Differences in perioperative femoral and radial arterial blood pressure in neonates and infants undergoing cardiac surgery requiring cardiopulmonary bypass / Diferenças na pressão arterial femoral e radial no perioperatório em neonatos e bebês submetidos a cirurgia cardíaca com bypass cardiopulmonar

Abstract Objective: Several reports claim that blood pressure (BP) in the radial artery may underestimate the accurate BP in critically ill patients. Here, the authors evaluated differences in mean blood pressure (MBP) between the radial and femoral artery during pediatric cardiac surgery to determine the effectiveness of femoral arterial BP monitoring. Method: The medical records of children under 1 year of age who underwent open-heart surgery between 2007 and 2013 were retrospectively reviewed. Radial and femoral BP were measured simultaneously, and the differences between these values were analyzed at various times: after catheter insertion, after the initiation of cardiopulmonary bypass (CPB-on), after aortic cross clamping (ACC), after the release of ACC, after weaning from CPB, at arrival in the intensive care unit (ICU), and every 6 h during the first day in the ICU. Results: A total of 121 patients who underwent open-heart surgery met the inclusion criteria. During the intraoperative period, from the beginning to the end of CPB, radial MBPs were significantly lower than femoral MBPs at each time-point measured (p < 0.05). Multivariate analysis showed that longer CPB time (>60 min, odds ratio: 7.47) was a risk factor for lower radial pressure. However, discrepancies between these two values disappeared after arrival in the ICU. There was no incidence of ischemic complications associated with the catheterization of both arteries. Conclusion: The authors suggest that femoral arterial pressure monitoring can be safely performed, even in neonates, and provides more accurate BP values during CPB-on periods, and immediately after weaning from CPB, especially when CPB time was greater than 60 min.

Resumo Objetivo: Diversos relatos alegam que a pressão arterial (PA) na artéria radial poderá subestimar a PA precisa em pacientes gravemente doentes. Aqui, avaliamos diferenças na pressão arterial média (PAM) entre a artéria radial e femoral durante cirurgia cardíaca pediátrica para determinar a eficácia do monitoramento da PA da artéria femoral. Método: Realizamos uma análise retrospectiva de prontuários médicos de crianças com menos de 1 ano de idade submetidas a cirurgia de coração aberto entre 2007 e 2013. As PAs radial e femoral foram auferidas simultaneamente, as diferenças entre esses valores foram analisadas diversas vezes: após a inserção do cateter, após o início do bypass cardiopulmonar (CPB-on), após pinçamento cruzado da aorta (ACC), após a liberação do ACC, após desmame do CPB, na entrada na unidade de terapia intensiva (UTI) e a cada 6 horas durante o primeiro dia na unidade de terapia intensiva (UTI). Resultados: Um total de 121 pacientes submetidos a cirurgia de coração aberto atenderam aos nossos critérios de inclusão. Durante o transoperatório, do início ao término do CPB, as PAMs da artéria radial foram significativamente menores do que as PAMs da artéria femoral em cada ponto de medição (p < 0,05). A análise multivariada mostrou que a duração mais longa do CPB (> 60 minutos, Razão de Chance = 7,47) representou um fator de risco de pressão radial mais baixa. Contudo, as diferenças entre esses dois valores desapareceram após a entrada na UTI. Não houve incidência de complicações isquêmicas associadas à cateterização de ambas as artérias. Conclusão: Sugerimos que o monitoramento da pressão arterial femoral pode ser realizado com segurança, mesmo em neonatos, e fornece valores da PA mais precisos durante períodos de CPBon e imediatamente após o desmame do CPB, principalmente nos casos em que a duração do CPB foi superior a 60 minutos.

Differences in perioperative femoral and radial arterial blood pressure in neonates and infants undergoing cardiac surgery requiring cardiopulmonary bypass.

OBJECTIVE: Several reports claim that blood pressure (BP) in the radial artery may underestimate the accurate BP in critically ill patients. Here, the authors evaluated differences in mean blood pressure (MBP) between the radial and femoral artery during pediatric cardiac surgery to determine the effectiveness of femoral arterial BP monitoring. METHOD: The medical records of children under 1 year of age who underwent open-heart surgery between 2007 and 2013 were retrospectively reviewed. Radial and femoral BP were measured simultaneously, and the differences between these values were analyzed at various times: after catheter insertion, after the initiation of cardiopulmonary bypass (CPB-on), after aortic cross clamping (ACC), after the release of ACC, after weaning from CPB, at arrival in the intensive care unit (ICU), and every 6h during the first day in the ICU. RESULTS: A total of 121 patients who underwent open-heart surgery met the inclusion criteria. During the intraoperative period, from the beginning to the end of CPB, radial MBPs were significantly lower than femoral MBPs at each time-point measured (p<0.05). Multivariate analysis showed that longer CPB time (>60min, odds ratio: 7.47) was a risk factor for lower radial pressure. However, discrepancies between these two values disappeared after arrival in the ICU. There was no incidence of ischemic complications associated with the catheterization of both arteries. CONCLUSION: The authors suggest that femoral arterial pressure monitoring can be safely performed, even in neonates, and provides more accurate BP values during CPB-on periods, and immediately after weaning from CPB, especially when CPB time was greater than 60min.

