ABSTRACT
Coagulation factor XII (FXII) is a plasma serine protease that belongs to the contact activation complex responsible for initiating the intrinsic coagulation pathway. FXII deficiency is a rare congenital disorder that is not associated with an increased tendency for bleeding. However, as contact activation is impaired in FXII deficiency, both the celite- and kaolin-initiated activated clotting time (ACT) measurements are prolonged markedly, which poses a challenge for anticoagulation monitoring in patients undergoing cardiac surgery. The authors successfully have used the standard Hemochron Jr. ACT+ test, which is activated by silica and phospholipid in addition to kaolin, to monitor anticoagulation for cardiopulmonary bypass in two patients with severe FXII deficiency. The ACT+ test showed low baseline values, increased adequately in response to heparin, and decreased to baseline after protamine. Importantly, there was no abnormal intra- or postoperative bleeding nor any thrombotic complications. Furthermore, in vitro dose-response ACT+ testing of FXII-deficient blood with increasing heparin concentrations supports the use of ACT+ in FXII deficiency.
Subject(s)
Factor XII Deficiency , Heparin , Anticoagulants , Cardiopulmonary Bypass , Factor XII Deficiency/complications , Factor XII Deficiency/diagnosis , Factor XII Deficiency/surgery , Humans , Kaolin , Point-of-Care Systems , Whole Blood Coagulation TimeABSTRACT
The aim of this study was to compare the immediate outcome of patients undergoing transcatheter (TAVI) versus surgical aortic valve replacement with the sutureless Perceval bioprosthesis (SU-AVR). This is a retrospective multicenter analysis of 773 patients who underwent either TAVI (394 patients, mean age, 80.8 ± 5.5 years, mean EuroSCORE II 5.6 ± 4.9 %) or SU-AVR (379 patients, 77.4 ± 5.4 years, mean EuroSCORE II 4.0 ± 3.9 %) with or without concomitant myocardial revascularization. Data on SU-AVRs were provided by six European institutions (Belgium, Finland, Germany, Italy and Sweden) and data on TAVIs were provided by a single institution (Catania, Italy). In-hospital mortality was 2.6 % after SU-AVR and 5.3 % after TAVI (p = 0.057). TAVI was associated with a significantly high rate of mild (44.0 vs. 2.1 %) and moderate-severe paravalvular regurgitation (14.1 vs. 0.3 %, p < 0.0001) as well as the need for permanent pacemaker implantation (17.3 vs. 9.8 %, p = 0.003) compared with SU-AVR. The analysis of patients within the 25th and 75th percentiles interval of EuroSCORE II, i.e., 2.1-5.8 %, confirmed the findings of the overall series. One-to-one propensity score-matched analysis resulted in 144 pairs with similar baseline characteristics and operative risk. Among these matched pairs, in-hospital mortality (6.9 vs. 1.4 %, p = 0.035) was significantly higher after TAVI. SU-AVR with the Perceval prosthesis in intermediate-risk patients is associated with excellent immediate survival and is a valid alternative to TAVI in these patients.
Subject(s)
Aortic Valve Stenosis/surgery , Aortic Valve/surgery , Cardiac Catheterization , Heart Valve Prosthesis Implantation/methods , Sutureless Surgical Procedures , Aged , Aged, 80 and over , Aortic Valve/diagnostic imaging , Aortic Valve/physiopathology , Aortic Valve Insufficiency/etiology , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/mortality , Aortic Valve Stenosis/physiopathology , Bioprosthesis , Cardiac Catheterization/adverse effects , Cardiac Catheterization/instrumentation , Cardiac Catheterization/mortality , Chi-Square Distribution , Europe , Female , Heart Valve Prosthesis , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/mortality , Hospital Mortality , Humans , Logistic Models , Male , Multivariate Analysis , Propensity Score , Prosthesis Design , Retrospective Studies , Risk Factors , Sutureless Surgical Procedures/adverse effects , Sutureless Surgical Procedures/mortality , Time Factors , Treatment OutcomeABSTRACT
OBJECTIVE: The aim of this study was to evaluate the outcome of aortic valve replacement with the sutureless Perceval S aortic valve bioprosthesis (Sorin Biomedica Cardio Srl, Saluggia, Italy). METHODS: This is a retrospective analysis of 314 patients (mean age, 77.9 ± 5.0 years, mean European System for Cardiac Operative Risk Evaluation II, 9.0% ± 7.6%) who underwent aortic valve replacement with the Perceval S valve with (94 patients) or without (220 patients) concomitant coronary artery bypass surgery at 5 European centers. RESULTS: The Perceval S valve was successfully implanted in all but 1 patient (99.7%). The mean aortic crossclamping time was 43 ± 20 minutes (isolated procedure, 39 ± 15 minutes; concomitant coronary surgery, 52 ± 26 minutes). Severe paravalvular leak occurred in 2 patients (0.6%). In-hospital mortality was 3.2% (1.4% after isolated procedure and 7.4% after concomitant coronary surgery). In-hospital mortality was 2.8% and 4.0% among patients with a European System for Cardiac Operative Risk Evaluation II less than 10% and 10% or greater, respectively (P = .558). Octogenarians had slightly higher in-hospital mortality (5.2% vs 2.0%, P = .125; after isolated procedure: 2.7% vs 0.7%, P = .223; after concomitant coronary surgery: 9.5% vs 5.8%, P = .491) compared with younger patients. Full sternotomy did not increase the in-hospital mortality risk compared with ministernotomy or minithoracotomy access (1.3% vs 1.4%, when adjusted for baseline covariates: P = .921; odds ratio, 0.886; 95% confidence interval, 0.064-12.346). One-year survival was 90.5%. Freedom from valve-related mortality, stroke, endocarditis, and reoperation was 99.0%, 98.1%, 99.2%, and 98.3%, respectively. CONCLUSIONS: The sutureless Perceval S valve is associated with excellent early survival in high-risk patients, particularly among those undergoing an isolated procedure. Further studies are needed to prove the durability of this bioprosthesis.
