Exploring the Utility of Brain Natriuretic Peptide Measurement in Vascular Surgery.

BACKGROUND: The Canadian Cardiovascular Society 2016 guidelines recommend pre-operative measurement of brain natriuretic peptide (BNP) to risk-stratify patients for a 30-day composite outcome of death, myocardial infarction, or asymptomatic myocardial injury after noncardiac surgery (MINS). Whether this practice affects outcomes is unclear. The aim of this study was to examine the clinical utility of brain natriuretic peptide and myocardial injury after noncardiac surgery. METHODS: Analysis of a prospectively maintained database identified all elective open vascular surgery cases at an academic teaching hospital from January 2015 to December 2018. Pre-operative BNP values were available from June 2018 onward after becoming institutionally mandated. Co-morbidities were also collected to stratify patients using the Revised Cardiac Risk Index. The composite outcome of 30-day mortality, myocardial infarction, or MINS was determined. RESULTS: Prior to BNP becoming an institutionally required test, data was available from 1176 open cases. The 30-day mortality was 1.3% (15/1176) and post-operative myocardial infarction rate was 2.3% (27/1176). BNP measurements were collected in 91 consecutive patients. Ten patients (11%) experienced the composite outcome of mortality, myocardial infarction, or MINS. Elevated BNP was associated with increased odds of the composite outcome (P = 0.04), but not with mortality or myocardial infarction. Revised Cardiac Risk Index score was not predictive of outcomes. The majority of patients who qualified for the composite outcome experienced only an asymptomatic troponin rise (80%). Two patients met the universal definition of myocardial infarction, one of whom died. No other deaths occurred within 30 days. Detection of MINS did not result in any significant changes to patient management. CONCLUSIONS: Elevated BNP correlates with increased MINS. An asymptomatic troponin rise is the most commonly observed event, with unclear clinical implications. BNP may over-estimate surgical risk. Further studies on the long-term outcomes of patients with elevated BNP and MINS are required before widely adopting this strategy in vascular surgery patients.

Effects of peak time of myocardial injury biomarkers on mid-term outcomes of patients undergoing OPCABG.

BACKGROUND: With the development of cardiac surgery techniques, myocardial injury is gradually reduced, but cannot be completely avoided. Myocardial injury biomarkers (MIBs) can quickly and specifically reflect the degree of myocardial injury. Due to various reasons, there is no consensus on the specific values of MIBs in evaluating postoperative prognosis. This retrospective study was aimed to investigate the impact of MIBs on the mid-term prognosis of patients undergoing off-pump coronary artery bypass grafting (OPCABG). METHODS: Totally 564 patients undergoing OPCABG with normal courses were included. Cardiac troponin T (cTnT) and creatine kinase myocardial band (CK-MB) were assessed within 48 h before operation and at 6, 12, 24, 48, 72, 96 and 120 h after operation. Patients were grouped by peak values and peak time courses of MIBs. The profile of MIBs and clinical variables as well as their correlations with mid-term prognosis were analyzed by univariable and multivariable Cox regression models. RESULT: Continuous assessment showed that MIBs increased first (12 h after surgery) and then decreased. The peak cTnT and peak CK-MB occurred within 24 h after operation in 76.8% and 67.7% of the patients respectively. No significant correlation was found between CK-MB and mid-term mortality. Delayed cTnT peak (peak cTnT elevated after 24 h after operation) was correlated with lower creatinine clearance rate (69.36 ± 21.67 vs. 82.18 ± 25.17 ml/min/1.73 m2), body mass index (24.35 ± 2.58 vs. 25.27 ± 3.26 kg/m2), less arterial grafts (1.24 ± 0.77 vs. 1.45 ± 0.86), higher EuroSCORE II (2.22 ± 1.12 vs.1.72 ± 0.91) and mid-term mortality (26.5 vs.7.9%). Age (HR: 1.067, CI: 1.006-1.133), left ventricular ejection fraction (HR: 0.950, CI: 0.910-0.993), New York Heart Association score (HR: 1.839, CI: 1.159-2.917), total venous grafting (HR: 2.833, CI: 1.054-7.614) and cTnT peak occurrence within 24 h (HR: 0.362, CI: 0.196-0.668) were independent predictors of mid-term mortality. CONCLUSION: cTnT is a better indicator than CK-MB. The peak value and peak occurrence of cTnT are related to mid-term mortality in patients undergoing OPCABG, and the peak phases have stronger predictive ability. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2000033850. Registered 14 June 2020, http://www.chictr.org.cn/edit.aspx?pid=55162&htm=4 .

Over time relationship between platelet reactivity, myocardial injury and mortality in patients with SARS-CoV-2-associated respiratory failure.

