided into two subgroups: the cohort of patients operated on from January 1998 until December 2003 (without ASCP) (P1998-2003, n=64) and the cohort operated on from January 2004 until December 2008 (with ASCP)(P2004-2008, n=78). RESULTS: The difference in hospital mortality was statistically significant (P1998-2003: 42.2%; P2004-2008: 14.1%, p<0.0005). Survival rates were 51.6±6.2% vs. 75.1±5.5% and 45.9±6.2% vs. 69.7±7.3% for one and four years, respectively (p=0.001). Multivariate logistic regression analysis revealed that ASCP was the only independent protective factor of hospital mortality (p=0.047). CONCLUSION: In patients operated on for AAAD, antegrade selective cerebral perfusion with moderate hypothermia is a significant factor in decreasing hospital mortality.

[How to diagnose infective endocarditis?] / Hoe herken je infectieuze endocarditis?

We report on three patients with infective endocarditis, which differ greatly in clinical manifestations. Infective endocarditis (IE) is defined by, a mostly bacterial, infection of a native or prosthetic heart valve, the endocardial surface or a cardiac device. It is a rare condition, but it's incidence is increasing because of an increased incidence of elderly patients with chronic disease and cardiac devices. IE is heterogeneous in aetiology, clinical manifestations, and course. It can involve almost any organ system. The presentation often remains subtle and varies with nonspecific symptoms ranging from a mild infection to septic shock and multiorgan failure. IE remains a highly mortal disease, since the diagnosis is missed often. A thorough anamnesis and physical examination can be helpful. Blood cultures prior to antibiotics and echocardiography are key diagnostic steps if there's a clinical suspicion of IE.

Vascular complications of Q-fever infections.

INTRODUCTION: Coxiella burnetii is a strict intracellular pathogen causing Q fever, a worldwide zoonosis with an extensive animal reservoir. Chronic Q fever infections are frequently associated with cardiovascular complications, mainly endocarditis, and also aortic aneurysms and vascular-graft infection. We present four cases of chronic Q fever infections and associated vascular complications, and review the literature to identify major symptoms and assess the prevalence, treatment and outcome in these challenging patients. MATERIALS AND METHODS: The demographic and clinical data of four patients presenting at our unit were analysed. PubMed was searched to identify articles describing patients with chronic Q-fever-associated vascular complications. RESULTS: Combining our own with the published experience, 58 cases (49 male) of chronic Q-fever-associated vascular complications were identified. The average age of the patients was 64 years (range: 30-83 years). As many as 26 patients had vascular graft infections (25 Dacron/polytetrafluoroethylene (PTFE), one homograft) and 32 had infected aneurysms. The majority of these patients presented with fever (n = 40) and/or pain (n = 43). Weight loss and fatigue were seen in 25 and 14 patients, respectively. Aneurysm rupture, aorto-enteric fistulae and lower-limb embolisation were seen in nine, four and four patients, respectively. Concurrent endocarditis was seen in two patients, whereas, for 15 cases, this information was not available. Patients were treated with antibiotics for an average of 23 months (range 1-54 months). Treatment of infected vascular segments was described in 50 patients. Ten patients were treated conservatively whilst 40 underwent resection of the infected vessel and reconstruction with a graft. Major surgical complications (graft infection, n = 3;aorto-enteric fistula, n = 2; bleeding, n = 1; anastomotic leakage, n = 1; aortic dissection, n = 1; vertebral osteomyelitis, n = 3; graft thrombosis, n = 1; renal failure, n = 2; and pneumonia, n = 1) were reported in 11 cases (21%) and were not specified in 13. The overall mortality was 24% (14/58). Seven (18%) surgically treated patients died. Six of them died within 6 months of surgery and one patient at 3 years' follow-up. Seven out of 10 of the conservatively treated patients died within 3 years of diagnosis. CONCLUSION: Aneurysms associated with Q-fever infections tend to be complicated, requiring challenging surgical corrections, and long-term antibiotic treatment. Major complications and mortality rates are significant, especially in conservatively treated patients.

