Nitric oxide enhancement supplement containing beet nitrite and nitrate benefits high intensity cycle interval training.

This study investigated the effects of a beet nitric oxide enhancing (NOE) supplement comprised of nitrite and nitrate on cycling performance indices in trained cyclists. METHODS: Subjects completed a lactate threshold test and a high-intensity interval (HIIT) protocol at 50% above functional threshold power with or without oral NOE supplement. RESULTS: NOE supplementation enhanced lactate threshold by 7.2% (Placebo = 191.6 ± 37.3 W, NOE = 205.3 ± 39.9; p = 0.01; Effect Size (ES) = 0.40). During the HIIT protocol, NOE supplementation improved time to exhaustion 18% (Placebo = 1251 ± 562s, NOE = 1474 ± 504s; p = 0.02; ES = 0.42) and total energy expended 22.3% (Placebo = 251 ± 48.6 kJ, NOE = 306.6 ± 55.2 kJ; p = 0.01; ES = 1.079). NOE supplementation increased the intervals completed (Placebo = 7.00 ± 2.5, NOE = 8.14 ± 2.4; p = 0.03; ES = 0.42) and distance cycled (Placebo = 10.9 ± 4.0 km, NOE = 13.5 ± 3.9 km; p = 0.01; ES = 0.65). Also, target power was achieved at a higher cadence during the HIIT work and rest periods (p = 0.02), which enhanced muscle oxygen saturation (SmO2) recovery. Time-to-fatigue was negatively correlated with the degree of SmO2, desaturation during the HIIT work interval segment (r = -0.67; p 0.008), while both SmO2 desaturation and the SmO2 starting work segment saturation level correlated with a cyclist's kJ expended (SmO2 desaturation: r = -0.51, p = 0.06; SmO2 starting saturation: r = 0.59, p = 0.03). CONCLUSION: NOE supplementation containing beet nitrite and nitrate enhanced submaximal (lactate threshold) and HIIT maximal effort work. The NOE supplementation resulted in a cyclist riding at higher cadence rates with lower absolute torque values at the same power during both the work and rest periods, which in-turn delayed over-all fatigue and improved total work output.

Effects of a Multi-Ingredient Preworkout Supplement Versus Caffeine on Energy Expenditure and Feelings of Fatigue during Low-Intensity Treadmill Exercise in College-Aged Males.

The primary purpose of this study was to examine the acute effects of a multi-ingredient (i.e., caffeine, green tea extract, Yohimbe extract, capsicum annum, coleus extract, L-carnitine, beta-alanine, tyrosine) preworkout supplement versus a dose of caffeine (6 mg·kg-1) on energy expenditure during low-intensity exercise. The effects of these treatments on substrate utilization, gas exchange, and psychological factors were also investigated. Twelve males (mean ± SD: age = 22.8 ± 2.4 years) completed three bouts of 60 min of treadmill exercise on separate days after consuming a preworkout supplement, 6 mg·kg-1 of caffeine, or placebo in a randomized fashion. The preworkout and caffeine supplements resulted in significantly greater energy expenditure (p < 0.001, p = 0.006, respectively), V˙O2 (p < 0.001, p = 0.007, respectively), V˙CO2 (p = 0.006, p = 0.049, respectively), and V˙E (p < 0.001, p = 0.007, respectively) compared to placebo (collapsed across condition). There were no differences among conditions, however, for rates of fat or carbohydrate oxidation or respiratory exchange ratio. In addition, the preworkout supplement increased feelings of alertness (p = 0.015) and focus (p = 0.005) 30-min postingestion and decreased feelings of fatigue (p = 0.014) during exercise compared to placebo. Thus, the preworkout supplement increased energy expenditure and measures of gas exchange to the same extent as 6 mg·kg-1 of caffeine with concomitant increased feelings of alertness and focus and decreased feelings of fatigue.

Comparison of Multi-Frequency Bioelectrical Impedance and Dual-Energy X-Ray Absorptiometry to Assess Body Composition in College-Aged Adults.

