Risk comparison of bleeding and ischemic perioperative complications after acute and elective orthopedic surgery in patients with cardiovascular disease.

INTRODUCTION: The study objective was to ascertain the incidence of bleeding and ischemic complications related to acute and planned orthopedic surgery in patients with known cardiovascular diseases. MATERIALS AND METHODS: The study conducted between 2010 and 2013 enrolled 477 patients (289 women, 188 men) with a diagnosed cardiovascular disease or a history of thromboembolic event. Aside from gender, age, height and weight, the study observed other anamnestic data and perioperative laboratory test results that may impact on a bleeding or ischemic event. RESULTS: Two hundred seventy-two (57 %) patients had acute surgery, and 205 (43 %) patients had elective surgery. Complications arose in 55 (11.6 %) patients, 32 (6.9 %) had bleeding complications, 19 (4.0 %) ischemic complications, and both complications were experienced by 4 (0.8 %) patients. Bleeding developed in 14 (5.1 %) patients who had acute surgery, and in 22 (10.7 %) who had elective surgery. Twenty-two (8.1 %) patients having acute surgery and one (0.1 %) undergoing elective surgery suffered from ischemic complications. The incidence of bleeding complications was significantly higher in elective surgery (p = 0.026, OR 2.22), and when adjusted (general anaesthesia, gender, and use of warfarin), the difference was even higher (p = 0.015, OR 2.44), whereas the occurrence of ischemic complications was significantly higher in acute surgery (p = 0.005, OR 18.0), and when adjusted (age), the difference remained significant (p = 0.044, OR 8.3). CONCLUSIONS: The study noted a significantly higher incidence of bleeding complications in elective orthopedic surgery when compared with acute surgery. Conversely, the incidence of ischemic complications was significantly higher in patients having acute orthopedic surgery when compared with those operated on electively.

THA and TKA in patients with cardiovascular disease: What makes the risk of perioperative bleeding?

Backround: The purpose of the study was to ascertain the incidence of bleeding and ischaemic complications in patients with cardiac disease after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: In total, 477 patients (289 women, 188 men) with known history of cardiac disease or thromboembolic disease treated with surgery in 2010-2013, were enrolled in the study. Perioperative prevention of thromboembolic disease using low-molecular-weight heparins was applied in all the patients. The data that could have an impact on the development of monitored perioperative complications, were observed. RESULTS: Complications occurred in 55 (11.6 %) patients: bleeding complications in 32, ischaemic in 19, and both in four patients. Complications were found in 13 (12.0 %) patients after THA and in 6 (9.5 %) patients after TKA. Bleeding complications were observed in 17 patients after THA and TKA, ischaemic in one, and both simultaneously in one patient.Bleeding complications occurred insignificantly more frequently after THA and TKA (p = 0.094); however, this difference was statistically significant after adjustment for risk factors (p = 0.003). On the contrary, ischaemic complications were significantly more frequent after other skeletal surgeries (p = 0.014). Nevertheless, this difference was not statistically significant after the adjustment (p = 0.880). The comparison of the risk of complications in patients after THA with that in patients after TKA showed no significant difference (p = 0.580). CONCLUSION: The study showed a significantly higher incidence of bleeding complications in patients after THA and TKA compared to other surgeries of the musculoskeletal system in patients with a history of cardiac disease. Bleeding complications cannot be detected in advance (Tab. 1, Ref. 16).

Perioperative cardiovascular complications versus perioperative bleeding in consecutive patients with known cardiac disease undergoing non-cardiac surgery. Focus on antithrombotic medication. The PRAGUE-14 registry.

