Expression and role of lumican in acute aortic dissection: A human and mouse study.

INTRODUCTION: Aortic dissection (AD) is a life-threatening emergency, and lumican (LUM) is a potential Biomarker for AD diagnosis. We investigated LUM expression patterns in patients with AD and explored the molecular functions of Lum in AD mice model. METHODS: LUM expression patterns were analyzed using aortic tissues of AD patients, and serum soluble LUM (s-LUM) levels were compared between patients with acute AD (AAD) and chronic AD (CAD). Lum-knockout (Lum-/-) mice were challenged with ß-aminopropionitrile (BAPN) and angiotensin II (Ang II) to induce AD. The survival rate, AD incidence, and aortic aneurysm (AA) in these mice were compared with those in BAPN-Ang II-challenged wildtype (WT) mice. Tgf-ß/Smad2, Mmps, Lum, and Nox expression patterns were examined. RESULTS: LUM expression was detected in the intima and media of the ascending aorta in patients with AAD. Serum s-LUM levels were significantly higher in patients with AAD than CAD. Furthermore, AD-associated mortality and thoracic aortic rupture incidence were significantly higher in the Lum-/- AD mice than in the WT AD mice. However, no significant pathologic changes in AA were observed in the Lum-/- AD mice compared with the WT AD mice. The BAPN-Ang II-challenged WT and Lum-/- AD mice had higher Tgf-ß, p-Smad2, Mmp2, Mmp9, and Nox4 levels than those of non-AD mice. We also found that Lum expression was significantly higher in the BAPN-Ang II-challenged WT in comparison to the unchallenged WT mice. CONCLUSION: LUM expression was altered in patients with AD display increased s-LUM in blood, and Lum-/- mice exhibited augmented AD pathogenesis. These findings support the notion that LUM is a biomarker signifying the pathogenesis of injured aorta seen in AAD. The presence of LUM is essential for maintenance of connective tissue integrity. Future studies should elucidate the mechanisms underlying LUM association in aortic changes.

Association of Family History With Incidence and Outcomes of Aortic Dissection.

BACKGROUND: Aortic dissection (AD) is a life-threatening emergency. However, the heritability and association of family history with late outcomes are unclear. OBJECTIVES: The purpose of this study was to evaluate the effect of family history of AD on the incidence and prognosis of AD and estimate the heritability and environmental contribution in AD in Taiwan. METHODS: Both cross-sectional and cohort studies were conducted using Taiwan National Health Insurance database. A registry parent-offspring relationship algorithm was used to reconstruct the genealogy of this population for heritability estimation. The cross-sectional study included 23,868 patients with a diagnosis of AD in 2015. The prevalence and adjusted relative risks (RRs) were evaluated, and the liability threshold model was used to examine the effects of heritability and environmental factors. Furthermore, a 1:10 propensity score-matched cohort comprising AD patients with or without a family history of AD was included to compare late outcomes in the cohort study. RESULTS: A family history of AD in first-degree relatives was associated with an RR of 6.82 (95% confidence interval [CI]: 5.12 to 9.07). The heritability of AD was estimated to be 57.0% for genetic factors, and 3.1% and 40.0% for shared and nonshared environmental factors, respectively. After excluding individuals with Marfan syndrome or bicuspid aortic valve, a family history of AD was associated with an RR of 6.56 (95% CI: 4.92 to 8.77) for AD. Furthermore, patients with AD and a family history of AD had a higher risk of later aortic surgery than those with AD without a family history (subdistribution hazard ratio: 1.40; 95% CI: 1.12 to 1.76). CONCLUSIONS: A family history of AD was a strong risk factor for AD. Furthermore, patients with AD with a family history of AD had a higher risk of later aortic surgery than those with no family history of AD.

[Nurse and Patient Dispute Litigation in Independent Nursing Practice].

