Perioperative Cardiac Troponin T and Risk of Postoperative Atrial Fibrillation in Coronary Artery Bypass Graft Surgery.

BACKGROUND: Postoperative atrial fibrillation (AF) is a common complication after cardiac surgery. We investigated whether perioperative cardiac troponin T (cTnT) is associated with the risk of AF after coronary artery bypass grafting (CABG). METHODS: Two thousand four hundred twenty-one patients with isolated CABG were studied. High sensitivity cTnT (hs-cTnT) was assessed before and then at 80 hour and 24 hour after the operation. Logistic regression models were applied to investigate the association of perioperative hs-cTnT with postoperative AF. The ROC curve analysis was applied to determine the optimal cutoff values. RESULTS: Postoperative AF was occurred in 356 (14.7%) patients. Age (adjusted odds ratio [ORs] 1.087-1.090), male gender (OR 1.390), left atrium size (ORs 1.055-1.111), on-pump coronary bypass (OR 1.561), and application of intra-aortic balloon pump (ORs 2.890-2.966) were independently associated with AF. Preoperative hs-cTnT was associated with AF in patients with off-pump coronary bypass (ORs 1.997-2.375). However, the area under the curve for preoperative hs-cTnT was 0.625 in this group. On-pump coronary bypass had major influence on postoperative hs-cTnT levels regardless of the occurrence of AF. CONCLUSIONS: Preoperative hs-cTnT level is associated with the risk of AF after isolated CABG in patients undergoing off-pump coronary bypass, but the accuracy of this biomarker is yet inadequate. Postoperative levels of hs-cTnT have no predictive value considering large influence by the surgical technique and the cardiac surgery itself. Therefore, perioperative hs-cTnT is not a clinically useful biomarker for predicting AF following CABG.

A Giant Left Circumflex Artery Aneurysm with Thrombosis Formation Presenting as a Left Atrioventricular Groove Mass.

A coronary artery aneurysm is defined as the dilation of a coronary artery segment that is 1.5-fold the diameter of the neighboring normal segments. A patient with a history of aortic valve replacement and coronary artery bypass graft surgery, transthoracic echocardiography revealed a large mass with an echolucent center in the left atrioventricular groove. Transesophageal echocardiography showed that the left atrial appendage was free of thrombosis, and there was a mass with an echolucent center beneath the left atrial appendage, suggestive of aneurysmal dilation in the left circumflex artery with thrombosis formation Coronary artery computed tomography angiography confirmed this finding. In patients with or without a history of coronary aneurysms, the presence of a mass in the atrioventricular groove on echocardiography should alert clinicians about the presence of a coronary artery aneurysm with thrombosis formation as a probable etiology.

Isolated tricuspid valve surgery; long-term outcomes based on Tehran Heart Center data bank report.

BACKGROUND: Given that isolated tricuspid valve (TV) repair or replacement is performed relatively rarely, we sought to evaluate the rate of long-term mortality and readmission following this surgery. METHODS: The current study was conducted in Tehran Heart Center on patients who underwent isolated TV repair or replacement between 2010 and 2018. Totally, 197 patients (repair = 150 vs replacement = 47) were included in our study and were then followed right after surgery for a median of 8 years to assess the incidence of postoperative events, readmission, and all-cause mortality. RESULTS: The final analysis was conducted on 197 patients at a mean age of 44.4 ± 13.8 years. Most of the patients were female (56.9%). Ejection fraction, TAPSE, and right ventricular function improved in both groups after TV surgery. Length of stay in the intensive care unit per hour and hospitalization per day were higher in the replacement group and compared to the repair group (158.34 vs. 55.11 and 18.21 vs. 9.34, respectively). In-hospital mortality occurred in 20 patients, of whom 15 had TV replacement. Readmission occurred in five (2.5%) patients,all were in the repair group. CONCLUSIONS: The result of this single-center study showed that TV replacement is associated with a higher rate of postoperative events and all-cause mortality compared to TV repair. Whereas, repair group had a higher rate of readmission. Therefore, the overwhelming tendency is toward repair; nonetheless, no hesitation is permissible if a replacement is adjudged to confer a better outcome for the patient.