BACKGROUND: Interruption of antithrombotic treatment before surgery may prevent bleeding, but at the price of increasing cardiovascular complications. This prospective study analysed the impact of antithrombotic therapy interruption on outcomes in non-selected surgical patients with known cardiovascular disease (CVD). METHODS: All 1200 consecutive patients (age 74.2 ± 10.2 years) undergoing major non-cardiac surgery (37.4 % acute, 61.4 % elective) during a period of 2.5 years while having at least one CVD were enrolled. Details on medication, bleeding, cardiovascular complications and cause of death were registered. RESULTS: In-hospital mortality was 3.9 % (versus 0.9 % mortality among 17,740 patients without CVD). Cardiovascular complications occurred in 91 (7.6 %) patients (with 37.4 % case fatality). Perioperative bleeding occurred in 160 (13.3 %) patients and was fatal in 2 (1.2 % case fatality). Multivariate analysis revealed age, preoperative anaemia, history of chronic heart failure, acute surgery and general anaesthesia predictive of cardiovascular complications. For bleeding complications multivariate analysis found warfarin use in the last 3 days, history of hypertension and general anaesthesia as independent predictive factors. Aspirin interruption before surgery was not predictive for either cardiovascular or for bleeding complications. CONCLUSIONS: Perioperative cardiovascular complications in these high-risk elderly all-comer surgical patients with known cardiovascular disease are relatively rare, but once they occur, the case fatality is high. Perioperative bleeding complications are more frequent, but their case fatality is extremely low. Patterns of interruption of chronic aspirin therapy before major non-cardiac surgery are not predictive for perioperative complications (neither cardiovascular, nor bleeding). Simple baseline clinical factors are better predictors of outcomes than antithrombotic drug interruption patterns.

Why we are not able to find the coronary heart disease gene - apoE as an example.

The apoprotein E gene ranks among the most discussed candidate genes for cardiovascular disease. We studied whether the association between apoprotein E gene polymorphism and manifestation of acute coronary syndrome is modulated by the presence/absence of traditional cardiovascular risk factors. The population under study were 1066 patients (men under 65 years) admitted between 2006- 2009 to five coronary care units in Prague (GENetic DEtermination of Myocardial Infarction in Prague) and the control population (1066 age-matched men selected from the Czech population sample). The frequency of disadvantage genotype E4+ was significantly higher (P < 0.01) in acute coronary syndrome patients (22.38 %) than in controls (16.76 %). When the acute coronary syndrome group was step by step limited to non-smokers, non-diabetics and normotensive individuals, the odds ratio displayed a gradual increase from 1.35 (for the entire group) through 1.48 (non-smokers), 1.53 (non-smokers+non-diabetics) to 1.71 (non-smokers+non-diabetics+normotensives). The effect of the apoprotein E gene on the individual risk of acute coronary syndrome is nonhomogenous within the patient groups. This association of apoprotein E gene with acute coronary syndrome is strongly modified by the presence/absence of traditional cardiovascular factors of atherosclerosis in a high-risk Czech population.

One-day kinetics of myocardial engraftment after intracoronary injection of bone marrow mononuclear cells in patients with acute and chronic myocardial infarction.

OBJECTIVE: To investigate the kinetics of myocardial engraftment of bone marrow-derived mononuclear cells (BMNCs) after intracoronary injection using 99mTc-d,l-hexamethylpropylene amine oxime (99mTc-HMPAO) nuclear imaging in patients with acute and chronic anterior myocardial infarction. DESIGN: Nuclear imaging-derived tracking of BMNCs at 2 and 20 h after injection in the left anterior descending (LAD) coronary artery. SETTING: Academical cardiocentre. PATIENTS: Five patients with acute (mean (SD) age 58 (11) years; ejection fraction range 33-45%) and five patients with chronic (mean (SD) age 50 (6) years; ejection fraction range 28-34%) anterior myocardial infarction. INTERVENTIONS: A total of 24.2 x 10(8)-57.0 x 10(8) BMNCs (20% labelled with 700-1000 MBq 99mTc-HMPAO) were injected in the LAD coronary artery. RESULTS: At 2 h after BMNC injection, myocardial activity was observed in all patients with acute (range 1.31-5.10%) and in all but one patient with chronic infarction (range 1.10-3.0%). At 20 h, myocardial engraftment was noted only in three patients with acute myocardial infarction, whereas no myocardial activity was noted in any patient with chronic infarction. CONCLUSIONS: Engraftment of BMNCs shows dynamic changes within the first 20 h after intracoronary injection. Persistent myocardial engraftment was noted only in a subset of patients with acute myocardial infarction.

Prospective use of EuroSCORE for the short-term risk evaluation of consecutive cardiac surgery candidates: are there any differences in prediction of perioperative risk versus risk of nonsurgical treatments?