The purpose of this study was to evaluate the validity of whole body percent fat (%BF) and segmental fat-free mass (FFM) using multi-frequency bioelectrical impedance analysis (MF-BIA) and dual-energy x-ray absorptiometry (DEXA) in college-aged adults. Sixty-two participants male (n = 32) and female (n = 30) completed MF-BIA and DEXA measurements following established pre-test guidelines. %BF and segmental FFM (right arm, left arm, trunk, right leg, and left leg) were collected and analyzed. The MF-BIA significantly (p < 0.05) underestimated %BF for all participants, females, and males compared to DEXA. In addition, MF-BIA significantly (p < 0.05) underestimated FFM in the arms and legs in all participants and males with the exception of the left arm in all subjects while significantly overestimating FFM in the trunk. In females, the MF-BIA overestimated FFM in the arms and trunk while significantly (p < 0.05) underestimating FFM in the legs. Difference plots also indicated that the underestimation of FFM from MF-BIA in the arms and legs increased as the amount of FFM increased. Thus, our findings suggested that the MF-BIA may not be accurate for measuring whole %BF and segmental FFM in the college-aged population.

Outcomes of transcatheter aortic valve implantation compared with surgical aortic valve replacement in geriatric patients with chronic kidney disease
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BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a less invasive treatment modality for patients with severe aortic valve stenosis (AS) who are at a higher risk if they have surgery. Preoperative chronic kidney disease (CKD) influences outcomes of cardiac surgery and is associated with a higher mortality and more complicated hospital course. The aims of our study were to evaluate the comparative outcomes of TAVI versus surgical aortic valve replacement (SAVR) in geriatric patients with preoperative CKD. MATERIALS AND METHODS: We prospectively collected data on patients > 75 years of age who underwent either SAVR or TAVI at Shaare Zedek Medical Center, Jerusalem, Israel. The outcomes studied were postoperative acute kidney injury (AKI), in-hospital and long-term mortality, and major neurologic and infectious morbidity. RESULTS: A total of 318 patients were analyzed, of those, 199 and 119 underwent SAVR and TAVI, respectively. In patients with CKD, there was no statistically significant difference in postoperative AKI. SAVR patients had significantly higher in-hospital mortality (OR 5.9; 95% CI 1.6 - 29.6, p = 0.02), postoperative infection (OR 4.2; 95% CI 1.6 - 12.4, p = 0.005), and longer duration of hospital stay. Mortality at 1 and 2 years was lower in the SAVR group, although the difference was not statistically significant (p = 0.059). CONCLUSION: For elderly patients with CKD who are at a higher risk if they have surgery. TAVI offers a good alternative with lower procedural risk.
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Neutrophil-Lymphocyte Ratio: Prognostic Impact in Heart Surgery. Early Outcomes and Late Survival.

BACKGROUND: The neutrophil-lymphocyte ratio (NLR) is a recognized marker of inflammation associated with poor outcomes in various clinical situations. We analyzed the prognostic significance of preoperative elevated NLR in patients undergoing cardiac surgery. METHODS: We performed a retrospective review of 3,027 consecutive patients undergoing cardiac surgery. Receiver-operating-characteristic was used to determine the cutoff value for elevated NLR. Multivariate regression was used to determine the predictive value of preoperative NLR on clinical outcomes. Cox proportional hazards functions were used to determine predictors of late events. Late survival data to 16 years was obtained from the Ministry of Interior. RESULTS: The cutoff value for elevated NLR was 2.6. Patients with elevated NLR were older (p < 0.0001), had a higher incidence of cardiac comorbidity (p < 0.0001), and higher European System for Cardiac Operative Risk Evaluation score (p < 0.0001). An elevated NLR emerged as an independent predictor of operative mortality (hazard ratio [HR] 2.15, 95% confidence interval [CI]: 1.51 to 3.08, p < 0.0001); pleural effusion (HR 1.42, 95% CI: 1.13 to 1.80, p = 0.003); low output syndrome (HR 1.54, 95% CI: 1.23 to 1.93, p = 0.0002); prolonged ventilation (HR 1.49, 95% CI: 1.23 to 1.82, p = 0.0001); or composite outcomes (HR 1.61, 95% CI: 1.36 to 1.91, p < 0.0001). The NLR emerged as an independent predictor of late mortality (HR 1.19, 95% CI: 1.11 to 1.28; p < 0.0001). CONCLUSIONS: Elevated NLR is associated with a higher incidence of adverse outcomes after cardiac surgery. It is a predictor of operative as well as late mortality. Further studies are warranted to determine whether prophylactic treatment with antiinflammatory agents can prevent such outcomes. It may be warranted to include the baseline NLR as another variable in risk stratification of patients about to undergo cardiac surgery.