Surgical treatment of a chronic postmyocardial infarction ventricular septal rupture.

The development of a postmyocardial infarction ventricular septal rupture is an uncommon but frequently fatal complication. Mortality with medical treatment only is extremely high. Septal rupture results in a left-to-right shunt, with right ventricular volume overload, increased pulmonary blood flow, and secondary volume overload of the left atrium and ventricle.  Surgical treatment consists of excluding rather than excising the infarcted septum and ventricular walls. This is accomplished by performance of a left ventriculotomy through the infarcted muscle and securing a glutaraldehyde-fixed bovine pericardium patch to the endocardium of the left ventricle all around the infarcted myocardium.

[Acute right heart failure due to aortic aneurysm: 2 patients with an aortocaval shunt]. / Acute rechtsdecompensatie bij een aneurysma aortae door een links-rechtsshunt.

Two patients, a 72-year-old man and a 34-year-old woman, presented with severe pain in the lower back and abdomen, respectively, accompanied by acute dyspnoea. One patient presented additionally with a palpable pulsatile abdominal mass and a continuous harsh bruit. He subsequently developed massive haemoptysis and went into deep shock. The second patient presented with peripheral cyanosis and a loud systolic heart murmur. She developed increasing respiratory distress and was maximally supported in the intensive care unit. Further investigation revealed acute left-to-right shunting based on rupture of an aortic aneurysm into the venous system in both patients; in the first this was into the V. cava inferior and in the second this was into the right atrium. In both patients, high-output heart failure was present. Acute right heart failure due to a fistula between the aorta and the venous system is a life-threatening and rapidly worsening haemodynamic disturbance. The diagnosis is not difficult but the condition is rare. In some cases, the patient's survival can be achieved by prompt diagnosis followed by operative closure of the fistula.

Clinical outcome of the PAS-Port® proximal anastomosis system in off-pump coronary artery bypass grafting in 201 patients.

AIM: The PAS-Port® Proximal Anastomosis System (Cardica, Inc, Redwood City, CA, USA) has been used worldwide since March 2003. The objective of the present study was to evaluate the clinical outcome of the PAS-Port® Proximal Anastomosis System. METHODS: All the patients who underwent off-pump coronary artery bypass grafting in the Catharina Hospital Eindhoven between August 2006 and April 2010 were included in a non-randomized retrospective case-control study, if they had at least one proximal vein graft anastomosis. Study end-points consisted of overall survival, coronary reintervention and postoperative stroke. RESULTS: The study included 312 patients (201 cases, 111 controls). After 36 months of follow-up there was no difference in survival between cases and controls (92.2% vs. 93.7%, P=0.52). No significant difference could be detected between cases and controls with respect to overall coronary reintervention-free survival (93% vs. 96.4%, P=0.20) and freedom from coronary reintervention due to proximal vein graft failure (98% vs. 100% P=0.14). The use of the PAS-Port system could not be identified as an independent risk factor of coronary reintervention (p=0.21). Postoperative stroke rates of cases and controls (2% vs. 0.9%, P=0.42) were comparable. CONCLUSION: The clinical outcomes in patients treated with the PAS-Port® Proximal Anastomosis System were satisfactory compared with those treated with the conventional hand-sewing technique. The use of the PAS-Port system was not associated with higher adverse outcome in terms of overall survival, stroke, coronary reintervention-free survival and freedom from reintervention due to proximal vein graft failure.

Impact of temperature and atmospheric pressure on the incidence of major acute cardiovascular events.