Effect of persistent opium consumption after surgery on the long-term outcomes of surgical revascularisation.

BACKGROUND: A wrong traditional belief persists among people that opium consumption beneficially affects cardiovascular disease and its risk factors. However, no evidence exists regarding the effect of opium consumption or cessation on the long-term risk of major adverse cardio-cerebrovascular events after coronary artery bypass grafting. We therefore aimed to evaluate the effect of persistent opium consumption after surgery on the long-term outcomes of coronary artery bypass grafting. METHODS: The study population consisted of 28,691 patients (20,924 men, mean age 60.9 years), who underwent coronary artery bypass grafting between 2007 and 2016 at our centre. The patients were stratified into three groups according to the status of opium consumption: never opium consumers (n = 23,619), persistent postoperative opium consumers (n = 3636) and enduring postoperative opium withdrawal (n = 1436). Study endpoints were 5-year mortality and 5-year major adverse cardio-cerebrovascular events, comprising all-cause mortality, acute coronary syndrome, cerebrovascular accident and revascularisation. RESULTS: After surgery, 3636 patients continued opium consumption, while 1436 patients persistently avoided opium use. The multivariable survival analysis demonstrated that persistent post-coronary artery bypass grafting opium consumption increased 5-year mortality and 5-year major adverse cardio-cerebrovascular events by 28% (hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.06-1.54; P = 0.009) and 25% (HR 1.25, 95% CI 1.13-1.40; P < 0.0001), respectively. It also increased the 5-year risk of acute coronary syndrome by 34% (sub-distribution HR 1.34, 95% CI 1.16-1.55; P < 0.0001). CONCLUSIONS: The present data suggest that persistent post-coronary artery bypass grafting opium consumption may significantly increase mortality, major adverse cardio-cerebrovascular events and acute coronary syndrome in the long term. Future studies are needed to confirm our findings.

Smoking Cessation After Surgery and Midterm Outcomes of Surgical Revascularization.

BACKGROUND: Although multiple studies have reported the devastating effect of cigarette smoking (CS) on short-term outcomes of patients who underwent coronary artery bypass grafting surgery (CABG), its effect on long-term outcomes is still questionable. We aimed to evaluate the long-term outcomes of CS cessation after CABG surgery. METHODS: This retrospective cohort study included all patients who underwent isolated CABG at our center between 2007 and 2016 and were cigarette smokers either just before or at the time of surgery. Patients were stratified into those who continued CS and those who were persistently CS abstinent after CABG. The endpoints of the study were 5-year mortality and 5-year major adverse cardiovascular and cerebrovascular events. RESULTS: Of 28,945 patients who underwent isolated CABG, 9173 current cigarette smokers (93.5% men; mean age, 58.6 years) met our selection criteria and were included in the final analysis. Of these 3302 patients (40.0%) continued CS after surgery and 5688 patients were persistently abstinent. Multivariable survival analysis demonstrated that CS cessation after CABG, adjusted for major coronary risk factors, could reduce the 5-year mortality by 35% (hazard ratio, 0.65; 95% confidence interval, 0.54-0.77; P < .001) and 5-year major adverse cardiovascular and cerebrovascular events by 18% (hazard ratio, 0.82; 95% confidence interval, 0.74-0.92; P = .001). CONCLUSIONS: Our study shows that CS abstinence after CABG significantly reduces long-term mortality and number of major adverse events. As a result, patients who smoke should be encouraged to participate in CS cessation programs after CABG surgery.

Early outcome of off-pump versus on-pump coronary revascularization.