Preoperative aldosterone receptor blockade and outcomes of cardiac surgery in patients with chronic kidney disease
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BACKGROUND AND AIMS: Recent clinical evidence demonstrates that chronic low-dose mineralocorticoid receptor antagonists (MRA), when added to optimal treatment, result in reductions in cardiovascular mortality. However, continuation of MRAs before cardiac surgery in patients with CKD has never been evaluated and its potential benefit or harm in this specific clinical setting is largely unknown. MATERIALS AND METHODS: This is an observational study that included adult CKD patients undergoing cardiac surgery. Patients were divided into two groups according to preoperative use of spironolactone (SPL). The studied outcomes were postoperative acute kidney injury (AKI) requiring dialysis, mortality, and major morbidities (cardiovascular, neurologic, and infectious). RESULTS: Data on 698 patients with preoperative CKD stage III and IV were analyzed: 99 received SPL preoperatively and 599 did not. At baseline, patients on SPL had higher EuroScore and had more complicated surgery. No significant differences in the incidence of postoperative AKI, myocardial infarction (MI), cardiovascular accident (CVA), sepsis, and mortality were detected between groups in both univariate and multivariate analyses. However, incidence of postoperative low cardiac output state (p < 0.008) was significantly higher in the SPL group. Propensity score matching analyses yielded similar results. CONCLUSIONS: Although SPL is usually administered to significantly sicker patients, its use is not associated with increased major postoperative complications. However, the modulating effect of SPL in this clinical study remains to be elucidated in a prospective randomized trial.
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Uniportal video-assisted thoracic surgery: the Middle East experience.

BACKGROUND: The application of uniportal video-assisted thoracic surgery (VATS) for both minor and major thoracic procedures is gaining widespread use across the globe. Believing its advantages, both in superb surgical results and less morbidity, our center has the privilege to be one of the first centers in the Middle East to introduce this surgical technique into our standard practice. This study presents our initial experience using this technique in 192 procedures and demonstrates the results of postoperative pain level in a sample of 90 patients. METHODS: In a retrospective study of prospectively collected data, 192 uniportal VATS procedures were analyzed between November 2013 and June 2016. The level of early post-operative pain (postoperative days 1-4) was analyzed in the first 90 cases between November 2013 and March 2015. Uniportal technique was used for a wide array of procedures: blebectomies, pleurectomies, wedge resections, anatomical major lung resections, mediastinal tumors, empyema drainage and decortications. RESULTS: The mean age of patients was 49.6 years, and 72 patients were females (37%). Thirty-five (18.2%) patients underwent anatomical resections with conversion to thoracotomy in three patients (8%). Six (3%) patients had air leak >4 days. The average chest drain duration was 3.25 days. The average length of stay was 4.2 days. Postoperative pain level was low in the first 4 days following the surgery and 30 days mortality was 0%. CONCLUSIONS: Uniportal VATS surgery is a safe and established technique with a minimal invasive thoracic surgery. Excellent results with minimal morbidity, short hospital stay and low postoperative pain are amongst its strong points. Thoracic surgeons experienced in thoracic surgical approaches can safely perform uniportal VATS.