The aim of this study (NCT04343053) is to investigate the relationship between platelet activation, myocardial injury, and mortality in patients affected by Coronavirus disease 2019 (COVID-19). Fifty-four patients with respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were enrolled as cases. Eleven patients with the same clinical presentation, but negative for SARS-CoV-2 infection, were included as controls. Blood samples were collected at three different time points (inclusion [T1], after 7 ± 2 days [T2] and 14 ± 2 days [T3]). Platelet aggregation by light transmittance aggregometry and the circulating levels of soluble CD40 ligand (sCD40L) and P-selectin were measured. Platelet biomarkers did not differ between cases and controls, except for sCD40L which was higher in COVID-19 patients (p = .003). In COVID-19 patients, P-selectin and sCD40L levels decreased from T1 to T3 and were higher in cases requiring admission to intensive care unit (p = .004 and p = .008, respectively). Patients with myocardial injury (37%), as well as those who died (30%), had higher values of all biomarkers of platelet activation (p < .05 for all). Myocardial injury was an independent predictor of mortality. In COVID-19 patients admitted to hospital for respiratory failure, heightened platelet activation is associated with severity of illness, myocardial injury, and mortality.ClinicalTrials.gov number: NCT04343053.

Comparison of pre- and postoperative myocardial injuries on mortality after non-cardiac surgery: a retrospective analysis using an inverse probability weighting adjustment.

Although both pre- and postoperative myocardial injuries are strongly associated with an increased postoperative mortality, no study has directly compared the effects of pre- and postoperative myocardial injuries on 30-day mortality after non-cardiac surgery. Therefore, we evaluated and compared the effects of pre- and postoperative myocardial injury on 30-day mortality after non-cardiac surgery. From January 2010 to December 2016, patients undergoing non-cardiac surgery were stratified into either the normal (n = 3182), preoperative myocardial injury (n = 694), or postoperative myocardial injury (n = 756) groups according to the peak cardiac troponin value. Myocardial injury was defined as a sole elevation of cardiac troponin value above the 99th percentile upper reference limit without ischemic symptom using the 4th universal definition of myocardial infarction. Patients in the preoperative myocardial injury group were further divided into the attenuated (n = 177) or persistent myocardial injury group (n = 517) according to the normalization of cardiac troponin level in postoperative period. As the primary outcome, postoperative 30-day mortalities were compared among the groups using the weighted Cox proportional-hazards regression models with the inverse probability weighting. Compared with the normal group, postoperative 30-day mortality was increased significantly both in the pre- and postoperative myocardial injury groups (1.4% vs. 10.7%; hazard ratio [HR] 3.12; 95% confidence interval [CI] 1.62-6.01; p = 0.001 and 1.4% vs. 7.4%; HR 4.49; 95% CI 2.34-8.60; p < 0.001, respectively), however, there was no difference between the pre- and postoperative myocardial injury groups (HR, 1.44; 95% CI 0.79-2.64; p = 0.45). In addition, the attenuated myocardial injury group showed a significantly lower postoperative 30-day mortality than the persistent myocardial injury group (5.6% vs. 12.4%; HR 2.23; 95% CI 1.17-4.44; p = 0.02). In patients undergoing non-cardiac surgery, preoperative myocardial injury also increased postoperative 30-day mortality to a similar degree of postoperative myocardial injury. Further studies on the importance of preoperative myocardial injury are needed.Clinical trial number and registry URL: KCT0004348 ( www.cris.nih.go.kr ).

Volatile versus total intravenous anesthesia for 30-day mortality following non-cardiac surgery in patients with preoperative myocardial injury.

We evaluated whether volatile anesthetics can improve the postoperative outcomes of non-cardiac surgery in patients with preoperative myocardial injury defined by the cardiac troponin elevation. From January 2010 to June 2018, 1254 adult patients with preoperative myocardial injury underwent non-cardiac surgery under general anesthesia and were enrolled in this study. Patients were stratified into following two groups according to anesthetic agents; 115 (9.2%) patients whose anesthesia was induced and maintained with continuous infusion of propofol and remifentanil (TIVA group) and 1139 (90.8%) patients whose anesthesia was maintainted with volatile anesthetics (VOLATILE group). The primary outcome was 30-day mortality. To diminish the remifentanil effect, a further analysis was conducted after excluding the patients who received only volatile anesthetics without remifentanil infusion. In a propensity-score matched analysis, 30-day mortality was higher in the TIVA group than the VOLATILE group (17.0% vs. 9.1%; hazard ratio [HR] 2.60; 95% confidence interval [CI], 1.14-5.93; p = 0.02). In addition, the TIVA group showed higher 30-day mortality than the VOLATILE group, even after eliminating the effect of remifentanil infusion (15.8% vs. 8.3%; HR 4.62; 95% CI, 1.82-11.74; p = 0.001). In our study, the use of volatile anesthetics showed the significant survival improvement after non-cardiac surgery in patients with preoperative myocardial injury, which appears to be irrelevant to the remifentanil use. Further studies are needed to confirm this beneficial effect of volatile anesthetics. Clinical trial number and registry URL: KCT0004349 (www.cris.nih.go.kr).