INTRODUCTION: The use of coronary artery bypass surgery (CABG) with cardiopulmonary bypass (CPB) or without CPB technique (off-pump) can be associated with different mortality and morbidity and their outcomes remain uncertain. The goal of this study was to evaluate the early outcome of on-pump versus off-pump CABG. METHODS: We conducted a retrospective database review of 13866 patients (13560 patients undergoing on-pump CABG and 306 patients undergoing off-pump CABG) at Tehran Heart Center between January 2002 and January 2007. We compared preoperative, operative, and postoperative characteristics between them. RESULTS: In-hospital mortality in the on-pump group was 0.8% compared to 0.7% in the off-pump group (P=0.999) and in-hospital morbidity was 11.7% and 6.5%, respectively (OR: 1.533, 95%CI: 0.902-2.605, P=0.114). Postoperative atrial fibrillation was more prevalent in on-pump versus off-pump surgery (6.0% vs 3.0%, P=0.028), however there were no statistical significant differences in other postoperative complications with regard to cardiac arrest (P=0.733), prolonged ventilation (P=0.363), brain stroke (P=0.999), renal failure (P=0.525), and postoperative bleeding (P=0.999). The mean length of stay in hospital (P=0.156) and in ICU (P=0.498) was also similar between the two groups. CONCLUSION: The results from an Iranian population-based study showed similar early mortality and morbidity of off-pump CABG in comparison to on-pump surgery.

Comparing the impact of supine and leg elevation positions during coronary artery bypass graft on deep vein thrombosis occurrence: a randomized clinical trial study.

Deep vein thrombosis (DVT) is a common preoperative complication that occurs in patients who undergoing coronary artery bypass grafting surgery (CABG). Early ambulation, elastic stockings, intermittent pneumatic compression, and leg elevation, before and after surgery, are among preventative interventions. The goal of the study was to compare the effect of supine position with that of leg elevation on the occurrence of DVT during CABG and after, until ambulation. Between October, 2008, and May, 2011, a total of 185 eligible CABG patients admitted to the Cardiac Surgery Unit were randomly assigned to groups designated as the supine group (n = 92) or the leg-elevation group (n = 93). Of this total, 92 patients were assigned to the supine group and 93 to the leg-elevation group. Doppler ultrasonography of the superficial and deep veins in the lower extremities was performed for each patient before and after surgery. Logistic regression analysis was conducted to investigate the possible independent factors associated with DVT. DVT was detected in 25 (13.5%) patients: 17 (18.4%) patients in the supine position group and 8 (8.6%) in the leg-elevation group (P value = .065). After adjustment for confounding factors there was no effect of position on the presence of DVT (P = .126).Clots were often localized in legs ipsilateral to the saphenous vein harvest. The authors conclude that a positive, albeit not statistically significant, trend was evident toward higher incidence of silent DVT in supine position during and after CABG in comparison with leg elevation. Future studies with larger sample sizes are required to confirm this result.

Do adventitial mast cells contribute to the pathogenesis of ascending thoracic aorta aneurysm?

The precise pathogenesis of the ascending aortic aneurysm (AscAA) remains to be determined. Mast cells in the adventitia of human AscAA lesions may play a role in this pathogenesis. Adventitial mast cell density per 10 high-power fields (0.25 mm(2)) was assessed in multiple biopsy samples, from aneurysmal aortic sections (n = 41) and control (nondilated) aortic specimens (n = 50), stained by orcein-Giemsa method, an inexpensive (<$1) method. In a multivariable adjusted logistic regression model, using AscAA as the dependent variable, mast cell density was found to be an independent predictor of AscAA occurrence (odds ratio = 2.21; 95% confidence interval = 1.58-3.08; P < .001). Receiver operating characteristic curve analysis showed that the proposed cutoff value of ≥ 3 mast cells per 10 high-power fields was very sensitive to detect AscAA occurrence, yielding a sensitivity of 90% with a specificity of 80%. In conclusion, a significant increase in the number of mast cells in the adventitia of human ascending aortic lesions proposes a role for these cells in the pathogenesis of AscAA.

Prophylactic ventral cardiac denervation: does it reduce incidence of atrial fibrillation after coronary artery bypass grafting?