Untreated Mitral Regurgitation Does Not Affect Survival of Elderly Patients Undergoing TAVI.

BACKGROUND: The study aim was to examine the impact of concomitant significant mitral regurgitation (MR) in patients undergoing transcatheter aortic valve implantation (TAVI). TAVI has become an acceptable mode of treatment for high-surgical risk patients with aortic stenosis (AS) requiring valve replacement. A significant number of patients have concomitant MR which cannot be addressed by TAVI alone, and therefore may not be considered candidates for this procedure. A comparison was conducted of results obtained from patients undergoing TAVI with or without MR. METHODS: Between 2008 and 2013, a total of 164 patients (mean age 81 ± 8 years) underwent TAVI at the authors' institution. Of these patients, 87 (53%) had MR of moderate or greater degree. The groups were similar with respect to age, gender, presence of congestive heart failure, left ventricular function and co-morbid conditions. The logistic EuroSCORE was higher in the MR group (p = 0.02). RESULTS: Procedural (30-day) mortality was 12% (n = 19) and similar between groups. Kaplan-Meier estimates showed the overall survival at three years to be 68% and 76% for the MR and non-MR groups, respectively (p = 0.6). By Cox regression, age (p = 0.007) and peripheral vascular disease (p = 0.03) were the only predictors of late survival. Regression of MR was seen in patients with functional MR. Neither the presence of MR nor residual MR emerged as predictors of late mortality. CONCLUSIONS: In elderly patients undergoing TAVI the presence of MR does not impact survival. TAVI should not be withheld from this group of patients because of concomitant MR.

Next-generation sequencing in patients with advanced cancer: are we ready for widespread clinical use? A single institute's experience.

The next-generation sequencing (NGS) assay targeting cancer-relevant genes has been adopted widely for use in patients with advanced cancer. The primary aim of this study was to assess the clinical utility of commercially available NGS. We retrospectively collected demographic and clinicopathologic data, recommended therapy, and clinical outcomes of 30 patients with a variety of advanced solid tumors referred to Foundation Medicine NGS. The initial pathologic examination was performed at the pathology department of the referring hospital. The comprehensive clinical NSG assay was performed on paraffin-embedded tumor samples using the Clinical Laboratory Improvement Amendments-certified FoundationOne platform. The median number of genomic alterations was 3 (0-19). The median number of therapies with potential benefit was 2 (0-8). In 12 cases, a comprehensive clinical NGS assay did not indicate any therapy with potential benefit according to the genomic profile. Ten of the 30 patients received treatments recommended by genomic profile results. In six of the 10 cases, disease progressed within 2 months and four patients died within 3 months of treatment initiation. Three of the 30 patients benefited from a comprehensive clinical NGS assay and the subsequent recommended therapy. The median PFS was 12 weeks (95% confidence interval 10-57) in patients treated with molecularly targeted agents chosen on the basis of tumor genomic profiling versus 48 weeks (95% confidence interval 8-38) in the control group treated with physician choice therapy (P=0.12). Our study suggests that NGS can detect additional treatment targets in individual patients, but prospective medical research and appropriate clinical guidelines for proper clinical use are vital.

Preoperative hemoglobin and outcomes in patients with CKD undergoing cardiac surgery.