Masked inherited primary arrhythmia syndromes in sudden cardiac death patients accompanied by coronary vasospasm.

BACKGROUND/AIMS: Coronary vasospasms are one of the important causes of sudden cardiac death (SCD). Provocation of coronary vasospasms can be useful, though some results may lead to false positives, with patients potentially experiencing recurrent SCD despite appropriate medical treatments. We hypothesized that it is not coronary vasospasms but inherited primary arrhythmia syndromes (IPAS) that underlie the development of SCD. METHODS: We analyzed 74 consecutive patients (3.8%) who survived out-of-hospital cardiac arrest among 1,986 patients who had angiographically proven coronary vasospasms. Electrical abnormalities were evaluated in serial follow-up electrocardiograms (ECGs) during and after the index event for a 3.9 years median follow-up. Major clinical events were defined as the composite of death and recurrent SCD events. RESULTS: Forty five patients (60.8%) displayed electrocardiographic abnormalities suggesting IPAS: Brugada type patterns in six (8.2%), arrhythmogenic right ventricular dysplasia patterns in three (4.1%), long QT syndrome pattern in one (2.2%), and early repolarization in 38 (51.4%). Patients having major clinical events showed more frequent Brugada type patterns, early repolarization, and more diffuse multivessel coronary vasospasms. Brugada type pattern ECGs (adjusted hazard ratio [HR], 4.22; 95% confidence interval [CI], 1.16 to 15.99; p = 0.034), and early repolarization (HR, 2.97; 95% CI, 1.09 to 8.10; p = 0.034) were ultimately associated with an increased risk of mortality. CONCLUSIONS: Even though a number of aborted SCD survivors have coronary vasospasms, some also have IPAS, which has the potential to cause SCD. Therefore, meticulous evaluations and follow-ups for IPAS are required in those patients.

Predictors of reversible severe functional tricuspid regurgitation in patients with atrial fibrillation.

BACKGROUND: Atrial remodeling associated with atrial fibrillation (AF) is known to be a risk factor for significant tricuspid regurgitation (TR), but the predictor of reversible TR in patients with severe functional TR and AF has been poorly studied. The aim of this study was to investigate the predictors of reversible TR in patients with severe functional TR and AF. METHODS: Among 232 patients with severe TR, a total of 71 patients with severe functional TR and AF were enrolled and divided into 2 groups: reversible TR group (n=16, 70.1±15.5 years, 7 males) vs. non-reversible TR group (n=55, 72.3±11.8 years, 20 males). Improvement of TR to moderate or lesser degree on follow-up (FU) echocardiography was considered as reversible TR in the present study. RESULTS: During 38.9±26.7 months of FU period, reversible TR was observed in 16 patients (22.5%). The presence of left ventricular (LV) systolic dysfunction was significantly prevalent (43.8% vs. 20.0%, p=0.03) and the improvement in LV ejection fraction (EF) more than 10% on FU echocardiography was more significantly frequent (62.5% vs. 23.3%, p=0.003) in the reversible TR group than in the non-reversible TR group. However, the other echocardiographic parameters, including right ventricular function were not different between the groups. In multivariate analysis using Cox proportional hazard model, the improvement of LVEF more than 10% was the only independent predictor of reversible TR (HR=7.39, 95%CI 1.80-30.28, p=0.005). Nine patients died only in patients with non-reversible TR (12.7%), but the reversibility of TR was not associated with mortality. CONCLUSIONS: The improvement of LV systolic function was the only independent predictor of reversible TR. Appropriate medical therapy including management for heart failure should be considered before performing surgery in patients with severe functional TR and AF, especially in patients with LV dysfunction.

Very Late Stent Thrombosis in a Drug-Eluting Stent due to Interruption of Anti-Platelet Agents in Patients With Acute Myocardial Infarction and Thrombocytosis.