OBJECTIVE: This study assessed the prophylactic effect of ventral cardiac denervation on reducing atrial fibrillation after coronary artery bypass grafting. METHODS: This randomized prospective study recruited 220 adult patients (aged 42-79 years) who were scheduled to undergo coronary artery bypass grafting. Of these patients, 110 underwent ventral cardiac denervation in addition to coronary artery bypass grafting and 110 underwent only coronary artery bypass grafting. The demographic, intraoperative, and postoperative factors comprising atrial fibrillation were compared between the 2 groups. In addition, the predictive factors of atrial fibrillation in all 220 cases were assessed. RESULTS: The mean age and the distribution of gender, body mass index, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, hypercholesterolemia, and left main disease were not significantly different between the 2 groups. Atrial fibrillation incidence was significantly different between the groups (P=.025), with an incidence of 20.9% in the ventral cardiac denervation group and 10% in the control group. Atrial fibrillation occurred in 34 of the 220 patients, and ventral cardiac denervation was considered as a variable to evaluate its possible role in the prevention of postoperative atrial fibrillation. Our multivariate analysis showed age (P=.002; odds ratio,1.098; confidence interval, 1.034-1.165) and ventral cardiac denervation (P=.044; odds ratio,2.32; confidence interval, 1022-5.298) as the predictive factors of atrial fibrillation after coronary artery bypass grafting. CONCLUSIONS: Given the surprising results of the present study demonstrating that ventral cardiac denervation is a predictive factor of atrial fibrillation after coronary artery bypass grafting, ventral cardiac denervation should not be routinely considered for the prevention of atrial fibrillation after coronary artery bypass grafting.

Short- and mid-term results of triple-valve surgery with an evaluation of postoperative quality of life.

The decision to proceed with triple-valve surgery should take into account reasonable estimates of the risk of the surgery and of the potential benefit to be gained. In the present study, we reviewed our experience with triple-valve surgery, focusing on short-term death and morbidity, mid-term survival, and postoperative quality of life.Among 107 patients with multiple-valve disease who underwent triple-valve surgery at Tehran University Heart Center from January 2002 through December 2007, 100 patients with complete, recorded data were entered into the study. Demographic and clinical characteristics and in-hospital postoperative complications were considered. Among 66 patients whose mid-term operative outcomes we were able to determine, these results were evaluated, together with their quality of life, during a mean follow-up period of 45.0 +/- 12.4 months.In-hospital mortality and morbidity rates were 5% and 61%, respectively. The Kaplan-Meier survival rate for the 66 monitored patients was 82.6%. Freedom from readmission was 77.3%, and freedom from rehospitalization was 89.4%. Freedom from thromboembolism was 87.8%, and freedom from anticoagulant-related hemorrhage was 91.3%. In the quality-of-life assessment, suitable physical and social activities were reported in 65.1% and 60.6% of patients, respectively. Although 63.6% of patients were satisfied with the results of the operation, only 51.5% were able to continue their work.Despite patients' satisfaction with early outcomes of triple-valve surgery and their acceptable mid-term survival rates, the improvement of quality of life after surgery is still far from ideal.

Factors affecting postoperative morbidity and mortality in isolated coronary artery bypass graft surgery.

PURPOSE: This study was conducted to investigate predictors of mortality before and after isolated coronary artery bypass grafting (CABG). METHODS: Single-institutional data on risk factors and mortality were collected for 8890 patients who underwent isolated CABG by the same group of surgeons. The relationship between risk factors and outcome was assessed using univariate and multivariate analyses in two risk models: a preoperative model (model 1) and then a pre-, intra-, and postoperative model (model 2). RESULTS: The mean age of the patients (25.4% women and 74.6% men) was 58.5 +/- 9.7 years. Fifty-five (0.6%) patients died after surgery. Hypercholesterolemia was the most common comorbidity factor (61.1%), followed by hypertension, a smoking habit, recent myocardial infarction (MI) <21 days, and diabetes. Postoperative tamponade, graft occlusion, and MI (0.01%) were the least common complications. The patients spent 39.7 +/- 33.9 h in the intensive care unit (ICU) postoperatively. Patients were followed up for a minimum of 30 days. The multivariate analysis of our preoperative risk model revealed that the best predictors of operative mortality were a history of diabetes, hypertension, previous CABG, the presence of angina, arrhythmia, Canadian Cardiovascular Society Classification (CCS) of grade III or IV, ejection fraction (EF) < or =30%, three-vessel disease, and left main disease. CONCLUSION: After surgery, and with the inclusion of all the pre-, intra-, and postoperative variables into model two, the following were revealed to be prognostic factors for in-hospital mortality: a history of diabetes, hypertension, the presence of angina, CCS grades III or IV, EF -30%, absence of internal mammary artery (IMA) use, prolonged cardiopulmonary bypass (CPB) time, and prolonged ICU stay.