BACKGROUND: In the era of modern medicine, the relevance of perioperative risk stratification with respect to the practice of cardiac surgeons and cardiologists worldwide has increased. AIM: This study aims at estimating the validity of a preoperative risk stratification model EuroSCORE in predicting short-term mortality in Czech adult cardiac population. METHODS: All consecutive patients (n = 460) presented to cardiac surgeons as surgery candidates during a six-month period were enrolled in this study. The Additive and logistic EuroSCORE were used for the risk assessment. The operative mortality, as well as the mortality within 30 days from discharge were recorded. The observed and predicted mortality derived from the EuroSCORE were compared. RESULTS: Fifty-seven percent of the patients underwent cardiac surgery, while 43% was refused for surgery by the cardiac surgeon. There was no significant difference between the observed and predicted mortality in both subgroups. EuroSCORE showed good discriminatory ability in predicting short-term mortality (C statistic 0.755 vs. 0.762 for the surgery subgroup and 0.695 vs. 0.716 for the refused subgroup). CONCLUSIONS: The EuroSCORE has a good discriminatory ability in predicting early mortality after cardiac surgery as well as in patients rejected for cardiac surgery. Both EuroSCORE risk prediction model forms are a suitable mortality predictor in Czech cardiac patients.

Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization.

AIMS: The purpose of the Euro Heart Survey Programme of the European Society of Cardiology is to evaluate to which extent clinical practice endorses existing guidelines as well as to identify differences in population profiles, patient management, and outcome across Europe. The current survey focuses on the invasive diagnosis and treatment of patients with established coronary artery disease (CAD). METHODS AND RESULTS: Between November 2001 and March 2002, 7769 consecutive patients undergoing invasive evaluation at 130 hospitals (31 countries) were screened for the presence of one or more coronary stenosis >50% in diameter. Patient demographics and comorbidity, clinical presentation, invasive parameters, treatment options, and procedural techniques were prospectively entered in an electronic database (550 variables+29 per diseased coronary segment). Major adverse cardiac events (MACE) were evaluated at 30 days and 1 year. Out of 5619 patients with angiographically proven coronary stenosis (72% of screened population), 53% presented with stable angina while ST elevation myocardial infarction (STEMI) was the indication for coronary angiography in 16% and non-ST segment elevation myocardial infarction or unstable angina in 30%. Only medical therapy was continued in 21%, whereas mechanical revascularization was performed in the remainder [percutaneous coronary intervention (PCI) in 58% and coronary artery bypass grafting (CABG) in 21%]. Patients referred for PCI were younger, were more active, had a lower risk profile, and had less comorbid conditions. CABG was performed mostly in patients with left main lesions (21%), two- (25%), or three-vessel disease (67%) with 4.1 diseased segments, on average. Single-vessel PCI was performed in 82% of patients with either single- (45%), two- (33%), or three-vessel disease (21%). Stents were used in 75% of attempted lesions, with a large variation between sites. Direct PCI for STEMI was performed in 410 cases, representing 7% of the entire workload in the participating catheterization laboratories. Time delay was within 90 min in 76% of direct PCI cases. In keeping with the recommendations of practice guidelines, the survey identified under-use of adjunctive medication (GP IIb/IIIa receptor blockers, statins, and angiotensin-converting enzyme-inhibitors). Mortality rates at 30 days and 1 year were low in all subgroups. MACE primarily consisted of repeat PCI (12%). CONCLUSION: The current Euro Heart Survey on coronary revascularization was performed in the era of bare metal stenting and provides a global European picture of the invasive approach to patients with CAD. These data will serve as a benchmark for the future evaluation of the impact of drug-eluting stents on the practice of interventional cardiology and bypass surgery.

[Huge sinus of Valsalva aneurysm in patient with cystic medial necrosis of the aorta]. / Obrovské aneuryzma Valsalvova sinu u pacientky s cystickou medionekrózou aorty.