Subject(s)
Aortic Valve Stenosis/surgery , Aortic Valve/surgery , Bioprosthesis , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis , Age Factors , Aged , Aged, 80 and over , Aortic Valve/physiopathology , Aortic Valve Stenosis/diagnosis , Aortic Valve Stenosis/mortality , Aortic Valve Stenosis/physiopathology , Disease-Free Survival , Europe , Female , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/mortality , Hospital Mortality , Humans , Kaplan-Meier Estimate , Male , Postoperative Complications/mortality , Postoperative Complications/surgery , Proportional Hazards Models , Prosthesis Design , Reoperation , Retrospective Studies , Risk Assessment , Risk Factors , Severity of Illness Index , Sternotomy , Thoracotomy , Time Factors , Treatment OutcomeABSTRACT
Patients aged ≥80 years are at high risk of adverse events after coronary artery bypass grafting. This study was performed to evaluate whether off-pump coronary artery bypass surgery (OPCAB) is superior to conventional surgery (CCAB) in these high-risk patients. The outcome of 185 patients aged ≥80 years who underwent OPCAB or CCAB at our institution was reviewed and a meta-analysis on this issue was performed. Similar immediate postoperative results were observed after OPCAB and CCAB at our institution, despite significantly different operative risk (mean logistic EuroSCORE, OPCAB 20.3% vs CCAB 13.4%, P = 0.003). Among 56 propensity score matched pairs a trend toward lower postoperative stroke (0%, 95% CI 0-0 vs 3.6%, 95% CI 0-10.0, P = 0.50) was observed after OPCAB. No significant differences were observed in the other outcome end points. Five-year survival was 81.0% after OPCAB and 78.1% after CCAB (P = 0.239). Pooled analysis of eight studies including 3416 patients showed a significantly higher risk of postoperative stroke after CCAB (pooled rates: 4.2%, 95% confidence interval (95% CI) 2.4-7.1 vs 1.5%, 95% CI 0.9-2.5, risk ratio (RR) 2.15, 95% CI 1.17-3.96, P = 0.01). A trend toward higher immediate postoperative mortality was observed after CCAB (15 studies including 4409 patients, pooled rates: 6.5%, 95% CI 5.2-8.0 vs 5.6%, 95% CI 4.2-7.4, RR 1.29, 95% CI 0.86-1.93, P = 0.21). Generic inverse variance analysis showed similar intermediate survival after CCAB and OPCAB (RR 1.31, 95% CI 0.85-2.01, P = 0.22). At 2 years, survival was 82.8% (95% CI 76.4-89.2) after CCAB and 88.3% (95% CI 82.9-93.7) after OPCAB. Current results indicate that OPCAB compared with CCAB in patients aged ≥80 years is associated with significantly lower postoperative stroke and with a trend toward better early survival. However, suboptimal quality of the available studies, particularly the lack of comparability of the study groups, prevents conclusive results on this controversial issue.