Coronary artery bypass grafting in patients with low ejection fraction: the effect of intra-aortic balloon pump insertion on early outcome.

BACKGROUND: Survival benefit with intra-aortic balloon pump (IABP) insertion for coronary artery bypass grafting (CABG) patients with left ventricular dysfunction is controversial. The aim of this study was to assess the early results of CABG that predict 30-day mortality and prolonged length of hospital stay (LOS) after isolated CABG and the role of IABP application as a main predictor in patients with an ejection fraction (EF) of 30% or less. MATERIALS AND METHODS: Eight hundred and thirty-three patients who underwent isolated CABG with EF < or = 30% were entered and compared with 10881 patients with EF > 30% as the control group. Demographic and clinical characteristics and postoperative complications were considered. Data were analyzed using the student's t-test and chi-square test for univariate analysis and the analysis of covariance and logistic regression for multivariate analysis. RESULTS: The thirty-day mortality rate (1.6% vs. 0.7%, P P P = 0.002) and prolonged LOS (P = 0.009). Also, urinary tract infection, prolonged ventilation, and renal failure as postoperative complications were statistically more in the group with the application of IABP. CONCLUSION: Low ejection fraction can positively affect thirty-day mortality and prolonged LOS and ICU stay in patients who undergo CABG. In these patients, IABP insertion is a strong predictor for early complication and mortality.

Delayed-onset heparin-induced thrombocytopenia presenting with multiple arteriovenous thromboses: case report.

BACKGROUND: Delayed-onset heparin-induced thrombocytopenia with thrombosis, albeit rare, is a severe side effect of heparin exposure. It can occur within one month after coronary artery bypass grafting (CABG) with manifestation of different thrombotic events. CASE PRESENTATION: A 59-year-old man presented with weakness, malaise, bilateral lower limb pitting edema and a suspected diagnosis of deep vein thrombosis 18 days after CABG. Heparin infusion was administered as an anticoagulant. Clinical and paraclinical work-up revealed multiple thrombotic events (stroke, renal failure, deep vein thrombosis, large clots in heart chambers) and 48 x103/mul platelet count, whereupon heparin-induced thrombocytopenia was suspected. Heparin was discontinued immediately and an alternative anticoagulant agent was administered, as a result of which platelet count recovered. Heparin-induced thrombocytopenia, which causes thrombosis, is a serious side effect of heparin therapy. It is worthy of note that no case of delayed-onset heparin-induced thrombocytopenia with thrombosis associated with cardiopulmonary bypass surgery has thus far been reported in Iran. CONCLUSION: Delayed-onset heparin-induced thrombocytopenia should be suspected in any patient presenting with arterial or venous thromboembolic disorders after recent heparin therapy, even though the heparin exposure dates back to more than a week prior to presentation; and it should be ruled-out before the initiation of heparin therapy.

24-hour in-hospital mortality predictions in coronary artery bypass grafting patients.

BACKGROUND: The purpose of this study was to determine the factors that can help predict risk of mortality in the first 24 h of coronary artery bypass grafting (CABG), because mortality within a few hours of surgery is a disastrous event for surgeons and the patient's family. METHODS: The study population consisted of 120 in-hospital mortality cases (1.07%) from 11,183 patients who underwent CABG from February 2002 to February 2006 by the same group of surgeons in a referral center. One group consisted of 40/120 (about 33.3%) patients who died during the first 24 h after surgery. The second group consisted of 80/120 patients (66.7%) who died between the 2(nd) and 30(th) day postoperatively. A set of data was gathered from the surgery database of the hospital and analyzed in a univariate model. RESULTS: Among the studied variables, only the following factors proved to be significant: previous percutaneous transluminal coronary angioplasty (PTCA), previous cerebrovascular accident (CVA), cardiopulmonary bypass (CBP) time, and postoperative atrial fibrillation (AF) (p