Penetrating cardiac trauma in stab wounds: A study of diagnostic accuracy of the cardiac area.

BACKGROUND: Stab wounds (SW) to the thorax raises suspicion for cardiac injuries; however, the topographic description is variable. The present study aims to evaluate different topographical descriptions within the thorax and establish their diagnostic value in penetrating cardiac trauma by SW. METHODS: Medical records of all patients admitted to our center with thoracic SW from January 2013 to June 2016 were included in this study. Diagnostic value potential was measured using different areas of the thorax described in the literature. RESULTS: In this study, we analyzed 306 cases. Thirty-eight (12.4%) patients had a cardiac injury managed surgically. Death by cardiac injury occurred in seven (18.4%) patients. The cardiac area defined between the right mid-clavicle line until the left anterior axillary line, and between 2nd and 6th intercostal spaces was the more accurate. It has sensitivity of 97.3%, specificity 72%, positive predictive value 33%, negative predictive value 99.4% and accuracy 75.1% for penetrating cardiac trauma. ROC was 0.894 IC 95% (0.760-0.901). CONCLUSION: Among the thoracic areas, topographical limits between the right mid-clavicle line and the left anterior axillary line, and between 2nd and 6th intercostal spaces are the more accurate and are highly indicative of cardiac injury in patients with SW to the thorax.

The association between cardiac injury and outcomes in hospitalized patients with COVID-19.

In this study, we aimed to assess the association between development of cardiac injury and short-term mortality as well as poor in-hospital outcomes in hospitalized patients with COVID-19. In this prospective, single-center study, we enrolled hospitalized patients with laboratory-confirmed COVID-19 and highly suspicious patients with compatible chest computed tomography features. Cardiac injury was defined as a rise of serum high sensitivity cardiac Troponin-I level above 99th percentile (men: > 26 ng/mL, women: > 11 ng/mL). A total of 386 hospitalized patients with COVID-19 were included. Cardiac injury was present among 115 (29.8%) of the study population. The development of cardiac injury was significantly associated with a higher in-hospital mortality rate compared to those with normal troponin levels (40.9% vs 11.1%, p value < 0.001). It was shown that patients with cardiac injury had a significantly lower survival rate after a median follow-up of 18 days from symptom onset (p log-rank < 0.001). It was further demonstrated in the multivariable analysis that cardiac injury could possibly increase the risk of short-term mortality in hospitalized patients with COVID-19 (HR = 1.811, p-value = 0.023). Additionally, preexisting cardiovascular disease, malignancy, blood oxygen saturation < 90%, leukocytosis, and lymphopenia at presentation were independently associated with a greater risk of developing cardiac injury. Development of cardiac injury in hospitalized patients with COVID-19 was significantly associated with higher rates of in-hospital mortality and poor in-hospital outcomes. Additionally, it was shown that development of cardiac injury was associated with a lower short-term survival rate compared to patients without myocardial damage and could independently increase the risk of short-term mortality by nearly two-fold.

Markers of Myocardial Stress, Myocardial Injury, and Subclinical Inflammation and the Risk of Sudden Death.

BACKGROUND: The majority of sudden cardiac deaths (SCDs) occur in low-risk populations often as the first manifestation of cardiovascular disease (CVD). Biomarkers are screening tools that may identify subclinical cardiovascular disease and those at elevated risk for SCD. We aimed to determine whether the total to high-density lipoprotein cholesterol ratio, high-sensitivity cardiac troponin I, NT-proBNP (N-terminal pro-B-type natriuretic peptide), or high-sensitivity C-reactive protein individually or in combination could identify individuals at higher SCD risk in large, free-living populations with and without cardiovascular disease. METHODS: We performed a nested case-control study within 6 prospective cohort studies using 565 SCD cases matched to 1090 controls (1:2) by age, sex, ethnicity, smoking status, and presence of cardiovascular disease. RESULTS: The median study follow-up time until SCD was 11.3 years. When examined as quartiles or continuous variables in conditional logistic regression models, each of the biomarkers was significantly and independently associated with SCD risk after mutually controlling for cardiac risk factors and other biomarkers. The mutually adjusted odds ratios for the top compared with the bottom quartile were 1.90 (95% CI, 1.30-2.76) for total to high-density lipoprotein cholesterol ratio, 2.59 (95% CI, 1.76-3.83) for high-sensitivity cardiac troponin I, 1.65 (95% CI, 1.12-2.44) for NT-proBNP, and 1.65 (95% CI, 1.13-2.41) for high-sensitivity C-reactive protein. A biomarker score that awarded 1 point when the concentration of any of those 4 biomarkers was in the top quartile (score range, 0-4) was strongly associated with SCD, with an adjusted odds ratio of 1.56 (95% CI, 1.37-1.77) per 1-unit increase in the score. CONCLUSIONS: Widely available measures of lipids, subclinical myocardial injury, myocardial strain, and vascular inflammation show significant independent associations with SCD risk in apparently low-risk populations. In combination, these measures may have utility to identify individuals at risk for SCD.