Subject(s)
Coronary Artery Bypass/methods , Myocardial Ischemia/surgery , Postoperative Complications/epidemiology , Age Factors , Aged, 80 and over , Coronary Artery Bypass, Off-Pump/methods , Global Health , Humans , Incidence , Survival Rate/trendsABSTRACT
OBJECTIVE: Excessive bleeding requiring re-exploration is a severe complication that may affect the outcome after coronary artery bypass grafting. The authors hypothesized that surgeon performance may contribute significantly to such a complication. DESIGN: Retrospective. SETTING: Tertiary referral center in a university hospital. PARTICIPANTS: Two thousand one patients. INTERVENTIONS: Isolated coronary artery bypass grafting. RESULTS: Re-exploration for bleeding was performed in 113 patients (5.3%). Re-exploration was performed ≥3 days after surgery in 11 patients. The surgical site of bleeding was identified in 83 patients (73.5%). Rates of re-exploration for excessive bleeding ranged from 1.4% to 11.7% according to different surgeons (p < 0.0001). When adjusted for the additive European System for Cardiac Operative Risk Evaluation, re-exploration for bleeding was associated with increased risks of low-cardiac-output syndrome (odds ratio [OR] 2.239, 95% confidence interval [CI] 1.328-3.777), prolonged need for inotropes (OR 1.894, 95% CI 1.198-2.994), and an intensive care unit stay ≥5 days (OR 2.129, 95% CI 1.202-3.770). Logistic regression showed that an individual surgeon (p < 0.0001), preoperative body mass index <25 kg/m(2) (OR 2.733, 95% CI 2.145-3.481), and estimated glomerular filtration rate <30 mL/min/1.73 m(2) (OR 3.891, 95% CI 1.669-9.076) were independent predictors of re-exploration for excessive bleeding. An individual surgeon also was an independent predictor of a postoperative blood loss ≥1,600 mL. CONCLUSIONS: An individual surgeon has a major impact on postoperative bleeding, and a meticulous surgical technique is expected to decrease significantly such a severe complication.
Subject(s)
Coronary Artery Bypass/adverse effects , Postoperative Hemorrhage/etiology , Aged , Body Mass Index , Female , Glomerular Filtration Rate , Humans , Logistic Models , Male , Middle Aged , Retrospective Studies , RiskABSTRACT
BACKGROUND: The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) has been recently developed to improve the performance of the original EuroSCORE. Herein we evaluated its discriminatory ability in predicting the immediate and late outcome after coronary artery bypass grafting (CABG). METHODS: Complete data on 1,027 patients who underwent isolated CABG were available for validation of EuroSCORE II and to compare its discriminatory ability with the original EuroSCORE and its Finnish modified version. RESULTS: EuroSCORE II performed somewhat better (area under the curve [AUC] 0.852, Brier score 0.031) than the original logistic EuroSCORE (AUC 0.838, Brier score 0.034) and its Finnish modified version (AUC 0.825, Brier score 0.034) in predicting operative mortality. The overall expected-to-observed operative mortality ratio for the original logistic EuroSCORE was 1.8, for its Finnish modified version was 0.6, and for EuroSCORE II was 1.2. EuroSCORE II showed expected-to-observed ratios ranging from 1.05 to 1.17 in its highest third quintiles. The best cutoff of EuroSCORE II in predicting operative postoperative mortality was 10% (21.5% vs 1.6%, p<0.0001; sensitivity 91.5%, specificity 60.5%, negative predictive value 98.4%, accuracy of 90.3%). The EuroSCORE II was predictive of de novo dialysis (AUC 0.805), prolonged use of inotropes (AUC 0.748), and intensive care unit stay 5 days or greater (AUC 0.793). The risk of late mortality significantly increased across increasing quintiles of EuroSCORE II (p<0.0001). CONCLUSIONS: The EuroSCORE II performs better than its original version in predicting operative mortality and morbidity after isolated CABG. Its ability to predict 30-day mortality in high-risk patients is of particular importance. The EuroSCORE II is also a good predictor of late postoperative survival.
Subject(s)
Coronary Artery Bypass/statistics & numerical data , Propensity Score , Aged , Area Under Curve , Cause of Death , Coronary Artery Bypass, Off-Pump/statistics & numerical data , Female , Finland , Heart Arrest, Induced , Hospital Mortality , Humans , Kaplan-Meier Estimate , Logistic Models , Male , Middle Aged , Postoperative Complications/mortality , Prognosis , Reproducibility of ResultsABSTRACT
OBJECTIVES: We investigated the prognostic impact of atherosclerosis and wall thickness of the ascending aorta in patients undergoing coronary artery bypass grafting (CABG). METHODS: A series of 781 patients who underwent CABG and in whom epiaortic ultrasound was performed to assess the status of the ascending aorta and to measure the thickness of its anterior and lateral walls were the subjects of the present analysis. RESULTS: At multivariate analysis, thickness of the ascending aortic wall, but not atherosclerosis, was an independent predictor of all-cause intermediate mortality [relative risk (RR): 1.628; 95% confidence interval (CI): 1.219-2.176]. Five-year overall survival rates in patients with an aortic wall thickness ≥1.8 mm and less were 82.2 and 92.6%, respectively (log-rank test: P < 0.0001). Ascending aortic wall thickness (RR: 1.629; 95% CI: 1.135-2.339), but not atherosclerosis, was also an independent predictor of cardiovascular mortality. Aortic wall thickness ≥1.8 mm combined with the presence of atherosclerosis of the ascending aorta was associated with a rather dismal overall survival compared with patients with normal findings at epiaortic ultrasound (at 5 years, 77.0 vs. 93.2%; adjusted analysis: P = 0.010). CONCLUSIONS: Ascending aortic wall thickness, but not the presence of atherosclerosis of any extent, is an independent predictor of intermediate all-cause and cardiovascular mortality. Thickened aortic wall is associated with significantly higher hazard of all cause and cardiovascular mortality and can be considered an important surrogate marker of aggressive atherosclerosis.