Stent thrombosis is a fatal complication in patients who have undergone percutaneous coronary intervention, and discontinuation of anti-platelet agent is a major risk factor of stent thrombosis. We report a rare case of very late stent thrombosis (VLST) following discontinuation of anti-platelet agents in a patient who experienced acute myocardial infarction and essential thrombocytosis. She had undergone implantation of a drug eluting stent (DES) and a bare metal stent (BMS) two and half years prior to her presentation. VLST developed in DES, not in BMS, following interruption of anti-platelet therapy.

Value of early risk stratification using hemoglobin level and neutrophil-to-lymphocyte ratio in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Complete blood count is the most widely available laboratory datum in the early in-hospital period after ST-elevation myocardial infarction (STEMI). We assessed the clinical utility of the combined use of hemoglobin (Hb) level and neutrophil-to-lymphocyte ratio (N/L) for early risk stratification in patients with STEMI. We analyzed 801 consecutive patients with STEMI treated with primary percutaneous coronary intervention (PCI) within 12 hours of onset of symptoms. Patients with cardiogenic shock or underlying malignancy were excluded, and 739 patients (63 ± 13 years, 74% men) were included in the final analysis. Patients were categorized into 3 groups using the median value of N/L (3.86) and the presence of anemia (Hb <13 mg/dl in men and <12 mg/dl in women); group I had low N/L and no anemia (n = 272), group II had low N/L and anemia, or high N/L and no anemia (n = 331), and group III had high N/L and anemia (n = 136). There were significant differences on clinical outcomes during 6-month follow-up among the 3 groups. Prognostic discriminatory capacity of combined use of Hb level and N/L was also significant in high-risk subgroups such as patients with advanced age, diabetes mellitus, multivessel coronary disease, low ejection fraction, and even in those having higher mortality risk based on Thrombolysis In Myocardial Infarction risk score. In a Cox proportional hazards model, after adjusting for multiple covariates, group III had higher mortality at 6 months (hazard ratio 5.6, 95% confidence interval 1.1 to 27.9, p = 0.036) compared to group I. In conclusion, combined use of Hb level and N/L provides valuable timely information for early risk stratification in patients with STEMI undergoing primary PCI.

Effect of contrast-induced nephropathy on cardiac outcomes after use of nonionic isosmolar contrast media during coronary procedure.

Contrast-induced nephropathy (CIN) has been increasing and seems to be associated with clinical outcomes in ischemic heart disease. This study aimed to assess the incidence, predictors, and cardiac outcomes of CIN when nonionic isosmolar contrast media (iodixanol, Visipaque(®), GE Healthcare, Cork, Ireland) was used. Between January 2005 and July 2008, 510 patients (69.2 ± 9.0 years of age, 384 men) undergoing diagnostic coronary angiography (CAG) or percutaneous coronary intervention (PCI) were divided into two groups according to the development of CIN (CIN group: n=74; non-CIN group: n=436). CIN developed in 74 patients (14.5%). They were more likely to have diabetes (55.4% vs. 42.9%, p=0.045), decreased left ventricular ejection fraction (LVEF) (50.1 ± 12.6% vs. 57.7 ± 13.9%, p<0.001), and lower baseline hematocrit level (32.4 ± 5.3% vs. 36.6 ± 5.5%, p<0.001). Multiple logistic regression analysis revealed baseline hematocrit (odds ratio 0.900, 95% confidence interval 0.851-0.952, p<0.001), decreased LVEF (odds ratio 0.967, 95% confidence interval 0.949-0.986, p=0.001), and baseline creatinine level (odds ratio 2.317, 95% confidence interval 1.252-4.286, p=0.007) as independent predictors of CIN. At 1-year follow-up, patients with CIN were found to have more adverse outcomes than without CIN in Cox proportional hazards analysis (hazard ratio 13.068, 95% confidence interval 2.425-70.434, p=0.003). CIN was mostly associated with baseline creatinine level rather than CM amount using nonionic isosmolar CM. We found that patients with CIN had worse event-free survival than patients without CIN after multifactorial adjustment.

Relation between aortic knob calcium observed by simple chest x-ray or fluoroscopy and plaque components in patients with diabetes mellitus.