BACKGROUND AND OBJECTIVES: Preoperative anemia adversely affects outcomes of cardiothoracic surgery. However, in patients with CKD, treating anemia to a target of normal hemoglobin has been associated with increased risk of adverse cardiac and cerebrovascular events. We investigated the association between preoperative hemoglobin and outcomes of cardiac surgery in patients with CKD and assessed whether there was a level of preoperative hemoglobin below which the incidence of adverse surgical outcomes increases. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This prospective observational study included adult patients with CKD stages 3-5 (eGFR<60 ml/min per 1.73 m(2)) undergoing cardiac surgery from February 2000 to January 2010. Patients were classified into four groups stratified by preoperative hemoglobin level: <10, 10-11.9, 12-13.9, and ≥ 14 g/dl. The outcomes were postoperative AKI requiring dialysis, sepsis, cerebrovascular accident, and mortality. RESULTS: In total, 788 patients with a mean eGFR of 43.5 ± 3.7 ml/min per 1.73 m(2) were evaluated, of whom 22.5% had preoperative hemoglobin within the normal range (men: 14-18 g/dl; women: 12-16 g/dl). Univariate analysis revealed an inverse relationship between the incidence of all adverse postoperative outcomes and hemoglobin level. Using hemoglobin as a continuous variable, multivariate logistic regression analysis showed a proportionally greater frequency of all adverse postoperative outcomes per 1-g/dl decrement of preoperative hemoglobin (mortality: odds ratio, 1.38; 95% confidence interval, 1.23 to 1.57; P<0.001; sepsis: odds ratio, 1.31; 95% confidence interval, 1.14 to 1.49; P<0.001; cerebrovascular accident: odds ratio, 1.31; 95% confidence interval, 1.00 to 1.67; P=0.03; postoperative hemodialysis: odds ratio, 1.38; 95% confidence interval, 1.11 to 1.75; P<0.01). Moreover, preoperative hemoglobin<12 g/dl was an independent risk factor for postoperative mortality (odds ratio, 2.6; 95% confidence interval, 1.1 to 7.3; P=0.04). CONCLUSIONS: Similar to the general population, preoperative anemia is associated with adverse postoperative outcomes in patients with CKD. Whether outcomes could be improved by therapeutically targeting higher preoperative hemoglobin levels before cardiac surgery in patients with underlying CKD remains to be determined.

[Does mitral valve annuloplasty improve long-term survival in patients having moderate ischemic mitral regurgitation undergoing CABG?].

BACKGROUND: The best surgical approach for patients with moderate ischemic mitral regurgitation (IMR) is still undetermined. We examined long term outcomes in patients with moderate IMR undergoing coronary bypass (CABG), and compared outcomes between those undergoing isolated CABG to those undergoing concomitant restrictive annuloplasty. METHODS: Between the years 1993-2011, 231 patients with moderate IMR underwent CABG: group 1 (n = 186) underwent isolated CABG, group 2 (n = 15) underwent CABG with concomitant mitral valve annuloplasty. Univariate analysis was used to compare baseline parameters. Kaplan-Meier estimates were used to compare survival. Cox multivariate regression was used to determine predictors for late survival. Survival data up to 20 years is 97% complete. RESULTS: The groups were similar with respect to age, prior MI, LV function, and incidence of atrial fibrillation. Patients undergoing mitral repair had a higher incidence of congestive heart failure (CHF) (p < 0.0001). After surgery more repair patients required use of inotropes (p = 0.0005). Overall operative mortality was 7% and similar between groups. Ten year survival was 55% and 52% for groups 1 and 2 respectively (p = 0.2). Predictors of late mortality included age, CHF, LV dimensions and LV dysfunction. Neither the addition of a mitral procedure and type of ring implanted nor residual MR after surgery, emerged as predictors of survival. CONCLUSIONS: In patients with moderate ischemic MR, neither operative mortality nor long term survival are affected by the performance of a restrictive annuloplasty. For patients with CHF, mitral repair may be beneficial in terms of survival.

Comparison between transcatheter and surgical aortic valve replacement: a single-center experience.