Subject(s)
Aorta/pathology , Aortic Diseases/complications , Atherosclerosis/complications , Coronary Artery Bypass/adverse effects , Aged , Aorta/diagnostic imaging , Aortic Diseases/diagnostic imaging , Aortic Diseases/pathology , Atherosclerosis/diagnostic imaging , Coronary Artery Bypass/methods , Coronary Disease/complications , Coronary Disease/pathology , Coronary Disease/surgery , Female , Follow-Up Studies , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Prognosis , Treatment Outcome , UltrasonographyABSTRACT
BACKGROUND: The impact of blood transfusion on the development of post-operative stroke after coronary artery bypass grafting (CABG) is not well established. We, therefore, investigated this issue. MATERIALS AND METHODS: Complete data on peri-operative blood transfusion were available for 2,226 patients who underwent CABG in three Finnish hospitals. RESULTS: Stroke occurred post-operatively in 53 patients (2.4%). Logistic regression showed that pre-operative creatinine (OR 1.003, 95% CI 1.000-1.006), extracardiac arteriopathy (OR 2.344, 95% CI 1.133-4.847), pre-operative atrial fibrillation (OR 2.409, 95% CI 1.149-5.052), and the number of packed red blood cell units transfused (OR 1.121, 95% CI 1.065-1.180) were significantly associated with post-operative stroke. When the various blood product transfusions instead of transfused units were included in the multivariable analysis, solvent/detergent treated plasma (Octaplas) transfusion (OR 2.149, 95% CI 1.141-4.047), but not red blood cell transfusion, was significantly associated with postoperative stroke. Use of blood products ranging from no transfusion (stroke rate 1.6%) to combined transfusion of red blood cells, platelets and Octaplas was associated with a significant increase in post-operative stroke incidence (6.6%, adjusted analysis: OR 1.727, 95% 1.350-2.209). Patients who received >2 units of red blood cells, >4 units of Octaplas units and >8 units of platelets had the highest stroke rate of 21%. CART analysis showed that increasing amount of transfused Octaplas, platelets and history of extracardiac arteriopathy were significantly associated with post-operative stroke. CONCLUSIONS: Transfusion of blood products after CABG has a strong, dose-dependent association with the risk of stroke. The use of Octaplas and platelet transfusions seem to have an even larger impact on the development of stroke than red blood cell transfusions.
Subject(s)
Coronary Artery Bypass/adverse effects , Erythrocyte Transfusion/adverse effects , Postoperative Complications/epidemiology , Stroke/epidemiology , Stroke/etiology , Aged , Female , Finland , Humans , Male , Middle Aged , Platelet Transfusion , Postoperative Complications/blood , Retrospective Studies , Risk Factors , Stroke/blood , Time FactorsABSTRACT
OBJECTIVE: The aim of this study was to evaluate the impact of re-exploration for bleeding after cardiac surgery on the immediate postoperative outcome. METHODS: Systematic review of the literature and meta-analysis of data on re-exploration for bleeding after adult cardiac surgery were performed. RESULTS: The literature search yielded eight observational studies reporting on 557,923 patients and were included in the present analysis. Patients requiring re-exploration were significantly older, more frequently males, had a higher prevalence of peripheral vascular disease and preoperative exposure to aspirin, and more frequently underwent urgent/emergency surgery. Re-exploration was associated with significantly increased risk ratio (RR) of immediate postoperative mortality (RR 3.27, 95% confidence interval (CI) 2.44-4.37), stroke, need of intra-aortic balloon pump, acute renal failure, sternal wound infection, and prolonged mechanical ventilation. The pooled analysis of four studies (two being propensity score-matched pairs analysis) reporting adjusted risk for mortality led to an RR of 2.56 (95%CI 1.46-4.50). Studies published during the last decade tended to report a higher risk of re-exploration-related mortality (RR 4.30, 95%CI 3.09-5.97) than those published in the 1990s (RR 2.75, 95%CI 2.06-3.66). CONCLUSIONS: This study suggests that re-exploration for bleeding after cardiac surgery carries a significantly increased risk of postoperative mortality and morbidity.