BACKGROUND: The impact of meteorological conditions on the occurrence of various cardiovascular events has been reported internationally. Data about the Dutch situation are limited. OBJECTIVES: We sought to find out a correlation between weather conditions and the incidence of major acute cardiovascular events such as type A acute aortic dissection (AAD), acute myocardial infarction (AMI) and acutely presented abdominal aortic aneurysms (AAAA). METHODS: Between January 1998 and February 2010, patients who were admitted to our hospital (Catharina Hospital, Eindhoven, the Netherlands) because of AAD (n = 212), AMI (n = 11389) or AAAA (n = 1594) were registered. These data were correlated with the meteorological data provided by the Royal Dutch Meteorological Institute (KNMI) over the same period. RESULTS: During the study period, a total number of 11,412 patients were admitted with AMI, 212 patients with AAD and 1593 patients with AAAA. A significant correlation was found between the daily temperature and the number of hospital admissions for AAD. The lower the daily temperature, the higher the incidence of AAD (p = 0.002). Lower temperature was also a predictor of a higher incidence of AMI (p = 0.02). No significant correlation was found between daily temperature and onset of AAAA. CONCLUSIONS: Cold weather is correlated with a higher incidence of AAD and AMI.

Inability to ventilate after tube exchange postoperative to pneumonectomy.

We report a case of inability to ventilate a patient after completion of pneumonectomy, due to migrated tumor tissue to the contralateral side. This represents an unusual complication with a high mortality rate. We have managed to find the cause in time and were able to remove the obstructive tissue using bronchoscopy.

Which method of estimating renal function is the best predictor of mortality after coronary artery bypass grafting?

OBJECTIVES: Definitions of renal function in patients undergoing coronary artery bypass graft surgery (CABG) vary in the literature. We sought to investigate which method of estimating renal function is the best predictor of mortality after CABG. METHODS: We analysed the preoperative and postoperative renal function data from all patients undergoing isolated CABG from January 1998 through December 2007. Preoperative and postoperative renal function was estimated using serum creatinine (SeCr) levels, creatinine clearance (CrCl) determined by the Cockcroft-Gault formula and the glomerular filtration rate (e-GFR) estimated by the Modification of Diet in Renal Disease (MDRD) formula. Receiver operator characteristic (ROC) curves and area under the ROC curves were calculated. RESULTS: In 9987 patients, CrCl had the best discriminatory power to predict early as well as late mortality, followed by e-GFR and finally SeCr. The odds ratios for preoperative parameters for early mortality were closer to 1 than those of the postoperative parameters. CONCLUSIONS: Renal function determined by the Cockcroft-Gault formula is the best predictor of early and late mortality after CABG. The relationship between renal function and mortality is non-linear. Renal function as a variable in risk scoring systems such as the EuroSCORE needs to be reconsidered.

Evaluation of the EuroSCORE risk scoring model for patients undergoing coronary artery bypass graft surgery: a word of caution.

Background. Risk-adjusted mortality rates are used to compare quality of care of different hospitals. We evaluated the EuroSCORE (European System for Cardiac Operative Risk Evaluation) in patients undergoing isolated coronary artery bypass grafting (CABG).Patients and method. Data of all CABG patients from January 2004 until December 2008 were analysed. Receiver-operating characteristics (ROC) curves for the additive and logistic EuroSCOREs and the areas under the ROC curve were calculated. Predicted probability of hospital mortality was calculated using logistic regression analyses and compared with the EuroSCORE. Cumulative sum (CUSUM) analyses were performed for the EuroSCORE and the actual hospital mortality.Results. 5249 patients underwent CABG of which 89 (1.7%) died. The mean additive EuroSCORE was 3.5+/-2.5 (0-17) (median 3.0) and the mean logistic EuroSCORE was 4.0+/-5.5 (0-73) (median 2.4). The area under the ROC curve was 0.80+/-0.02 (95% confidence interval (CI) 0.76 to 0.84) for the additive and 0.81+/-0.02 (0.77 to 0.85) for the logistic EuroSCORE. The predicted probability (hazard ratio) was different from the additive and logistic EuroSCOREs. The hospital mortality was half of the EuroSCOREs, resulting in positive variable life-adjusted display curves. Conclusions. Both the additive and logistic EuroSCOREs are overestimating the in-hospital mortality risk in low-risk CABG patients. The logistic EuroSCORE is more accurate in high-risk patients compared with the additive EuroSCORE. Until a more accurate risk scoring system is available, we suggest being careful when comparing the quality of care of different centres based on risk-adjusted mortality rates. (Neth Heart J 2010;18:355-9.).