BACKGROUND: Although medical dispute and other contentious cases involving patients and nurses have risen significantly in recent years, few studies have examined the litigation issues involved in nurse-patient disputes. PURPOSE: This study was designed to explore the background, categories, and degrees of harm to patients and the judgments made by the courts. METHODS: Qualitative research was used. Cases of criminal, written judgments related to nurse practice negligence and recorded in district courts in Taiwan from 2008 to 2017 were selected. Data were analyzed using content analysis. RESULTS: A total of 41 hospitals and 55 nurses were identified. The largest number of cases involved regional hospitals (36.6%), internal medicine departments (31.7%), general wards (46.3%), night shifts (40.0%), and staff nurses (85.5%). Four categories of independent nurse practice negligence were identified, including observation-evaluation, environmental security, physician notification, and nursing records. Negligent homicide (58.2%) was the most common court judgment and ten nurses (18.2%) were found guilty of the charges brought against them. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: The results of this study highlight for nurses the content of nurse practice negligence and the related judgments by the courts, which hopefully may guide nurses to avoid practice negligence in the future.

Direct aortic route versus transaxillary route for transcatheter aortic valve replacement: a systematic review and meta-analysis.

BACKGROUND: The transfemoral route is contraindicated in nearly 10% of transcatheter aortic valve replacement (TAVR) candidates because of unsuitable iliofemoral vessels. Transaxillary (TAx) and direct aortic (DAo) routes are the principal nonfemoral TAVR routes; however, few studies have compared their outcomes. METHODS: We performed a systematic review and meta-analysis to compare the rates of mortality, stroke, and other adverse events of TAx and DAo TAVR. The study was prospectively registered with PROSPERO (registration number: CRD42017069788). We searched Medline, PubMed, Embase, and Cochrane databases for studies reporting the outcomes of DAo or TAx TAVR in at least 10 patients. Studies that did not use the Valve Academic Research Consortium definitions were excluded. We included studies that did not directly compare the two approaches and then pooled rates of events from the included studies for comparison. RESULTS: In total, 31 studies were included in the quantitative meta-analysis, with 2,883 and 2,172 patients in the DAo and TAx TAVR groups, respectively. Compared with TAx TAVR, DAo TAVR had a lower Society of Thoracic Surgery (STS) score, shorter fluoroscopic time, and less contrast volume use. The 30-day mortality rates were significantly higher in the DAo TAVR group (9.6%, 95% confidence interval (CI) = [8.4-10.9]) than in the TAx TAVR group (5.7%, 95% CI = [4.8-6.8]; P for heterogeneity <0.001). DAo TAVR was associated with a significantly lower risk of stroke in the overall study population (2.6% vs. 5.8%, P for heterogeneity <0.001) and in the subgroup of studies with a mean STS score of ≥8 (1.6% vs. 6.2%, P for heterogeneity = 0.005). DAo TAVR was also associated with lower risks of permanent pacemaker implantation (12.3% vs. 20.1%, P for heterogeneity = 0.009) and valve malposition (2.0% vs. 10.2%, P for heterogeneity = 0.023) than was TAx TAVR. CONCLUSIONS: DAo TAVR increased 30-day mortality rate compared with TAx TAVR; by contrast, TAx TAVR increased postoperative stroke, permanent pacemaker implantation, and valve malposition risks compared with DAo TAVR.

Unilateral Pedicled Pectoralis Major Harvested by Endoscopic-Assisted Method Achieves Adequate Management of Sternal Infection and Mediastinitis.