Postoperative statin treatment may be associated with improved mortality in patients with myocardial injury after noncardiac surgery.

Myocardial injury after noncardiac surgery (MINS) is recently accepted as a strong predictor of mortality, regardless of symptoms. However, anticoagulation is the only established treatment. This study aimed to evaluate the association between statin treatment and mortality after MINS. From January 2010 to June 2019, a total of 5,267 adult patients who were discharged after the occurrence of MINS were enrolled. The patients were divided into two groups according to statin prescription at discharge. The outcomes were 1-year and overall mortalities. Of the total 5,109 patients, 1,331 (26.1%) patients were in the statin group and 3,778 (73.9%) patients were in the no statin group. The 1-year and overall mortalities were significantly lower in the statin group compared with the no statin group (6.1% vs. 13.3%; hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.41-0.74; p < 0.001 for 1-year mortality and 15.0% vs. 25.0%; HR, 0.62; 95% CI, 0.51-0.76; p < 0.001 for overall mortality). Analyses after inverse probability treatment weighting showed similar results (HR, 0.61; 95% CI, 0.50-0.74; p < 0.001 for 1-year mortality and HR, 0.70; 95% CI, 0.54-0.90; p = 0.006 for overall mortality), and the mortalities did not differ according to the dose of statin. Our results suggest that statin treatment may be associated with improved survival after MINS. A trial is needed to confirm this finding and establish causality.

Penetrating injury to the cardiac box.

BACKGROUND: A penetrating injury to the "cardiac box" is thought to be predictive of an injury to the heart; however, there is very little evidence available to support this association. This study aims to evaluate the relationship between penetrating trauma to the cardiac box and a clinically significant injury. METHODS: All patients presenting to a Level I trauma center from January 2009 to June 2015 who sustained a penetrating injury isolated to the thorax were retrospectively identified. Patients were categorized according to the location of injury: within or outside the historical cardiac box. Patients with concurrent injuries both inside and outside the cardiac box were excluded. Clinical demographics, injuries, procedures, and outcomes were compared. RESULTS: During this 7-year period, 330 patients (92% male; median age, 28 years) sustained penetrating injuries isolated to the thorax: 138 (42%) within the cardiac box and 192 (58%) outside the cardiac box. By mechanism, 105 (76%) were stab wounds (SW) and 33 (24%) were gunshot wounds (GSW) inside the cardiac box, and 125 (65%) SW and 67 (35%) GSW outside the cardiac box. The overall rate of thoracotomy or sternotomy (35/138 [25.4%] vs. 15/192 [7.8%], p < 0.001) and the incidence of cardiac injury (18/138 [13%] vs. 5/192 [2.6%], p < 0.001) were significantly higher in patients with penetrating trauma within the cardiac box. This was, however, dependent on mechanism with SW demonstrating a higher incidence of cardiac injury (15/105 [14.3%] vs. 3/125 [2.4%], p = 0.001) and GSW showing no significant difference (3/33 [9.1%] vs. 2/67 [3%], p = 0.328]. There was no difference in overall mortality (9/138 [6.5%] vs. 6/192 [3.1%], p = 0.144). CONCLUSION: The role of the cardiac box in the clinical evaluation of a patient with a penetrating injury to the thorax has remained unclear. In this analysis, mechanism is important. Stab wounds to the cardiac box were associated with a higher risk of cardiac injury. However, for GSW, injury to the cardiac box was not associated with a higher incidence of injury. The diagnostic interaction between clinical examination and ultrasound, for the diagnosis of clinically significant cardiac injuries, warrants further investigation. LEVEL OF EVIDENCE: Prognostic study, Level IV, Therapeutic V.

Bailout bypass surgery for complications of coronary interventions.

BACKGROUND: Mechanical complications of percutaneous coronary interventions are treated percutaneously in most cases. If the rescue intervention is unsuccessful, bailout bypass surgery is necessary to restore the coronary flow. The surgical risk in these cases is higher than that of patients operated on for other indications. The aim of our study was to characterize patients who underwent surgical treatment at our institution and to compare their long-term outcomes with patients who underwent emergency bypass surgery for other indications. METHODS: We analyzed 707 consecutive patients who underwent isolated emergency bypass surgery at our institution from 2007 to 2015. In 44 of these cases, the surgery was necessitated by mechanical complications of percutaneous coronary interventions. There were 31 coronary dissections, 5 entrapped guidewires, and 8 coronary perforations. We compared patients in these three groups with one another. Follow-up was performed to assess long-term outcomes. RESULTS: The median age of the cohort was 68 years (range 59-75 years), and 36 (81.8%) patients presented in cardiogenic shock. Thirty-seven (84.1%) patients had history of a percutaneous coronary intervention. The courses were typical for bypass patients. The long-term survival was similar in all three subgroups (p = 0.16). The survival profiles within our sample did not differ significantly from that in patients who underwent emergency bypass surgery for other indications. CONCLUSIONS: Surgical risk and short- and long-term outcomes of patients undergoing emergency bypass surgery due to mechanical complications of percutaneous coronary interventions are similar to those of patients receiving the same surgery for other indications.