BACKGROUND AND AIM OF THE STUDY: A comparison was made of the outcomes after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR) in high-risk patients. METHODS: All patients aged > 75 years that underwent a procedure for severe aortic stenosis with or without coronary revascularization at the authors' institution were included in the study; thus, 64 patients underwent TAVI and 188 underwent AVR. Patients in the TAVI group were older (mean age 84 +/- 5 versus 80 +/- 4 years; p < 0.0001) and had a higher logistic EuroSCORE (p = 0.004). RESULTS: Six patients (9%) died during the procedure in the TAVI group, and 23 (12%) died in the AVR group (p = 0.5). Predictors for mortality were: age (p < 0.0001), female gender (p = 0.02), and surgical valve replacement (p = 0.01). Gradients across the implanted valves at one to three months postoperatively were lower in the TAVI group (p < 0.0001). Actuarial survival at one, two and three years was 78%, 64% and 64%, respectively, for TAVI, and 83%, 78% and 75%, respectively, for AVR (p = 0.4). Age was the only predictor for late mortality (p < 0.0001). CONCLUSION: TAVI patients were older and posed a higher predicted surgical risk. Procedural mortality was lower in the TAVI group, but mid-term survival was similar to that in patients undergoing surgical AVR. Age was the only predictor for late survival. These data support the referral of high-risk patients for TAVI.

Diagnosis and treatment of early bioprosthetic malfunction in the mitral valve position due to thrombus formation.

Bioprosthetic valve thrombosis is uncommon and the diagnosis is often elusive and may be confused with valve degeneration. We report our experience with mitral bioprosthetic valve thrombosis and suggest a therapeutic approach. From 2002 to 2011, 149 consecutive patients who underwent mitral valve replacement with a bioprosthesis at a single center were retrospectively screened for clinical or echocardiographic evidence of valve malfunction. Nine were found to have valve thrombus. All 9 patients had their native valve preserved, representing 24% of those with preserved native valves. Five patients (group 1) presented with symptoms of congestive heart failure at 16.4 ± 12.4 months after surgery. Echocardiogram revealed homogenous echo-dense film on the ventricular surface of the bioprosthesis with elevated transvalvular gradient, resembling early degeneration. The first 2 patients underwent reoperation: valve thrombus was found and confirmed by histologic examination. Based on these, the subsequent 3 patients received anticoagulation treatment with complete thrombus resolution: mean mitral gradient decreased from 23 ± 4 to 6 ± 1 mm Hg and tricuspid regurgitation gradient decreased from 83 ± 20 to 49 ± 5 mm Hg. Four patients (group 2) were asymptomatic, but routine echocardiogram showed a discrete mass on the ventricular aspect of the valve: 1 underwent reoperation to replace the valve and 3 received anticoagulation with complete resolution of the echocardiographic findings. In conclusion, bioprosthetic mitral thrombosis occurs in about 6% of cases. In our experience, onset is early, before anticipated valve degeneration. Clinical awareness followed by an initial trial with anticoagulation is warranted. Surgery should be reserved for those who are not responsive or patients in whom the hemodynamic status does not allow delay. Nonresection of the native valve at the initial operation may play a role in the origin of this entity.

Very prolonged stay in the intensive care unit after cardiac operations: early results and late survival.

BACKGROUND: Prolonged intensive care unit (ICU) stay is a surrogate for advanced morbidity or perioperative complications, and resource utilization may become an issue. It is our policy to continue full life support in the ICU, even for patients with a seemingly grim outlook. We examined the effect of duration of ICU stay on early outcomes and late survival. METHODS: Between 1993 and 2011, 6,385 patients were admitted to the ICU after cardiac surgery. Patients were grouped according to length of stay in the ICU: group 1, 2 days or less (n = 4,631; 73%); group 2, 3 to 14 days (n = 1,423; 22%); group 3, more than 14 days (n = 331; 5%). Length of stay in ICU for group 3 patients was 38 ± 24 days (range, 15 to 160; median 31). Clinical profile and outcomes were compared between groups. RESULTS: Patients requiring prolonged ICU stay were older, underwent more complex surgery, had greater comorbidity, and a higher predicted operative mortality (p < 0.0001). They had a higher incidence of adverse events and increased mortality (p < 0.0001). Of the 331 group 3 patients, 60% were discharged: survival of these patients at 1, 3, and 5 years was 78%, 65%, and 52%, respectively. Operative mortality as well as late survival of discharged patients was proportional to duration of ICU stay. CONCLUSIONS: Current technology enables keeping sick patients alive for extended periods of time. Nearly two thirds of patients requiring prolonged ICU leave hospital, and of these, 50% attain 5-year survival. These data support offering full and continued support even for patients requiring very prolonged ICU stay.