BACKGROUND: Bilateral PM muscles or combination with rectus abdominis or omentum are commonly used for upper and lower sternal wound infections. Unilateral PM harvesting using endoscopic-assisted method may have a simple, safe, and reliable entire muscle harvesting with comparable result of less donor-site violation. METHODS: A retrospective review was performed from 2003 till 2015 on 38 patients referred to a single plastic surgeon for treatment of sternal wound infection following median sternotomy for cardiovascular surgery. After the humerus insertion of PM was cut with the assistance of endoscope visualization, all the other PM insertions on the sternum, rib, and clavicle were divided, the unilateral pedicled PM can be advanced approximately 10 cm to cover the cephalad and caudal sternum, and fill the retrosternal mediastinum. RESULTS: Four re-explorations in three patients for postoperative hematoma occurred. No early recurrent infection for wound dehiscence experienced. Three patients died of multiple organs failures as 30-day mortality. Two patients underwent late recurrent infections; one patient had twice wire infection removals at 4 and 6 months after transfer, and the other had another PM for rib osteomyelitis in 3 years. CONCLUSION: Unilateral PM transfer is justified to provide a simple, reliable, straightforward procedure for sternal infection management and mediastinal obliteration without violation of second flap in compromised patients.

Risk factor analysis of postoperative acute respiratory distress syndrome after type A aortic dissection repair surgery.

To investigate the incidence, outcomes, and risk factors of postoperative acute respiratory distress syndrome (ARDS) in patients undergoing surgical repair for acute type A aortic dissection.This retrospective study involved 270 patients who underwent surgical repair for acute type A aortic dissection between January 2009 and December 2015. Data on clinical characteristics and outcomes were collected. Patients who immediately died after surgery and with preoperative myocardial dysfunction were excluded. The included patients were divided into the ARDS (ARDS patients who met the Berlin definition) and non-ARDS groups. Primary outcome was postoperative ARDS, according to the 2012 Berlin definition for ARDS and was reviewed by 2 qualified physicians with expertise in critical care and cardiac surgery. Outcomes of interest were the incidence and severity of risk factors for ARDS in this population, and perioperative outcomes and survival rates were compared with patients with or without ARDS.A total of 233 adult patients were enrolled into this study; of these, 37 patients (15.9%) had ARDS. Three, 20, and 14 patients had mild, moderate, and severe ARDS, respectively, according to the Berlin definition, with no significant difference in age, sex, and underlying disease. The ARDS group had lower mean oxygenation index (OI) than the non-ARDS group in the first 3 days post-surgery and demonstrated an improvement in lung function after the fourth day. Postoperative complication risks were higher in the ARDS group than in the non-ARDS group. However, no significant difference was observed in in-hospital mortality between the 2 groups (10.8% vs 5.6%, P = .268). Additionally, there was also no significant difference in the 3-year mortality rate between the 2 groups (P of log-rank test = .274). Postoperative hemoglobin level (odds ratio [OR]: 0.78; 95% confidence interval [CI]: 0.62-0.99) and perioperative blood transfusion volume (OR: 1.07; 95% CI: 1.03-1.12) were associated with ARDS risk.Postoperative ARDS after type A aortic dissection repair surgery was associated with risks of postoperative complications but not with risk of in-hospital mortality or 3-year mortality. A higher perioperative blood transfusion volume and a lower postoperative hemoglobin level may be risk factors for ARDS.

Microenvironment of saphenous vein graft preservation prior to coronary artery bypass grafting.

OBJECTIVES: The best preservation solution for a free vascular graft prior to coronary artery bypass grafting (CABG) remains controversial. The aim of this investigation was to evaluate the microenvironment of the human saphenous vein graft when preserved in normal saline (NS) solution or autologous heparinized whole blood (AWB). METHODS: Between January 2014 and December 2014, 21 patients who underwent CABG were enrolled and a total of 162 saphenous vein graft rings were collected. NS and AWB were used to investigate the influence of the microenvironment. The hypoxia, oxidative stress and vascular apoptosis were assayed by western blot, and endothelial integrity was assessed by immunohistochemical analysis. RESULTS: The level of PaO2 in AWB was lower than that in NS (median: 100.5 mmHg vs 185.8 mmHg, P = 0.004). This hypoxic condition led to the production of more hypoxia-inducible factor-1 (median: 60.1% vs 15.1%, P = 0.008) and endothelial nitric oxide synthase (median: 52.6% vs 25%, P = 0.046) within 30 min of preservation time. The fact that higher levels of glutathione peroxidase resulted in the preservation of AWB suggests that it is beneficial to boost the vascular antioxidant defense with lower levels of NOX2. AWB led to increased Bcl-2, reduced cytochrome c and cleaved 85 kDa poly ADP-ribose polymerase apoptotic fragments. CONCLUSIONS: We concluded that AWB possesses a microenvironment that is superior to that of NS for saphenous vein graft preservation prior to CABG.