In this case we present a patient with unruptured non-coronary sinus of Valsalva aneurysm associated with diverse clinical findings, caused by acquired degenerative changes of the aortic wall. A previously healthy 36-year-old female was admitted to the neurological clinic of our hospital having suffered from an episode of unconsciousness prior to admission, with accompanying seizures. For the preceding two months she had also been suffering from dyspnoea and palpitation. Neurological examination, computed tomography of the head and electroencephalography were with normal findings. Thereafter, due to paroxysm of supraventricular tachycardia she was referred to cardiology clinic. On routine physical examination a diastolic murmur was detected and the patient was referred for transthoracic echocardiography. This examination revealed a large, unruptured noncoronary sinus of Valsalva aneurysm, which was thereafter confirmed by transoesophageal echocardiography a angiography. The patient was indicated for surgical correction with aortic valve and aortic root replacement by Bentall procedure. Histological examination of the part of resected aneurysm found cystic medial degeneration of the aortic wall, also called cystic medial necrosis.

Value of first day angiography/angioplasty in evolving Non-ST segment elevation myocardial infarction: an open multicenter randomized trial. The VINO Study.

AIMS: Direct angioplasty is an effective treatment for ST-elevation myocardial infarction. The role of very early angioplasty in non-ST-elevation infarction is not known. Thus, a randomized study of first day angiography/angioplasty vs early conservative therapy of evolving myocardial infarction without persistent ST-elevation was conducted. METHODS: One hundred and thirty-one patients with confirmed acute myocardial infarction without ST-segment elevations were randomized within 24 h of last rest chest pain: 64 in the first day angiography/angioplasty group and 67 in the early conservative group (coronary angiography only after recurrent or stress induced myocardial ischaemia). RESULTS: All patients in the invasive group underwent coronary angiography on the day of admission (mean randomization-angiography time 6.2 h). First day angioplasty of the infarct related artery was performed in 47% of the patients and bypass surgery in 35%. In the conservative group, 55% underwent coronary angiography, 10% angioplasty and 30% bypass surgery within 6 months. The primary end-point (death/reinfarction) at 6 months occurred in 6.2% vs 22.3% (P<0.001). Six month mortality in the first day angiography/angioplasty group was 3.1% vs 13.4% in the conservative group (P<0.03). Non-fatal reinfarction occurred in 3.1% vs. 14.9% (P<0.02). CONCLUSIONS: First day coronary angiography followed by angioplasty whenever possible reduces mortality and reinfarction in evolving myocardial infarction without persistent ST-elevation, in comparison with an early conservative treatment strategy.

Thoracic epidural anesthesia for off-pump coronary artery bypass without intubation.

Thoracic epidural anesthesia without intubation was used in 10 patients undergoing off-pump coronary artery reconstruction performed through median sternotomy. Considering the preoperative finding of impaired pulmonary function, all were moderate-risk patients for surgery using conventional general anesthesia with intubation. All patients had an uneventful postoperative course. In indicated cases, we regard thoracic epidural anesthesia as a suitable method again modifying the term "minimally invasive" in cardiac surgery.

Prior aspirin use predicts worse outcomes in patients with non-ST-elevation acute coronary syndromes. PURSUIT Investigators. Platelet IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy.

Aspirin is beneficial in the prevention and treatment of cardiovascular events, but patients who have events while taking aspirin may have worse outcomes than those not on aspirin. We investigated the association between prior aspirin use and clinical outcomes in 9,461 patients with non-ST-elevation acute coronary syndromes enrolled in the Platelet IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, before and after adjustment for baseline factors. We also examined whether eptifibatide has a differential treatment effect in prior aspirin users. Prior aspirin users were less likely to have an enrollment myocardial infarction (MI) (vs unstable angina) (43.9% vs 48.8%, p = 0.001) but more likely to have death or MI at 30 days (16.1% vs 13.0%, p = 0.001) and at 6 months (19.9% vs 15.9%, p = 0.001). After adjustment, prior aspirin users remained less likely to have an enrollment MI (odds ratio 0.88, 95% confidence interval 0.79 to 0.97) and more likely to have death or MI at 30 days (odds ratio 1.16, 95% confidence interval 1.00 to 1.33) but not at 6 months (odds ratio 1.14, 95% confidence interval 0.98 to 1.33). In a multivariable model, eptifibatide did not have a different treatment effect in prior aspirin users compared with nonusers (p = 0.534). Prior aspirin users had fewer enrollment MIs but worse long-term outcomes than nonusers. We found no evidence for a different treatment effect of eptifibatide in prior aspirin users.