Preoperative renal dysfunction and clinical outcomes of cardiac surgery in octogenarians.

BACKGROUND: The proportion of elderly individuals is growing and the prevalence of chronic kidney disease (CKD) among elderly people undergoing cardiac surgery is increasing constantly. The aim of this study was to determine the influence of different degrees of preoperative renal dysfunction on postoperative outcomes in patients older than 80years of age. METHODS: This is an observational study that included adult patients undergoing cardiac surgery in which data were collected prospectively. Patients were divided into groups according to their preoperative plasma creatinine and eGFR levels. RESULTS: From February 1997 to January 2010, 318 octogenarians underwent cardiac surgery. Of these, 140 patients (44%) had abnormal preoperative creatinine levels. A significantly higher incidence of postoperative sepsis (4% vs. 17%, p 0.03), CVA (1% vs. 6%, p 0.03), and prolonged hospital stay (16±13 vs. 20±16days, p 0.04) were detected in patients with preoperative kidney dysfunction. Subgroup analysis revealed that preoperative CKD stage IV (eGFR 15-30ml/min/1.73m(2)) but not CKD stage III (eGFR 30-60ml/min/1.73m(2)) and preoperative creatinine >1.8mg/dl were independently associated with increased incidence of postoperative CVA (OR 4; 95% CI 0.07-0. 8, p=0.05 for eGFR, and OR 7.8; 95% CI 1.2-60, p=0.003 for creatinine). However, no significant increment in postoperative mortality with decreasing eGFR or increasing preoperative creatinine was demonstrated. CONCLUSIONS: A substantial increase in the risk of postoperative CVA and sepsis, but not mortality, was demonstrated in octogenarians with advanced but not mild degrees of preoperative CKD. Compared to younger patients, a high burden of comorbidities in octogenarians may have a greater influence on outcomes post cardiac surgery than impaired renal function. Our data may provide a rationale for modified risk stratification in octogenarian candidates for cardiac surgery.

Influence of minimal changes in preoperative renal function on outcomes of cardiac surgery.

BACKGROUND/AIMS: Cardiovascular morbidity and mortality are high in patients with chronic kidney disease. We evaluated the influence of small differences in preoperative kidney function on mortality and complications following cardiac surgery. METHODS: This is an observational study that included adult patients undergoing cardiac surgery. Preoperative estimated glomerular filtration rate (eGFR) was estimated by the 4-component Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations based on preoperative creatinine levels. For analysis, patients were divided into groups according to their preoperative creatinine (0.2 mg/dl increments) and eGFR levels (15-30 ml/min/1.73 m(2) decrements). RESULTS: Data on 5,340 patients were analyzed. A significant increase in postoperative mortality was demonstrated with preoperative creatinine at high-normal versus low-normal values (OR 1.7, 95% CI: 1-2.5; p = 0.02). For preoperative creatinine >1.2 mg/dl, adjusted OR for in-hospital mortality increased stepwise with every 0.2-mg/dl increment of creatinine. In addition, a statistically significant increment of mortality was detected with every 15-ml/min/1.73 m(2) decrement in preoperative eGFR. CONCLUSIONS: Minimal changes of preoperative kidney function are associated with a substantial increase in the risk of mortality and morbidity following cardiac surgery. Even within the 'normal' range, minimal increases in serum creatinine levels are associated with increased risk of adverse events postoperatively.

Surgery for ischemic mitral regurgitation: should the valve be repaired?