Subject(s)
Cardiac Surgical Procedures/adverse effects , Postoperative Hemorrhage/surgery , Adult , Cardiac Surgical Procedures/mortality , Humans , Postoperative Hemorrhage/epidemiology , Postoperative Hemorrhage/etiology , Prognosis , Reoperation/adverse effects , Reoperation/mortality , Risk Assessment/methodsABSTRACT
OBJECTIVE: Whether aspirin should be discontinued before coronary artery bypass grafting is controversial. The potential benefits and harms associated with late use of aspirin (no discontinuation or discontinuation <3 days before surgery) were investigated in this retrospective, multicenter study. DESIGN: Retrospective, multicenter study. SETTING: Two university hospitals and one central hospital. PARTICIPANTS: A consecutive series of 859 patients who underwent elective coronary artery bypass grafting from January 2008 through December 2010. INTERVENTIONS: Aspirin (100 mg/day) was used <3 days before surgery in 240 patients and was discontinued >3 days before surgery in 619 patients. RESULTS: In the overall series, similar in-hospital mortality, amount of postoperative blood loss, rate of re-exploration for excessive bleeding, and use of blood products were observed in the study groups. However, aspirin discontinuation >3 days before surgery tended to be associated with a higher postoperative stroke rate (1.9% v 0.4%, p = 0.13). Such a trend was observed after off-pump (1.9% v 0%, p = 0.58) and on-pump (2.0% v 0.6%, p = 0.46) surgery. Among 153 pairs matched by the propensity score, patients with aspirin discontinued >3 days before surgery had a significantly higher rate of postoperative stroke (5.9% v 0.7%, p = 0.02) and tended to have a higher risk of the composite adverse outcome endpoint (19.6% v 12.4%, p = 0.09). The postoperative release of troponin I was similar in the study groups. CONCLUSIONS: Late or no discontinuation of low-dose aspirin before coronary artery bypass grafting may decrease the risk of postoperative stroke without increased postoperative bleeding and need for blood transfusion. These findings and the risk of cardiovascular events possibly occurring at the time of its discontinuation suggest that the use of aspirin until the day of elective coronary surgery may be beneficial.
Subject(s)
Aspirin/administration & dosage , Coronary Artery Bypass/adverse effects , Elective Surgical Procedures/adverse effects , Postoperative Complications/prevention & control , Preoperative Care/methods , Aged , Female , Humans , Male , Middle Aged , Postoperative Complications/etiology , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: We have evaluated the outcome of patients who underwent surgical treatment of parapneumonic pleural empyema. METHODS: This study included 143 consecutive patients older than 18 years who were operated on for parapneumonic pleural empyema. RESULTS: The overall survival at 30 days, 3 months, 5 years, and 10 years was 97.2, 92.3, 80.6, and 61.9%, respectively. Serum albumin (OR = 0.78, 95% CI = 0.65-0.94), cerebrovascular disease (OR = 30.49, 95% CI = 1.35-689.05), pulmonary embolism (OR = 984.63, 95% CI = 7.81-124206.8), and Thoracoscore (OR = 1.61, 95% CI = 1.10-2.35) were independent predictors of 3-month overall survival. Age (RR = 1.08, 95% CI = 1.03-1.14), serum albumin (RR = 0.89, 95% CI = 0.82-0.98), chronic obstructive pulmonary disease (COPD) (RR = 5.14, 95% CI = 1.3319.84), and cerebrovascular disease (RR = 6.76, 95% CI = 1.33-34.34) were independent predictors of pneumonia/pleural empyema-related death. Twenty-two patients required 33 reinterventions after the primary procedure: 19 patients after primary thoracoscopy and 3 patients after primary thoracotomy. Reintervention did not have any significant impact on 30-day mortality (4.5% vs. 2.5%, p = 0.49), but it affected 3-month mortality (26.1% vs. 4.2%, p < 0.0001). Reoperation was an independent predictor of late overall survival (at 10 years: 35.5% vs. 67.4%, RR = 2.95, 95% CI = 1.33-6.57) and freedom from pneumonia/pleural empyema-related death (at 10 years: 73.9% vs. 91.3%, RR = 4.40, 95% CI = 1.24-15.66). CONCLUSIONS: Surgical treatment of pleural empyema can be associated with good immediate results, but longer follow-up showed that pneumonia/pleural empyema-related mortality and all-cause mortality are rather poor.
Subject(s)
Empyema, Pleural/mortality , Empyema, Pleural/surgery , Female , Humans , Logistic Models , Male , Middle Aged , Proportional Hazards Models , ROC Curve , Reoperation/statistics & numerical data , Risk Factors , Survival Rate , Thoracoscopy , Thoracotomy , Treatment OutcomeABSTRACT
We present a case of a 73-year-old man with implantable cardioverter-defibrillator pocket erosion and Staphylococcus aureus infection who was admitted to our hospital for lead extraction. During the mechanical extraction procedure, the 12-year-old lead broke and the distal coil was trapped in the right ventricle. After several attempts to grasp the coil using a femoral workstation and various snaring tools failed, a steerable transseptal sheath was placed into the right ventricle via the right femoral vein. The sheath allowed better positioning of the basket retriever and the lead remnant was successfully grasped and extracted with direct traction.