Long-Term Mortality in Cardioinhibitory Carotid Sinus Hypersensitivity Patient Cohort / Mortalidade de uma Coorte de Portadores da Resposta Cardioinibitória à Massagem do Seio Carotídeo - Estudo Longitudinal com 11 Anos de Seguimento

Abstract Background: Cardioinhibitory carotid sinus hypersensitivity (CICSH) is defined as ventricular asystole ≥ 3 seconds in response to 5-10 seconds of carotid sinus massage (CSM). There is a common concern that a prolonged asystole episode could lead to death directly from bradycardia or as a consequence of serious trauma, brain injury or pause-dependent ventricular arrhythmias. Objective: To describe total mortality, cardiovascular mortality and trauma-related mortality of a cohort of CICSH patients, and to compare those mortalities with those found in a non-CICSH patient cohort. Methods: In 2006, 502 patients ≥ 50 years of age were submitted to CSM. Fifty-two patients (10,4%) were identified with CICSH. Survival of this cohort was compared with that of another cohort of 408 non-CICSH patients using Kaplan-Meier curves. Cox regression was used to examine the relation between CICSH and mortality. The level of statistical significance was set at 0.05. Results: After a maximum follow-up of 11.6 years, 29 of the 52 CICSH patients (55.8%) were dead. Cardiovascular mortality, trauma-related mortality and the total mortality rate of this population were not statistically different from that found in 408 patients without CICSH. (Total mortality of CICSH patients 55.8% vs. 49,3% of non-CICSH patients; p: 0.38). Conclusion: At the end of follow-up, the 52 CICSH patient cohort had total mortality, cardiovascular mortality and trauma-related mortality similar to that found in 408 patients without CICSH.

Resumo Fundamento: A resposta cardioinibitória (RCI) à massagem do seio carotídeo (MSC) caracteriza-se por assistolia ≥ 3 segundos provocada por 5 a 10 segundos de MSC. Existe uma preocupação de que pacientes com RCI e episódios prolongados de assistolia possam falecer em consequência direta de bradiarritmia, ou em decorrência de lesão cerebral, trauma grave ou arritmia ventricular pausa dependente. Objetivos: Determinar a mortalidade total, a mortalidade cardiovascular e a mortalidade relacionada ao trauma de uma coorte de pacientes com RCI à MSC e comparar essas mortalidades com as de uma coorte de pacientes sem RCI à MSC. Métodos: Em 2006, 502 pacientes com idade igual ou superior a 50 anos foram submetidos à MSC. Destes, 52 pacientes (10,4%) foram identificados com RCI. A sobrevida desta coorte foi comparada àquela observada em uma coorte de 408 pacientes sem RCI por meio de curvas de Kaplan-Meier. A regressão de Cox foi utilizada para avaliação da relação entre a RCI à MSC e a mortalidade. Variáveis com p < 0,05 foram consideradas estatisticamente significativas. Resultados: Após seguimento máximo de 11,6 anos, 29 dos 52 portadores de RCI (55,8%) faleceram. A mortalidade total, a mortalidade cardiovascular e a mortalidade relacionada ao trauma desta coorte de pacientes não foram significativamente diferentes daquelas encontradas nos 408 pacientes sem RCI (mortalidade total com RCI: 55,8% versus 49,3% sem RCI; p: 0,38). Conclusões: No fim do seguimento, a mortalidade dos 52 portadores de RCI foi semelhante à observada em uma coorte de pacientes sem RCI. A mortalidade cardiovascular e a relacionada ao trauma também foi semelhante nas duas coortes.

Comparison of the causes of death and wounding patterns in urban firearm-related violence and civilian public mass shooting events.