Preoperative Right Ventricular Dysfunction Indicates High Vasoactive Support Needed After Cardiac Surgery.

OBJECTIVE: The aim of this study was to explore the relationship between preoperative right ventricular (RV) function and high vasoactive-inotropic score (VIS) after cardiac surgery. DESIGN: Prospective observational study. SETTING: A single medical center setting. PARTICIPANTS: One hundred three patients undergoing elective cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Consecutive patients referred for cardiac surgery were enrolled prospectively. Comprehensive transesophageal echocardiography was performed before sternal incision. Specific RV indices, encompassing RV fractional area change, tricuspid annular plane systolic excursion, and RV global longitudinal strain (RVGLS), were measured offline. High VIS was defined as a maximum VIS of ≥20 in 24 hours postoperatively. Postoperative adverse events were recorded. One hundred three patients (mean age 61.2 ± 11.0, 72 men) were included in this study, where 17 patients (16.5%) achieved high VIS with a mean maximum VIS of 39 in 24 hours postoperatively. Patients with high VIS encountered increased occurrence of extracorporeal membrane oxygenation placement, acute kidney injury, and mortality. Risk factors for high VIS included operation type, cardiopulmonary bypass duration, left atrium size, and pre-incisional RV indices. After adjustment for age, left ventricular ejection fraction, and the covariates, only RVGLS (odds ratio 1.19, p = 0.011) showed an independent association with high VIS. The optimal cutoff of RVGLS was -16.7% (sensitivity of 88.2%, specificity of 75.6%). CONCLUSION: Preoperative RV dysfunction is an independent risk factor for postoperative high VIS. Pre-incisional RVGLS is a reliable tool to predict high VIS after cardiac surgery. Patients with high VIS had increased adverse events postoperatively.

Sutureless aortic bioprosthesis replacement in elderly Asian patients with aortic stenosis: Experience in a single institution.

BACKGROUND: Sutureless aortic valve replacement (SU-AVR) has emerged as a promising alternative for the treatment of patients with aortic valve stenosis. This study aims to assess the safety and efficacy of SU-AVR in an elderly Asian population. METHODS: From June 2015 to May 2016, 15 adults with severe aortic stenosis (9 females) with a median age of 79 years underwent Perceval sutureless bioprosthesis (LivaNova, UK) implantation in a single Taiwanese institution; peri-operative recovery, clinical improvement, and valve performance were analyzed. RESULTS: Three (20%) patients underwent concomitant procedures (coronary artery bypass grafting, 1 patient; maze, 2 patients) and 6/12 (50%) patients underwent J-ministernotomy for isolated SU-AVR. Median cardiopulmonary bypass and cross-clamp time were 105 min and 69 min, respectively. All sutureless bioprosthesis were implanted successfully without conversion to a traditional valve, but 2 patients (13.3%) need intraoperative valve repositioning because of paravalvular leakage. Median extubation time and intensive care unit stay were 5 h and 2 days, respectively. One patient experienced in-hospital mortality due to sudden collapse thought secondary to high degree atrioventricular block. Serial echocardiographic evaluations were performed preoperatively and at 1, 3, and 6 months postoperatively. The final echocardiographic exams showed nothing greater than mild aortic insufficiency and the median mean trans-valvular gradient was 13.2 (range, 6.0-26.3) mmHg. CONCLUSIONS: By simplified procedure and improved hemodynamics, SU-AVR can be implanted safely in elderly Asian population with excellent valvular performance.