Subject(s)
Defibrillators, Implantable/adverse effects , Device Removal/instrumentation , Electrodes, Implanted/adverse effects , Foreign Bodies/etiology , Foreign Bodies/surgery , Heart Ventricles/injuries , Heart Ventricles/surgery , Aged , Device Removal/methods , Humans , Male , Treatment OutcomeABSTRACT
BACKGROUND: We have evaluated the immediate and intermediate outcome after off-pump (OPCAB) and conventional on-pump coronary artery bypass surgery (CCAB) in patients with unstable angina pectoris requiring nitrates infusion until arrival in the operating room. METHODS: A consecutive series of 153 and 161 patients with unrelenting angina pectoris underwent CCAB and OPCAB, respectively. Conversion from OPCAB to beating heart surgery with perfusion occurred in 4 patients. RESULTS: The OPCAB patients had a significantly higher operative risk than CCAB patients (logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE]: 13.8 +/- 12.8% vs 10.5 +/- 10.0%, p = 0.005). In the overall series, a lower 30-day postoperative mortality was observed among OPCAB patients (1.9% vs 3.9%, p = 0.33), the difference increased along the logistic EuroSCORE tertiles (upper tertile: 3.2% vs 9.5%, p = 0.14), but failed to reach statistical significance. Similar results have been observed among one-to-one propensity score matched pairs. The results of three surgeons who treated most of their patients (96.9%) with OPCAB were compared with those of three surgeons who used, in most of cases (97.1%), the CCAB technique. When adjusted for logistic EuroSCORE, patients operated on by CCAB surgeons had a significantly higher 30-day postoperative mortality (7.1% vs 2.1%, p = 0.04; odds ratio [OR] 10.143; 95% confidence interval [CI] 1.084 to 94.945) as well as a higher risk of combined adverse events (47.1% vs. 35.1%, p = 0.009; OR 2.586; 95% CI 1.274 to 5.250). CONCLUSIONS: This study provided further evidence on the safety and efficacy of OPCAB in the treatment of high-risk patients. A dedicated approach to OPCAB seems to provide particularly good results. Such findings further support a more confident approach with OPCAB in these patients.
Subject(s)
Angina, Unstable/mortality , Angina, Unstable/surgery , Coronary Artery Bypass, Off-Pump/methods , Hospital Mortality/trends , Aged , Analysis of Variance , Angina, Unstable/diagnosis , Cardiac Catheterization , Cohort Studies , Coronary Angiography , Coronary Artery Bypass/adverse effects , Coronary Artery Bypass/methods , Coronary Artery Bypass, Off-Pump/adverse effects , Coronary Circulation/physiology , Female , Heart Function Tests , Hemodynamics/physiology , Humans , Logistic Models , Male , Middle Aged , Postoperative Complications/mortality , Prognosis , ROC Curve , Retrospective Studies , Risk Assessment , Severity of Illness Index , Statistics, Nonparametric , Survival Analysis , Time Factors , Treatment OutcomeABSTRACT
The aim of this study was to evaluate the value of statins in reducing abdominal aortic aneurysm (AAA) growth rate and improving freedom from aneurysm repair or rupture. One hundred and twenty-one patients with AAA undergoing ultrasonographic surveillance for at least one year were included in this retrospective study. Patients treated with statins had a decreased linear aneurysm growth rate than those not receiving statins (1.9+/-1.8 mm/year vs. 2.6+/-2.4 mm/year, P=0.27), but this difference did not reach statistical significance. Statin users had a better survival freedom from aneurysm repair or rupture (at 5 years: 72.3% vs. 52.5%, P=0.048). The impact of treatment with statins was even more evident in patients with a baseline aneurysm diameter<40 mm (at 5 years: 84.0% vs. 58.8%, P=0.022). When adjusted for age, coronary artery disease and baseline aneurysm diameter, treatment with statins had significantly better survival freedom from aneurysm repair or rupture (P=0.012, RR 0.34, 95% CI 0.14-0.78). The use of statins seems to slightly decrease the AAA growth rate and to significantly improve freedom from aneurysm repair and rupture.
Subject(s)
Aortic Aneurysm, Abdominal/drug therapy , Aortic Rupture/prevention & control , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Aged , Aortic Aneurysm, Abdominal/complications , Aortic Aneurysm, Abdominal/diagnostic imaging , Aortic Aneurysm, Abdominal/surgery , Aortic Rupture/diagnostic imaging , Aortic Rupture/etiology , Aortic Rupture/surgery , Disease Progression , Female , Humans , Male , Middle Aged , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , Ultrasonography , Vascular Surgical ProceduresABSTRACT
PURPOSE: The Spyder aortic connector (Medtronic, Minneapolis, MN) is a new, promising connector device and its safety and efficacy have been evaluated in this study. DESCRIPTION: Twenty-two patients were randomized to proximal vein graft anastomosis with the Spyder aortic connector (Medtronic) or hand-sewn technique. EVALUATION: Twenty patients underwent multi-detector computed tomographic scans of the chest 6 months after surgery to evaluate vein graft patency. We have failed to successfully deploy three Spyder connector devices. Thus in this study we have evaluated the graft patency of 19 hand-sewn grafts and of 19 vein grafts anastomosed with the Spyder anastomotic device. Three vein grafts whose proximal anastomosis was accomplished with the Spyder anastomotic connector were occluded and all hand-sewn vein grafts were patent (16% vs 0%; p = 0.23). Stenosis of the proximal anastomosis was observed in seven vein grafts (37%), accomplished with the Spyder anastomotic connector, and in one (5%) hand-sewn vein graft (p = 0.042). CONCLUSIONS: The results of this study suggest that the use of the Spyder aortic connector device is associated with suboptimal 6-month graft patency.