BACKGROUND: There are no reports comparing wounding pattern in urban and public mass shooting events (CPMS). Because CPMS receive greater media coverage, there is a connation that the nature of wounding is more grave than daily urban gun violence. We hypothesize that the mechanism of death following urban gunshot wounds (GSWs) is the same as has been reported following CPMS. METHODS: Autopsy reports of all firearm-related deaths in Washington, DC were reviewed from January 1, 2016, to December 31, 2017. Demographic data, firearm type, number and anatomic location of GSWs, and organ(s) injured were abstracted. The organ injury resulting in death was noted. The results were compared with a previously published study of 19 CPMS events involving 213 victims. RESULTS: One hundred eighty-six urban autopsy reports were reviewed. There were 171 (92%) homicides and 13 (7%) suicides. Handguns were implicated in 180 (97%) events. One hundred eight (59%) gunshots were to the chest/upper back, 85 (46%) to the head, 77 (42%) to an extremity, and 71 (38%) to the abdomen/lower back. The leading mechanisms of death in both urban firearm violence and CPMS were injury to the brain, lung parenchyma, and heart. Fatal brain injury was more common in CPMS events as compared with urban events involving a handgun. CONCLUSION: There is little difference in wounding pattern between urban and CPMS firearm events. Based on the organs injured, rapid point of wounding care and transport to a trauma center remain the best options for mitigating death following all GSW events. LEVEL OF EVIDENCE: Epidemiological, level IV.

Survival after pre-hospital emergency clamshell thoracotomy for blunt cardiac rupture.

Blunt trauma causing cardiac rupture is usually fatal. We report a patient with blunt cardiac injury that suffered traumatic cardiac arrest in the pre-hospital phase of their care. A cardiac tamponade was confirmed with portable ultrasound in a brief return of circulation. The patient had a further cardiac arrest and subsequently underwent damage control emergency surgery via a clamshell thoracotomy at the scene. The tamponade was released and a clamp was applied to the identified left atrial appendage rupture, a return of circulation then occurred. He was transferred to a cardiothoracic centre where a left atrial appendage rupture was identified and closed. The patient had a complicated recovery in hospital but went on to survive neurologically intact. This is the first documented case report of a neurologically intact survivor of a pre-hospital clamshell thoracotomy for blunt trauma. Although survivors of blunt trauma who have pre-hospital thoracotomy are extremely rare it should be considered in very specific circumstances.

Outcomes of patients who undergo percutaneous coronary intervention with covered stents for coronary perforation: A systematic review and pooled analysis of data.

OBJECTIVES: This review aims to evaluate the adverse outcomes for patients after treatment with covered stents. BACKGROUND: Coronary perforation is a potentially fatal complication of percutaneous coronary revascularization which may be treated using covered stents. Studies have evaluated long-term outcomes among patients who received these devices, but hitherto no literature review has taken place. METHODS: We conducted a systematic review of adverse outcomes for patients after treatment with covered stents. Data from studies were pooled and outcomes were compared according to stent type. RESULTS: A total of 29 studies were analyzed with data from 725 patients who received covered stents. The proportion of patients with chronic total occlusions, vein graft percutaneous coronary intervention (PCI), intracoronary imaging and rotational atherectomy were 16.9, 11.5, 9.2, and 6.6%, respectively. The stents used were primarily polytetrafluoroethylene (PTFE) (70%) and Papyrus (20.6%). Mortality, major adverse cardiovascular events, pericardiocentesis/tamponade and emergency surgery were 17.2, 35.3, 27.1, and 5.3%, respectively. Stratified analysis by use of PTFE, Papyrus and pericardial stents, suggested no difference in mortality (p = .323), or target lesion revascularization (p = .484). Stent thrombosis, pericardiocentesis/tamponade and emergency coronary artery bypass surgery (CABG) occurred more frequently in patients with PTFE stent use (p = .011, p = .005, p = .012, respectively). In-stent restenosis was more common with pericardial stent use (<.001, pooled analysis for first- and second-generation pericardial stents). CONCLUSIONS: Cases of coronary perforation which require implantation of a covered stent are associated with a high rate of adverse outcomes. The use of PTFE covered stents appears to be associated with more stent thrombosis, pericardiocentesis/tamponade, and emergency CABG when compared to Papyrus or pericardial stents.

Traumatismo penetrante cardiaco: caracterización, resultados inmediatos y variables asociadas a morbilidad y mortalidad en pacientes operados / Penetrating cardiac trauma: findings, outcomes and prognostic factors in operated patients

INTRODUCCIÓN: El traumatismo penetrante cardiaco (TPC) por sus características y en particular por su alta mortalidad, constituye un desafío quirúrgico permanente. OBJETIVOS: Describir las características, resultados inmediatos y factores pronósticos en TPC. MATERIALES Y MÉTODO: Estudio descriptivo transversal, revisión de protocolos prospectivos de traumatismo torácico, registros de pabellón y fichas clínicas. Período enero de 1990-diciembre de 2017. Se incluyeron todos los pacientes con TPC operados. Se describen y analizan diversas variables. Se realizó regresión logística con análisis univariado y multivariado para identificar variables asociadas a morbilidad, deterioro neurológico y mortalidad. RESULTADOS: 220 pacientes operados por TPC, 209 (95,0%) hombres, edad promedio 30,4 ± 13,3, mediana 27 años. Mecanismo: agresión en 202 (91,8%). El agente traumático fue en 186 (84,5%) arma blanca, en 21 (9,5%) arma de fuego. Presentaban taponamiento 169 (76,8%) pacientes, ingresaron en shock 103 (46,8%) y en paro cardiorrespiratorio 20 (9,1%). Vía de abordaje fue esternotomía en 157 (71,4%), toracotomía izquierda en 58 (26,4%). Las cavidades cardiacas lesionadas más frecuentes fueron ventrículo derecho en 110 (50,0%), ventrículo izquierdo en 72 (32,7%). Se hospitalizaron en UCI en el postoperatorio 135 (61,4%), se transfundieron 74 (33,6%), presentaron complicaciones 60 (27,3%) y se reoperaron 21 (9,5%). Mortalidad 28 (12,7%). La estadía postoperatoria tuvo una mediana de 6 días (rango 1-150). Se identificaron factores pronósticos. DISCUSIÓN: Los TPC operados son más frecuentes en hombres agredidos con arma blanca, la cavidad lesionada más frecuente es el ventrículo derecho. Nuestra morbimortalidad es comparable con series internacionales.

