Prognostic value of high-sensitivity cardiac troponin I early after coronary artery bypass graft surgery.

BACKGROUND: The diagnosis of periprocedural myocardial infarction (PMI) after coronary artery bypass graft (CABG) is based on biochemical markers along with clinical and instrumental findings. However, there is not a clear cutoff value of high-sensitivity cardiac troponin (hs-cTn) to identify PMI. We hypothesized that isolated hs-cTn concentrations in the first 24 h following CABG could predict cardiac adverse events (in-hospital death and PMI) and/or left ventricular ejection fraction (LVEF) decrease. METHODS: We retrospectively enrolled all consecutive adult patients undergoing CABG, alone or in association with other cardiac surgery procedures, over 1 year. Hs-cTn I concentrations (Access, Beckman Coulter) were serially measured in the post-operative period and analyzed according to post-operative outcomes. RESULTS: 300 patients were enrolled; 71.3% underwent CABG alone, 33.7% for acute coronary syndrome. Most patients showed hs-cTn I values superior to the limit required by the latest guidelines for the diagnosis of PMI. Five patients (1.7%) died, 8% developed a PMI, 10.6% showed a LVEF decrease ≥ 10%. Hs-cTn I concentrations did not significantly differ with respect to death and/or PMI whereas they were associated with LVEF decrease ≥ 10% (p value < 0.005 at any time interval), in particular hs-cTn I values at 9-12 h post-operatively. A hs-cTn I cutoff of 5556 ng/L, a value 281 (for males) and 479 (for females) times higher than the URL, at 9-12 h post-operatively was identified, representing the best balance between sensitivity (55%) and specificity (79%) in predicting LVEF decrease ≥ 10%. CONCLUSIONS: Hs-cTn I at 9-12 h post-CABG may be useful to early identify patients at risk for LVEF decrease and to guide early investigation and management of possible post-operative complications.

Clinical profile and in-hospital outcome of patients supported by intra-aortic balloon pump in the clinical setting of cardiogenic shock.

Background: Despite controversial evidences, intra-aortic balloon pump (IABP) is still the most widely used temporary mechanical support device in cardiogenic shock (CS), as a bridge to recovery or to more invasive mechanical supports/heart transplantation. Methods: We analyzed retrospectively data of all patients receiving IABP for CS from 2009 to 2018 in a referral centre for advanced heart failure and heart transplantation; we included CS following acute coronary syndrome (ACS) and other CS etiologies different from ACS. We excluded patients in which IABP was implanted as a support following cardiac surgery, non-cardiac surgery in patients with severe chronic heart failure, or in elective high risk or complicated Cath Lab procedures.We focused on in-hospital outcomes (including death, recovery, heart transplantation, LVAD) and IABP complications. Results: 403 patients received IABP, 303 (75.2%) following ACS and 100 (24.8%) in non-ACS CS. Non-ACS patients were younger (59 ± 18.3 vs 73.1 ± 12.6 years, p < 0.001), had lower median left ventricular ejection fraction (LVEF) (25% [18-35] vs 38% [25-45], p < 0.001). In patients with non-ACS etiologies IABP was more frequently a bridge to heart transplantation [20% (n = 20) vs 0.3% (n = 1), P < 0.001] or LVAD [4% (n = 4) vs 0.6% (n = 2), P = 0.055], while ACS patients were more frequently discharged without transplantation/LVAD [65.7% (n = 199) vs 33% (n = 33), P < 0.001]. Non-ACS patients showed higher in-hospital mortality [46% (n = 46) vs 33.9% (n = 103), P = 0.042]. Post-transplant/LVAD outcome in non-ACS subgroup was favorable (21 out of 24 patients were discharged). Serious IABP-related adverse events occurred in 21 patients (5.2%). Ischemic/hemorrhagic complications, infections and thrombocytopenia were more frequent with longer IABP stay. Conclusions: Despite therapy including percutaneous circulatory support, mortality in CS is still high. In our experience, in the clinical setting of refractory CS an IABP support represents a relatively safe circulatory support, associated with a low rate of serious complications in complex clinical scenarios.

Digoxin-specific Fab and therapeutic plasma exchange for digitalis intoxication and renal failure.

Treatment of chronic digitalis intoxication includes suspension of drug intake, which may be sufficient in case of mild manifestations, and supportive measures. Severe bradycardia requires the administration of atropine or isoproterenol; placement of a temporary pacemaker may be required in case of absent response to pharmacological therapy. Severe and life-threatening manifestations should be treated with digoxin-specific fragment antigen binding antibodies (Fab). Therapeutic plasma exchange has been suggested, in addition to Fab therapy, to maximize the clearance of Fab-digoxin complexes in patients with renal failure. To date, few case reports have described the use of such a therapeutic approach; currently, extracorporeal methods are not recommended as part of the treatment of digitalis intoxication, and stronger evidence is required to establish their benefit.