We used virtual histology and intravascular ultrasound (VH-IVUS) to evaluate the relation between aortic knob calcium (AKC) and plaque components in diabetic patients. The presence of AKC was assessed by posteroanterior view of chest x-ray or fluoroscopy at the time of coronary angiography. A total of 137 de novo coronary culprit lesions in 137 consecutive diabetic patients were studied and coronary plaque components were analyzed using VH-IVUS according to the presence (n = 45) or absence (n = 92) of AKC. Patients with AKC were significantly older (68 +/- 8 vs 62 +/- 9 years, p <0.001) and had significantly higher high-sensitivity C-reactive protein levels (1.97 +/- 1.33 vs 0.48 +/- 1.35 mg/dl, p = 0.005) compared to patients without AKC. Absolute and percent necrotic core (NC) volumes (30 +/- 26 vs 20 +/- 19 mm(3), p = 0.003; 23.4 +/- 10.3% vs 17.4 +/- 8.9%, p = 0.005, respectively) and absolute and percent dense calcium (DC) volumes (17 +/- 12 vs 11 +/- 12 mm(3), p = 0.010; 13.3 +/- 7.3% vs 9.6 +/- 7.9%, p = 0.011, respectively) were significantly greater in lesions with AKC compared to those without AKC. Multivariable analysis showed that age (odds ratio [OR] 1.233, 95% confidence interval [CI] 1.121 to 1.355, p <0.001), high-sensitivity C-reactive protein (OR 1.871, 95% CI 1.090 to 2.943, p = 0.007), absolute DC volume (OR 1.020, 95% CI 1.050 to 1.178, p = 0.003), and absolute NC volume (OR 1.026, 95% CI 1.057 to 1.199, p <0.001) were independent predictors of AKC. In conclusion, diabetic patients with AKC were older, had greater NC- and DC-containing plaques, and higher inflammatory status compared to diabetic patients without AKC.

Successful management of huge floating thrombus within aortic arch in a patient with old myocardial infarction.

Few cases of a floating thrombus in an aorta have been reported without any systemic embolic complications. We report an unusual case of a huge floating thrombus (3 cm × 10 cm in size) in the aortic arch. The patient had a history of old myocardial infarction and had undergone successful percutaneous coronary intervention 16 years previously. The aortic thrombus was detected incidentally after echocardiography and computed tomography without any evidence of aortic dissection or distal embolization. The huge thrombus was removed successfully from the aortic arch by urgent surgery.

Relation between N-terminal pro-B-type natriuretic peptide and coronary plaque components in patients with acute coronary syndrome: virtual histology-intravascular ultrasound analysis.

BACKGROUND: The N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) is a sensitive indicator of hemodynamic stress and its increased level is associated with higher mortality in acute coronary syndrome (ACS) patients. Virtual histology-intravascular ultrasound (VH-IVUS) can provide quantitative information on plaque components. METHODS: We measured preprocedural serum NT-pro-BNP levels in 156 ACS patients with preserved left ventricular systolic function and normal serum creatinine. VH-IVUS classified the color-coded tissue into four major components: fibrotic, fibro-fatty, dense calcium, and necrotic core (NC). Thin-cap fibroatheroma (TCFA) was defined as focal, NC-rich (>or=10% of the cross-sectional area) plaques being in contact with the lumen in a plaque burden of at least 40%. We divided the patients into two groups according to the NT-pro-BNP levels [group I: >or=200 pg/ml (n = 58) vs. group II: <200 pg/ml (n = 98)]. RESULTS: The percent areas of NC at the minimum lumen site (19.8+/-13.1% vs. 15.2+/-11.1%, P = 0.027) and at the largest NC site (24.7+/-10.3% vs. 19.2+/-11.4%, P = 0.015) were significantly greater in group I than in group II. Percent NC volume was significantly greater in group I than in group II (15.8+/-8.1% vs. 10.1+/-9.1%, P = 0.008). The total number of TCFAs was 38 in group I and 56 in group II. The presence of at least one TCFA (58 vs. 38%, P = 0.009) and multiple TCFAs (25 vs. 10%, P = 0.005) within culprit lesions were observed more frequently in group I than in group II. The TCFAs were located more in proximal in group I than in group II [the length from coronary ostium to TCFA: 10.8+/-7.6 mm in group I vs. 25.7+/-16.3 mm in group II (P<0.001)]: 85% of TCFAs was located within 20 mm from coronary ostium in group I; conversely only 36% of TCFAs was located within 20 mm from coronary ostium in group II (P<0.001). CONCLUSION: VH-IVUS analysis shows that ACS patients with high NT-pro-BNP levels had more vulnerable plaque component (more NC-containing lesions and higher frequency of culprit lesion TCFAs) and had more proximally located TCFAs.

Characteristics of patients with a significant stenosis in a conventional coronary angiogram with a normal multi-detector computed tomographic coronary angiogram.