Preoperative risk assessment improves biomarker detection for predicting acute kidney injury after cardiac surgery.

BACKGROUND: Although urinary neutrophil gelatinase-associated lipocalin (NGAL) has emerged as a promising biomarker for the early detection of kidney injury, previous studies of adult patients who underwent cardiac surgery have reported only moderate discrimination. The age, creatinine, and ejection fraction (ACEF) score is a preoperative validated risk model with satisfactory accuracy for predicting AKI following cardiac surgery. It remains unknown whether combining preoperative risk assessment through ACEF scores followed by urinary NGAL test in a population of high-risk individuals is an optimal approach with improved predictive performance. MATERIAL AND METHODS: A total of 177 consecutive patients who underwent cardiac surgery were enrolled. Clinical characteristics, prognostic model scores, and outcomes were assessed. Urinary NGAL were examined within 6 hours after cardiac surgery. Patients were stratified according to preoperative ACEF scores, and comparisons were made using the area under the receiver operator characteristic curve (AUROC) for the prediction of AKI. RESULTS: A total of 45.8% (81/177) of the patients had AKI. As expected, patients with ACEF scores ≥ 1.1 were older and more likely to have class III or IV heart failure. They were also more likely to have diabetes mellitus, myocardial infarction, and peripheral arterial disease. Urinary NGAL alone moderately predicted AKI, with an AUROC of 0.732. Risk stratification by ACEF scores ≥ 1.1 substantially improved the AUROC of urinary NGAL to 0.873 (95% confidence interval, 0.784-0.961; P < .001). CONCLUSIONS: Risk stratification by preoperative ACEF scores ≥ 1.1, followed by postoperative urinary NGAL, provides more satisfactory risk discrimination than does urinary NGAL alone for the early detection of AKI after cardiac surgery. Future studies should investigate whether this strategy could improve the outcomes and cost-effectiveness of care in patients undergoing cardiac surgery.

Cerebral desaturation in heart failure: Potential prognostic value and physiologic basis.

Cerebral tissue oxygen saturation (SctO2) reflects cerebral perfusion and tissue oxygen consumption, which decline in some patients with heart failure with reduced ejection fraction (HFrEF) or stroke, especially during exercise. Its physiologic basis and clinical significance remain unclear. We aimed to investigate the association of SctO2 with oxygen transport physiology and known prognostic factors during both rest and exercise in patients with HFrEF or stroke. Thirty-four HFrEF patients, 26 stroke patients, and 17 healthy controls performed an incremental cardiopulmonary exercise test using a bicycle ergometer. Integrated near-infrared spectroscopy and automatic gas analysis were used to measure cerebral tissue oxygenation and cardiac and ventilatory parameters. We found that SctO2 (rest; peak) were significantly lower in the HFrEF (66.3±13.3%; 63.4±13.8%,) than in the stroke (72.1±4.2%; 72.7±4.5%) and control (73.1±2.8%; 72±3.2%) groups. In the HFrEF group, SctO2 at rest (SctO2rest) and peak SctO2 (SctO2peak) were linearly correlated with brain natriuretic peptide (BNP), peak oxygen consumption ([Formula: see text]), and oxygen uptake efficiency slope (r between -0.561 and 0.677, p < 0.001). Stepwise linear regression showed that SctO2rest was determined by partial pressure of end-tidal carbon dioxide at rest (PETCO2rest), hemoglobin, and mean arterial pressure at rest (MAPrest) (adjusted R = 0.681, p < 0.05), while SctO2peak was mainly affected by peak carbon dioxide production ([Formula: see text]) (adjusted R = 0.653, p < 0.05) in patients with HFrEF. In conclusion, the study delineates the relationship of cerebral saturation and parameters associated with oxygen delivery. Moreover, SctO2peak and SctO2rest are correlated with some well-recognized prognostic factors in HFrEF, suggesting its potential prognostic value.