INTRODUCTION: Penetrating cardiac trauma (PCT) constitute a permanent surgical challenge due to it characteristics and high mortality. AIM: To describe the findings, outcomes and prognostic factors in PCT. MATERIAL AND METHOD: Cross-sectional descriptive study, review of prospective thoracic trauma protocols and surgical registries. Period January 1990-December 2017. All patients with PCT were included. Various variables are described and analyzed. Univariate and multivariate analysis were performed to identify factors associated with morbidity, neurologic dysfunction and mortality. RESULTS: 220 patients PCT, 209 (95.0%) men, mean age 30.4 ± 13.3, median 27 years. Mechanism: Aggression in 202 (91.8%). The traumatic agent was cold steel in 186 (84.4%) and fire arm in 21 (9.5%). 169 (76.8%) patients presented with tamponade, 103 (46.8%) shock and 20 (9.1%) cardiopulmonary arrest. Approach was sternotomy in 157 (71.4%), left thoracotomy in 58 (26.4%). The most common injured areas were right ventricle in 110 (50.0%), left ventricle in 72 (32.7%). 135 (61.4%) patients needed postoperative ICU and 74 (33.6%) were transfused. Complications occurred in 60 (27.3%). Twenty-one (9.5%) were reoperated. Mortality 28 (12.7%). The postoperative median stay was 6 days (Range 1-150). Prognostic factors were identified. DISCUSSION: Operated PCT are more frequent in men with stab wound, the most common injured area is the right ventricle. The morbidity and mortality is comparable with international series.

Association Between Mean Arterial Pressure and Acute Kidney Injury and a Composite of Myocardial Injury and Mortality in Postoperative Critically Ill Patients: A Retrospective Cohort Analysis.

OBJECTIVES: Hypotension thresholds that provoke renal injury, myocardial injury, and mortality in critical care patients remain unknown. We primarily sought to determine the relationship between hypotension and a composite of myocardial injury (troponin T ≥ 0.03 ng/mL without nonischemic cause) and death up to 7 postoperative days. Secondarily, we considered acute kidney injury (creatinine concentration ≥ 0.3 mg/dL or 1.5 times baseline). DESIGN: Retrospective cohort. SETTING: Surgical ICU at an academic medical center. PATIENTS: Two-thousand eight-hundred thirty-three postoperative patients admitted to the surgical ICU. INTERVENTIONS: A Cox proportional hazard survival model was used to assess the association between lowest mean arterial pressure on each intensive care day, considered as a time-varying covariate, and outcomes. In sensitivity analyses hypotension defined as pressures less than 80 mm Hg and 70 mm Hg were also considered. MEASUREMENTS AND MAIN RESULTS: There was a strong nonlinear (quadratic) association between the lowest mean arterial pressure and the primary outcome of myocardial injury after noncardiac surgery or mortality, with estimated risk increasing at lower pressures. The risk of myocardial injury after noncardiac surgery or mortality was an estimated 23% higher at the 25th percentile (78 mm Hg) of lowest mean arterial pressure compared with at the median of 87 mm Hg, with adjusted hazard ratio (95% CI) of 1.23 (1.12-1.355; p < 0.001). Overall results were generally similar in sensitivity analyses based on every hour of mean arterial pressure less than 80 mm Hg and any mean arterial pressure less than 70 mm Hg. Post hoc analyses showed that the relationship between ICU hypotension and outcomes depended on the amount of intraoperative hypotension. The risk of acute kidney injury increased over a range of minimum daily pressures from 110 mm Hg to 50 mm Hg, with an adjusted hazard ratio of 1.27 (95% CI, 1.18-1.37; p < 0.001). CONCLUSIONS: Increasing amounts of hypotension (defined by lowest mean arterial pressures per day) were strongly associated with myocardial injury, mortality, and renal injury in postoperative critical care patients.

Predictors of periprocedural complications in patients undergoing percutaneous coronary interventions within coronary artery bypass grafts.