Multi-detector computed tomography (MDCT) has high diagnostic value for detecting or excluding coronary artery stenosis. However, conventional coronary angiograms (CCA) are occasionally required in patients having persistent chest pain with normal MDCT. We retrospectively analyzed 90 patients who underwent CCA due to persistent chest pain with normal MDCT. The patients were classified into patients having more than 50% diameter stenosis in CCA (false negative, group I: n = 14, 62.6 +/- 7.5 years, 7 males) and those having less than 50% diameter stenosis (true negative, group II: n = 76, 52.1 +/- 12.0 years, 42 males). Significant stenosis was observed in 9 patients at the left anterior descending artery, 4 at the right coronary artery, and 1 at the left circumflex artery in group I. Group I patients were older than group II patients (63 +/- 8 versus 52 +/- 12 years, P < 0.001). There were more patients with hypertension and smoking in group I (64.3% versus 7.9%, 35.7% versus 3.9%, P < 0.001, P < 0.001, respectively). The levels of uric acid and homocysteine were higher in group I than in group II (5.7 +/- 1.5 versus 4.6 +/- 1.2 mg/dL, 9.6 +/- 3.1 versus 7.4 +/- 2.5 mol/L, P = 0.008, P = 0.010, respectively). There were more ST or T changes in the electrocardiograms in group I (35.7% versus 1.3%) (P < 0.001). In multivariate analysis, a history of hypertension, uric acid levels, and ischemic evidence in the electrocardiogram were independent factors for a false negative of MDCT (odds ratio 11.11, 4.76, 1.81, 95% confidence interval 4.67 to 10.00, 1.41 to 1.61, 1.05 to 3.33, P = 0.009, P = 0.012, P = 0.046, respectively). In certain situations, the findings of coronary stenosis by MDCT do not always correlate with that of CCA.

Age-related differences in intravascular ultrasound findings in 1,009 coronary artery disease patients.

BACKGROUND: The aim of this study was to assess the age-related differences in intravascular ultrasound (IVUS) findings of target lesions in patients with coronary artery disease. METHODS AND RESULTS: The 1,009 patients who underwent IVUS imaging were grouped according to an increase of 10 years of age: Group I [<50 years (n=144)]; Group II [51-60 years (n=259)]; Group III [61-70 years (n=249)]; Group IV [71-80 years (n=264)]; and Group V [>80 years, (n=93)]. Calcified plaque (18%, 25%, 33%, 38%, and 46%, p<0.001) and negative remodeling (29%, 48%, 44%, 44%, and 66%, p<0.001) were most common, and reference segment plaque burden (35+/-11%, 35+/-10%, 39+/-10%, 38+/-10%, and 40+/-11%, p<0.001) was greatest in Group V. Plaque rupture (52%, 31%, 42%, 38%, and 20%, p=0.009) and thrombus (38%, 30%, 31%, 24%, and 11%, p=0.026) were most common in Group I. In the multiple logistic regression analysis, patient age was an independent predictor of calcified plaque (odds ratio (OR)=1.03, p=0.001), negative remodeling (OR=1.04, p=0.001), and mean reference segment plaque burden >50% (OR=1.03, p=0.006). CONCLUSION: Elderly patients have more severe calcifications with negative remodeling and diffuse atherosclerosis, whereas younger patients have more unstable plaque morphology.

N-terminal pro-B-type natriuretic Peptide predicts significant coronary artery lesion in the unstable angina patients with normal electrocardiogram, echocardiogram, and cardiac enzymes.

BACKGROUND: Brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) are not specific for ventricular dysfunction and other cardiac processes, such as myocardial ischemia, may also cause elevation of these markers. METHODS AND RESULTS: To determine whether elevation of NT-proBNP without elevation of cardiac specific markers can predict coronary artery disease (CAD), the serum level of NT-proBNP was measured in 161 patients with unstable angina (61.0+/-8.1 years, male 54.0%) with normal ventricular function (left ventricular ejection fraction >55% and no regional wall motion abnormality by echocardiography) and normal troponin I level (<0.05 ng/ml). In these patients, levels of C-reactive protein and myoglobin were normal and none had Q wave on electrocardiographic (ECG). The NT-proBNP level was higher in patients with CAD (n=74) than in patients without CAD (n=87) (173.1+/-231.6 vs 68.1+/-62.5 pg/ml, p<0.001). At the standard cut-off point of >200 pg/ml, elevated NT-proBNP level shows high probability of CAD (odds ratio, 10.1; 95% confidence interval, 2.6-38.7, p=0.001). The NT-proBNP level positively correlated with the extent of CAD (r=0.329, p=0.001). In multivariate analysis, the NT-proBNP was an independent predictor of CAD. CONCLUSION: These results suggested that NT-proBNP is a useful screening test for CAD in the unstable angina patients with normal ECG, echocardiogram and cardiac enzyme levels.