[The optimal diagnostic approach in myocardial infarct]. / Optimální diagnostický prístup k infarktu myokardu.

In the submitted review the authors discuss rational criteria for the diagnosis of myocardial infarction, indications for thrombolysis, coronarography and possibly PTCA, the method of indirect (non-invasive) assessment of an occluded coronary artery and the most frequent mistakes in the diagnosis of infarction. Essential examinations in the acute stage of myocardial infarction are: case-history, ECG, CK-MB (possibly echocardiography). For indication of thrombolysis of acute PTCA case-history and ECG (or echocardiography) are sufficient. Indications of early coronarography before discharge from hospital: postinfarction angina pectoris, malignant arrhythmia (except on the first day), haemodynamic instability, evidence of myocardial ischaemia (restricted symptoms) during a maximal load before discharge.

[Echocardiographic detection of wedged emboli in the right heart in patients with pulmonary embolisms]. / Echokardiografický prukaz zaklínených embolu v pravém srdci u nemocných s plicní embolií.

The authors describe two case-histories of patients with the clinical picture of pulmonary embolism where on echocardiography a mobile formation in the right atrium was detected. In both patients the embolus of peripheral origin wedged in the right atrium was removed by surgery.

[Disorders of heart rhythm in hypertrophic cardiomyopathy]. / Poruchy srdecního rytmu u hypertrofických kardiomyopatií.

In 64 patients with hypertrophic cardiomyopathy 24-hour Holter monitoring of the ECG was made in order to detect the incidence of individual disorders of the cardiac rhythm. The examination revealed a large number of potentially malignant ventricular arrhythmias (47% of the patients). Most frequently polytopic ventricular extrasystoles were involved (31.3%), attacks of ventricular tachycardia (20.3%), less frequently bigeminy was recorded (10.9%) and early extrasystoles type R on T (3.1%). As to other disorders of the cardiac rhythm, paroxysmal supraventricular tachycardia was frequent (34.4%), atrial fibrillation or flutter (9.4%) and more numerous supraventricular extrasystoles (7.8%). Sinoatrial (4.7%) and atrioventricular blocks (7.8%) were relatively rare. Examination of patients with hypertrophic cardiomyopathy is an essential prerequisite for the initiation of early and effective treatment which can exert a favourable effect on the subsequent fate of the patients.

The picture of hypertrophic cardiomyopathy in the elderly.

The aim of the study was to analyse the findings obtained in 27 patients with hypertrophic cardiomyopathy who lived to be 60 and more. Elderly patients are, more frequently than younger ones, women, mostly with a negative family history (81% vs. 30% in younger patients), with a lower incidence of syncope (11% vs. 25%), smaller myocardial wall thickness and lesser extent of hypertrophy. Elderly patients displayed mitral ring calcification more often (18%) than younger subjects (6%) or those of the same age but free of hypertrophic cardiomyopathy (3%). Pathological Q waves on the ECG recording were likewise less frequent (7.6% vs. 20.4%). While elderly patients exhibited manifest proneness to elevated values of left ventricular end-diastolic pressure, there were no marked differences in obstruction.

Echocardiography in sarcoidosis.

We examined 39 patients with biopsy proven sarcoidosis of the lungs by one-dimensional, two-dimensional and pulsed Doppler echocardiography. In 18 (46.2%) we revealed a prolapse of one or both cusps of the mitral valve which can partly explain some of the complaints and objective findings in these patients (palpitations, chest pain, changes on ECG resembling myocardial infarctions, murmurs, etc.). A minor pericardial effusion was present in 8 (20.5%) of the patients. The finding of reduced systolic thickening and excursions of the interventricular septum in 4 (10.2%) may be related to the frequent prevalence of sarcoid granulomas in the septum. Asymmetric septal hypertrophy, recorded in 4 (10.2%) patients, may have had a similar origin. Administration of corticosteroids did not influence in a significant way any of the echocardiographic indicators nor the amount of pericardial effusion. In patients with palpitations and extrasystolic arrhythmias, however, the extrasystoles disappeared and the patients reported subjective relief in all instances.