Surgical interventions of isolated active mitral valve endocarditis: Predisposing factors and impact of neurological insults on final outcome.

The feasibility and durability of mitral valve (MV) repair in active infective endocarditis (IE) has been reported, but proper management of perioperative neurological complications and surgical timing remains uncertain and may crucially affect the outcome.In this single-center retrospective observational study, patients who underwent isolated MV surgery for active native IE in our institution between August 2005 and August 2015 were reviewed and analyzed. Patients who were operated on for healed IE or who required combined procedures were excluded from this study.A total of 71 patients were enrolled in the study with a repair rate of 53.5% (n = 38). Isolated posterior leaflet lesion was found in 15 patients (21%) and was related to higher reparability (86.7%, P = .004). The overall in-hospital mortality was 10 (14.1%): 3 (7.9%) in the repair group and 7 (21.2%) in replacement group (P = .17). Prognosis was not related to age, preoperative renal function, cerebral emboli, or duration of antibiotics. The only significant predictor was postoperative intracranial hemorrhage (ICH) [odds ratio 14.628 (1.649-129.78), P = .04]. At a mean follow-up period of 43.1 months, neither recurrent endocarditis nor late cardiac death was observed in both groups.Surgical timing and procedural options of MV surgery in active native IE did not make any difference, but occurrence of ICH after surgery jeopardized the final outcome. Routine preoperative brain imaging to detect silent ICH or mycotic aneurysm and aggressive treatment of these lesions may prevent catastrophe and optimize the results.

Predictors of hospital mortality in adult trauma patients receiving extracorporeal membrane oxygenation for advanced life support: a retrospective cohort study.

BACKGROUND: Using extracorporeal membrane oxygenation (ECMO) to provide advanced life support in adult trauma patients remains a controversial issue now. The study was aimed at identifying the independent predictors of hospital mortality in adult trauma patients receiving ECMO for advanced cardiopulmonary dysfunctions. METHODS: This retrospective study enrolled 36 adult trauma patients receiving ECMO due to advanced shock or respiratory failure in a level I trauma center between August 2006 and October 2014. Variables collected for analysis were demographics, serum biomarkers, characteristics of trauma, injury severity score (ISS), damage-control interventions, indications of ECMO, and associated complications. The outcomes were hospital mortality and hemorrhage on ECMO. The multivariate logistic regression method was used to identify the independent prognostic predictors for the outcomes. RESULTS: The medians of age and ISS were 36 (27-49) years and 29 (19-45). Twenty-three patients received damage-control interventions before ECMO. Among the 36 trauma patients, 14 received ECMO due to shock and 22 for respiratory failure. The complications of ECMO are major hemorrhages (n = 12), acute renal failure requiring hemodialysis (n = 10), and major brain events (n = 7). There were 15 patients died in hospital, and 9 of them were in the shock group. CONCLUSIONS: The severity of trauma and the type of cardiopulmonary dysfunction significantly affected the outcomes of ECMO used for sustaining patients with post-traumatic cardiopulmonary dysfunction. Hemorrhage on ECMO remained a concern while the device was required soon after trauma, although a heparin-minimized protocol was adopted. TRIAL REGISTRATION: This study reported a health care intervention on human participants and was retrospectively registered. The Chang Gung Medical Foundation Institutional Review Board approved the study (no. 201601610B0) on December 12, 2016. All of the data were extracted from December 14, 2016, to March 31, 2017.

The impacts of baseline ventilator parameters on hospital mortality in acute respiratory distress syndrome treated with venovenous extracorporeal membrane oxygenation: a retrospective cohort study.

BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a valuable life support in acute respiratory distress syndrome (ARDS) in adult patients. However, the success of VV-ECMO is known to be influenced by the baseline settings of mechanical ventilation (MV) before its institution. This study was aimed at identifying the baseline ventilator parameters which were independently associated with hospital mortality in non-trauma patients receiving VV-ECMO for severe ARDS. METHODS: This retrospective study included 106 non-trauma patients (mean age: 53 years) who received VV-ECMO for ARDS in a single medical center from 2007 to 2016. The indication of VV-ECMO was severe hypoxemia (PaO2/ FiO2 ratio < 70 mmHg) under pressure-controlled MV with peak inspiratory pressure (PIP) > 35 cmH2O, positive end-expiratory pressure (PEEP) > 5 cmH2O, and FiO2 > 0.8. Important demographic and clinical data before and during VV-ECMO were collected for analysis of hospital mortality. RESULTS: The causes of ARDS were bacterial pneumonia (n = 41), viral pneumonia (n = 24), aspiration pneumonitis (n = 3), and others (n = 38). The median duration of MV before ECMO institution was 3 days and the overall hospital mortality was 53% (n = 56). The medians of PaO2/ FiO2 ratio, PIP, PEEP, and dynamic pulmonary compliance (PCdyn) at the beginning of MV were 84 mmHg, 32 cmH2O, 10 cmH2O, and 21 mL/cmH2O, respectively. However, before the beginning of VV-ECMO, the medians of PaO2/ FiO2 ratio, PIP, PEEP, and PCdyn became 69 mmHg, 36 cmH2O, 14 cmH2O, and 19 mL/cmH2O, respectively. The escalation of PIP and the declines in PaO2/ FiO2 ratio and PCdyn were significantly correlated with the duration of MV before ECMO institution. Finally, the duration of MV (OR: 1.184, 95% CI: 1.079-1.565, p < 0.001) was found to be the only baseline ventilator parameter that independently affected the hospital mortality in these ECMO-treated patients. CONCLUSION: Since the duration of MV before ECMO institution was strongly correlated to the outcome of adult respiratory ECMO, medical centers are suggested to find a suitable prognosticating tool to determine the starting point of respiratory ECMO among their candidates with different duration of MV. TRIAL REGISTRATION: This study reported a health care intervention on human participants and was retrospectively registered. The Chang Gung Medical Foundation Institutional Review Board approved the study (no. 201601483B0 ) on November 23, 2016. All of the data were extracted from December 1, 2016, to January 31, 2017.

Effect of different surgical type of coronary artery bypass grafting on kidney injury: A propensity score analysis.

Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) is associated with a less favorable outcome. Off-pump surgery results in lower kidney dysfunction than conventional on-pump arrest surgery. On-pump arrest surgery results in a lower revascularization rate compared with off-pump surgery. On-pump beating heart (OPBH) CABG combines the advantages of beating heart surgery and cardiopulmonary bypass. This study compared the renal outcomes of 3 cardiac surgical methods. From January 2010 to December 2012, 373 patients who underwent on-pump CABG were enrolled. Propensity analysis was performed to compare the postoperative outcomes of postoperative AKI, renal replacement therapy (RRT), intensive care unit (ICU) stay, mortality, and extubating time. In total, 98 patients received conventional on-pump surgery, 160 received OPBH surgery, and 115 received off-pump surgery. The Society of Thoracic Surgeons scores of these 3 groups were 6.1 ±â€Š13.6, 7.4 ±â€Š13.6, and 5.6 ±â€Š10.9, respectively. Propensity analysis revealed lower AKI incidence in the off-pump group than in the on-pump surgery group. No substantial differences were observed in mortality, RRT, and the ICU stay between the off-pump and OPBH surgery groups. Among the 3 surgical methods, off-pump surgery results in lower AKI incidence. The short-term outcome, including kidney function, of OPBH surgery is similar to that of the off-pump group. Therefore, OPBH surgery is a considerable choice for patients with a high surgical risk.

Postoperative Renal Outcomes of On-Pump Beating-Heart versus Cardioplegic Arrest Coronary Artery Bypass Grafting.