Subject(s)
Aorta/surgery , Coronary Artery Bypass, Off-Pump/instrumentation , Aged , Anastomosis, Surgical/instrumentation , Coronary Artery Bypass, Off-Pump/adverse effects , Female , Graft Occlusion, Vascular/epidemiology , Humans , Male , Middle Aged , Saphenous Vein/transplantationABSTRACT
OBJECTIVE: The value of off-pump over conventional coronary artery bypass surgery in reducing the risk of postoperative stroke is controversial. This issue has been evaluated in light of our recent clinical experience. METHODS: Off-pump coronary artery bypass surgery was performed in 557 patients, and conventional coronary artery bypass surgery was performed in 445 patients. Preoperative stroke risk was calculated according to the Northern New England Cardiovascular Disease Study Group stroke risk-scoring method. RESULTS: Off-pump coronary artery bypass surgery was associated with a lower but not significant rate of postoperative stroke in the overall series (1.8% vs 2.5%, P = .45), a difference that slightly increased in the highest tertile of the Northern New England Cardiovascular Disease Study Group score (2.8% vs 4.2%, P = .75). The postoperative stroke rate was significantly lower when the operation was performed by off-pump coronary artery bypass surgeons using routinely epiaortic ultrasonographic scanning compared with conventional coronary artery bypass surgeons not using epiaortic ultrasonographic scanning (0.4% vs 3.9%, P = .015). The Northern New England Cardiovascular Disease Study Group score (mean, 4.6 +/- 2.1 vs 4.9 +/- 2.2; P = .189) was similar in these groups. Logistic regression showed that when adjusted for Northern New England Cardiovascular Disease Study Group stroke risk score and critical preoperative status, the treatment approach (off-pump coronary artery bypass surgery and routine epiaortic ultrasonographic scanning) was an independent predictor of postoperative stroke (P = .012; odds ratio, 34.1; 95% confidence interval, 2.2-533.7). CONCLUSIONS: The neuroprotective efficacy of off-pump coronary artery bypass surgery is marginal compared with that of conventional coronary artery bypass surgery. A decreased risk of postoperative stroke after off-pump coronary artery bypass surgery is expected, mostly in high-risk patients and when epiaortic ultrasonographic examination is routinely used for better planning of operative strategy, aiming to minimize the risk of intraoperative embolism.
Subject(s)
Coronary Artery Bypass, Off-Pump/adverse effects , Coronary Artery Bypass/adverse effects , Stroke/etiology , Aged , Female , Humans , Male , Postoperative Complications , Risk FactorsABSTRACT
OBJECTIVE: To identify the preoperative risk factors associated with increased prevalence of atherosclerotic lesions of the ascending aorta among patients undergoing off-pump coronary artery bypass surgery (OPCAB). MATERIAL AND METHODS: OPCAB was performed in 241 patients who were intraoperatively investigated by epiaortic ultrasound for the presence of atherosclerotic lesions of the ascending aorta. The Northern New England Cardiovascular Disease Study Group (NNECVDSG) and the Multicenter Study of Perioperative Ischemia (McSPI) stroke risk scores were retrospectively calculated. RESULTS: A diseased ascending aorta was detected by intraoperative epiaortic ultrasound in 74 patients (30.7%). Patient's age (P = .002, odds ratio [OR] 1.067, 95% confidence interval [CI] 1.025-1.110), diabetes (P = .023; OR, 2.211; 95% CI, 1.117-4.378), extracardiac arteriopathy (P = .014; OR, 2.567; 95% CI, 1.214-5.428) and urgent/emergency operation (P < .0001; OR, 3.066; 95% CI, 1.685-5.580) were independent preoperative predictors of a diseased ascending aorta. The area under the ROC curve of the NNECVDSG score in predicting a diseased ascending aorta was 0.710 (95% CI, 0.642-0.778), and that of the McSPI score was 0.722 (95% CI, 0.655-0.788). The prevalence of a diseased ascending aorta was 11.2%, 34.7%, and 49.4% among the NNECVDSG score tertiles (P < .0001), and 11.3%, 31.7%, and 49.4% among the McSPI score tertiles (P < .0001). CONCLUSIONS: These findings confirm the reported high incidence of a diseased ascending aorta in patients undergoing coronary artery bypass surgery. Current stroke risk scores, particularly the simple NNECVDSG score, are valuable predictors of increased prevalence of a diseased ascending aorta.