BACKGROUND: During the first decade following the coronary bypass grafting, at least ten percent of the patients require percutaneous coronary interventions (PCI) due to graft failure. Saphenous vein grafts (SVG) are innately at a higher risk of periprocedural complications. The present study aimed to investigate predictors of periprocedural complications of PCI within coronary artery bypass grafts. METHODS: This study analyzed data gathered in the Polish National Registry (ORPKI) between January 2015 and December 2016. Of the 221,195 patients undergoing PCI, data on 2,616 patients after PCI of SVG and 442 patients after internal mammary artery (IMA) were extracted. The dissimilarities in periprocedural complications between the SVG, IMA and non-IMA/SVG groups and their predictors were investigated. RESULTS: Patients in the SVG group were older (p < 0.001), with a higher burden of concomitant disease and differing clinical presentation. The rate of de-novo lesions was lower, while restenosis was higher at baseline in the SVG (p < 0.001). The rate of no-reflows (p < 0.001), perforations (p = 0.01) and all periprocedural complications (p < 0.01) was higher in the SVG group, while deaths were lower (p < 0.001). Among the predictors of no-reflows, it was found that acute coronary syndromes (ACS), thrombectomy and past cerebral stroke, while the complications included arterial hypertension, Thrombolysis in Myocardial Infarction (TIMI) flow before PCI and thrombectomy. CONCLUSIONS: Percutaneous coronary interventions of SVG is associated with increased risk of specific periprocedural complications. The ACS, slower TIMI flow before PCI and thrombectomy significantly increase the periprocedural complication rate in patients undergoing PCI of SVG.

Incidence, predictors, management and outcomes of coronary perforations.

OBJECTIVES: We examined the contemporary incidence, types, predictors, angiographic characteristics, management and outcomes of coronary perforation. BACKGROUND: Coronary perforation is a rare, but important, complication of percutaneous coronary intervention (PCI). There is lack of data on perforations stratified as large and distal vessel perforations. METHODS: Retrospective, observational cohort study of all patients who underwent PCI at a high volume, tertiary hospital between the years 2009 and 2016. Angiograms of all coronary perforation cases were reviewed to determine the mechanism, type, and management of perforation. Risk-adjusted periprocedural complication rates were compared between patients with and without coronary perforation. One-year mortality outcomes of patients with large vessel vs. distal vessel perforation were also examined. RESULTS: Coronary perforation occurred in 68 of 13,339 PCIs (0.51%) performed during the study period: 51 (75%) were large vessel perforations and 17 (25%) distal vessel perforations. Most (67%) large vessel perforations were due to balloon/stent inflation, whereas most (94%) distal vessel perforations were due to guidewire exit. Patients with coronary perforations had significantly higher risk for periprocedural complications (adjusted odds ratio 7.57; 95% CI: 4.22-13.50; P < 0.001). Only one patient with large vessel perforation required emergency cardiac surgery, yet in-hospital mortality was high with both large vessel (7.8%) and distal vessel (11.8%) perforations. CONCLUSIONS: Coronary perforation is an infrequent, but potentially severe PCI complication. Most coronary perforations are large vessel perforations. Although coronary perforations rarely lead to emergency cardiac surgery, both distal vessel and large vessel perforations are associated with high in-hospital mortality, highlighting the importance of prevention.

Outcome of penetrating chest injuries in an urban level I trauma center in the Netherlands.

INTRODUCTION: Most patients with penetrating chest injuries benefit from early treatment with chest tube drainage or surgery. Although penetrating chest injury is not uncommon, few descriptive studies are published, especially in Europe. The aim of this study was to review our experience and further improve our management of penetrating chest injuries in a level I trauma center in the Netherlands. METHODS: All patients with penetrating chest injury between August 2004 and December 2012 were included. Demographics, mechanism of injury, physiological parameters, Injury Severity Scores (ISS), surgical and non-surgical treatment, length of intensive care unit (ICU) stay, length of hospital stay (LOS), complications and rate of mortality were collected. RESULTS: A total of 159 patients were analyzed. Patients included 116 (73 %) stab wounds and 34 (21 %) gunshot wounds. In 27 patients (17 %), cardiac injury was seen. The mean ISS was 12. Almost half of all patients (49 %) were treated with only chest tube drainage. Alternatively, surgical treatment was performed in 24 % of all cases. Anterolateral incision was most frequently used to gain access to the thoracic cavity. The mean LOS was 9 days. Among all patients, 17 % were admitted to the ICU with a mean stay of 3 days. In 18 (11 %) patients, one or more complications occurred. The 30-day mortality was 7.5 %. CONCLUSION: Patients presenting with penetrating chest injury are not uncommon in the Netherlands and can mostly be treated conservatively. In one-fourth of the patients, surgical treatment is performed. A structural and vigorous approach is needed for good clinical outcome.