BACKGROUND AND AIM OF THE STUDY: Patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG) often have concomitant mitral regurgitation (MR). Repairing the valve at the time of surgery is not universally accepted. The results of CABG with or without mitral valve annuloplasty (MVA) were compared in patients with reduced left ventricular (LV) function and ischemic MR. METHODS: Among a total of 195 patients, 108 underwent isolated CABG, and 87 underwent CABG with MVA. The study end-points included survival, degree of MR, and NYHA functional class. RESULTS: Patients in the MVA group were younger (mean age 63 +/- 10 versus 68 +/- 9 years; p <0.001), but had a more severe cardiac pathology, with severe LV dysfunction in 45% versus 26% (p = 0.006) and severe MR in 82% versus 14% (p < 0.001). The operative mortality was 9%, and similar in both groups. The follow up was complete, with a mean survival period of 87 +/- 50 months. Although, overall, no improvement was seen in LV function, symptomatic improvement was more pronounced in the MVA group (p = 0.006). At follow up, residual MR was present in 2% of the MVA group and in 47% of the CABG-only group (p < 0.0001). For the MVA and CABG-only groups, respectively, survival at five and 10 years was 68% and 46% versus 77% and 52% (p = NS). By multivariate analysis, neither degree of MR nor LV function at follow up had any impact on survival. CONCLUSION: In patients with a reduced LV function undergoing CABG, the addition of a mitral annuloplasty does not increase the operative risk. Although patients in the MVA group were more ill, there was a better symptomatic improvement in this group, and they attained a similar survival. It is recommended that MVA be performed at the time of CABG in patients having moderate or greater MR associated with a reduced LV function.

No symptomatic intracerebral hemorrhage after cardiac surgery: a 14-year retrospective study.

BACKGROUND: In the presence of new neurological findings occurring after cardiac surgery, the clinical question is whether to exclude symptomatic intracerebral hemorrhage (ICH), particularly in the context of routine postoperative anticoagulation treatment. METHODS: This is a retrospective 14-year study including 5,275 patients who underwent cardiovascular surgery. The control cohort included all patients with acute cerebrovascular accidents hospitalized in 2 general hospitals in Jerusalem during a 2-month period in 2007 (part of a national survey). RESULTS: After cardiac surgery, 78 patients developed ischemic strokes, mostly of large-vessel etiology. These ischemic strokes occurred more often in patients who underwent combined operations (22/647 = 3.4% vs. 45/3,489 = 1.3%; p = 0.0004). ICH was found in 6% of all acute cerebrovascular accidents in the general survey, but was absent after cardiac surgery (5 vs. 0; p = 0.02). CONCLUSIONS: Despite hypertension as a main risk factor and the administration of postoperative anticoagulation, we found that symptomatic ICH did not occur after cardiac surgery.

The possible risk for strokes complicating cardiac surgery in patients with intraoperative hypothermia.

BACKGROUND: The effect of hypothermia as a possible neuroprotective tool on the outcome of cardiac surgery is still controversial. METHODS: We retrospectively assessed all patients who underwent cardiac surgery within a 14-year period and compared patients with and without postoperative stroke. RESULTS: Stroke occurred more frequently in patients who underwent valve repair/replacement combined with coronary artery bypass grafting (CABG) than in patients who had CABG alone (p = 0.0002). All strokes (1.4%) were ischemic and mostly of large-vessel etiology. All patients with stroke had intraoperative minimal temperature <34°C. More patients in this group than in the group without stroke had an intraoperative minimal temperature <30°C (p = 0.01). Stepwise multivariate analysis of all pre- and intraoperative parameters identified significant risk factors for stroke: hypertension, diabetes mellitus and previous stroke as preoperative risk factors, but only lower minimal temperature as a significant intraoperative risk factor (p = 0.03; odds ratio 1.080/1°C, 95% confidence interval 1.004-1.152). The mean intraoperative temperature was 28 ± 4°C in patients who developed stroke and 30 ± 3°C in patients without stroke. CONCLUSIONS: Intraoperative hypothermia around 28°C might be harmful and associated with increased risk for postsurgical stroke.