Subject(s)
Aortic Diseases/diagnosis , Aortic Diseases/epidemiology , Atherosclerosis/epidemiology , Atherosclerosis/surgery , Coronary Artery Bypass, Off-Pump/statistics & numerical data , Outcome Assessment, Health Care/methods , Risk Assessment/methods , Aged , Aorta , Comorbidity , Female , Finland/epidemiology , Health Status Indicators , Humans , Incidence , Male , Preoperative Care/methods , Prognosis , Reproducibility of Results , Risk Factors , Sensitivity and SpecificityABSTRACT
BACKGROUND: Avoidance of manipulation of diseased ascending aorta has been shown to be associated with a reduced risk of postoperative stroke after off-pump coronary artery bypass surgery (OPCAB). The use of the Heartstring device (Guidant, Indianapolis, USA) to accomplish a proximal aortic anastomosis without aortic clamping has been suggested in such patients. PATIENTS AND METHODS: From April 2004 to December 2005, proximal aortic anastomoses have been accomplished employing the Heartstring device in 19 patients with calcified ascending aorta who underwent OPCAB. The diagnosis of diseased ascending aorta was made intraoperatively by epiaortic ultrasound scanning. RESULTS: Eighteen vein grafts and three radial artery grafts have been successfully anastomosed to the ascending aorta by employing the Heartstring device. Breaking of eight seals occurred during insertion. One patient (5.2%) had stroke two days after urgent OPCAB. CONCLUSION: The use of the Heartstring anastomotic device should be considered in high-risk patients with diseased ascending aorta requiring a prompt myocardial revascularization, whenever there is a place to safely insert this device into the ascending aorta.
Subject(s)
Anastomosis, Surgical/instrumentation , Aortic Diseases/surgery , Blood Vessel Prosthesis , Coronary Artery Bypass, Off-Pump/instrumentation , Aged , Aorta/surgery , Aortic Diseases/diagnostic imaging , Female , Humans , Postoperative Complications/prevention & control , Stroke/prevention & control , Ultrasonography , Vascular Surgical Procedures/instrumentationABSTRACT
BACKGROUND: The incidence of pulmonary embolism (PE) after coronary artery bypass surgery is ill defined. METHODS: Twenty-four patients undergoing off-pump coronary artery bypass surgery were enrolled in a prospective randomized study evaluating a new proximal aortic anastomotic device. Computed tomography was performed postoperatively about 1 week after surgery. RESULTS: Computed tomography showed signs of PE in 6 patients (25%), which were bilateral in 2 cases. None of these patients had symptoms or signs of PE or deep venous thrombosis. CONCLUSIONS: The present findings widen the controversial issue of thromboprophylaxis after cardiac surgery and suggest that low-dose heparin may be indicated after coronary artery bypass surgery.
Subject(s)
Coronary Artery Bypass, Off-Pump/adverse effects , Pulmonary Embolism/diagnostic imaging , Pulmonary Embolism/epidemiology , Aged , Anastomosis, Surgical/instrumentation , Aorta/surgery , Coronary Artery Bypass, Off-Pump/instrumentation , Female , Follow-Up Studies , Humans , Incidence , Male , Middle Aged , Prospective Studies , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
BACKGROUND: The use of aortic connector devices for proximal vein graft anastomosis has been shown to be associated with a relevant rate of early graft complications. Cardica PAS-Port is a new aortic connector whose preliminary clinical results seem promising. The safety and efficacy of this aortic connector device have been evaluated in this prospective, randomized study. MATERIAL AND METHODS: Twenty-four patients were randomized to receive proximal aorta-vein graft anastomosis with either the Cardica PAS-port aortic connector or by the hand-sewn technique. Twenty-three patients underwent multidetector computed tomographic scan (MDCT) of the chest 6 months after surgery to evaluate graft patency. RESULTS: All aortic connector devices (18) were successfully deployed and 31 proximal anastomoses were performed by the hand-sewn technique. MDCT showed that 6-month freedom from vein graft complication was 22.2% in the PAS-Port group and 58.1% in the hand-sewn group (P = .04). Four vein grafts (22.2%) anastomosed with the PAS-Port and 2 hand-sewn vein grafts (6.5%) were occluded (P = .10). The use of the PAS-Port aortic connector was also predictive of any vein graft complication when adjusted for vein graft flow (P = .01; OR 8.64, 95% CI 1.66-45.00) and for peripheral resistance units (P = .02; OR 6.14, 95% CI 1.33-28.43). CONCLUSIONS: The results of this prematurely stopped, prospective, randomized study suggest that the use of PAS-Port aortic connector device is associated with a higher rate of early vein graft complications than the hand-sewn technique.