BACKGROUND: The aim of this investigation is to compare the postoperative renal outcomes after on-pump beating- heart versus conventional cardioplegic arrest coronary artery bypass grafting (CABG). METHODS: Between January 2010 and December 2012, 254 patients who underwent isolated CABG were enrolled. The primary outcome was postoperative acute kidney injury (AKI) within 7 days [defined by the Kidney Disease Improving Global Outcome (KDIGO) Clinical Practice Guideline] and loss of kidney function at 1 year (defined as > 20% loss in estimated glomerular filtration rate from baseline preoperative creatinine level). RESULTS: There was less AKI found for the on-pump beating-heart CABG (30.2% versus 46.3%; p = 0.010) group; with significant less stage I AKI (17.6% versus 29.5%; p = 0.035); a trend of less stage II AKI (4.4% versus 10.5%; p = 0.088) and no significant difference in stage III AKI (8.2% versus 6.3%; p = 0.587). The on-pump beating-heart group also had less patients who have lost their kidney function at 1 year (24.8% versus 41.2%; p = 0.021). Furthermore, multivariate analysis identified conventional arrest CABG is an independent risk factor for postoperative AKI and loss of kidney function at 1 year. CONCLUSIONS: On-pump beating-heart CABG has superior short-term and mid-term renal outcomes than conventional cardioplegic arrest CABG.

Risk analysis of dialysis-dependent patients who underwent coronary artery bypass grafting: Effects of dialysis modes on outcomes.

Cardiovascular disease is the major morbidity and leading cause of mortality for dialysis-dependent patients. This study aimed to stratify the risk factors and effects of dialysis modes in relation to coronary artery bypass grafting (CABG) surgery among dialysis-dependent patients.This retrospective study enrolled dialysis-dependent patients who underwent CABG from October 2005 to January 2015. All data of demographics, medical history, surgical details, postoperative complications, and in-hospital mortality were analyzed, and patients were categorized as those with or without in-hospital mortality and those with preoperative hemodialysis (HD) or peritoneal dialysis (PD).Of 134 enrolled patients, 25 (18.7%) had in-hospital mortality. Multivariate analyses identified that older age [odds ratio (OR): 1.110, 95% confidence interval (CI): 1.030-1.197, P = .006], previous stroke history (OR: 5.772, 95% CI: 1.643-20.275, P = .006), PD (OR: 19.607, 95% CI: 3.676-104.589, P < .001), and emergent operation (OR: 8.788, 95% CI: 2.697-28.636, P < .001) were statistically significant risk factors for in-hospital mortality among dialysis-dependent patients with CABG surgery. Patients with PD had a higher in-hospital mortality rate (58.3% vs 14.8%, P < .001) and lower 1-year overall survival (33.3% vs 56.6%, P = .031) than did HD patients. The major in-hospital mortality cause was cardiac events among HD patients and septic shock among PD patients.Among dialysis patients who received CABG, those with older age, previous stroke history, PD, and emergent operation had higher risks. Those with PD were prone to poorer in-hospital outcomes after CABG surgery.

Impact of prior coronary stenting on the outcome of subsequent coronary artery bypass grafting.

BACKGROUND: The percentage of patients referred for coronary artery bypass grafting (CABG) who have previously undergone percutaneous coronary interventions (PCIs) is increasing. The purpose of this study was to review the outcomes of patients who had received coronary stenting before CABG, and to examine the validity of a mortality risk stratification system in this patient group. METHODS: From 2010 to 2012, 439 patients who underwent isolated CABG at our medical center were reviewed. The patients were divided into two study groups: those who had previously received coronary artery stenting (97 patients, 24.7%), and those who had not (342 patients, 75.3%). The patients who received balloon angioplasty were excluded. RESULTS: There were no significant differences in baseline characteristics. The prior stenting group had a lower risk of mortality, although the difference was not significant. The prior stenting group had fewer graft anastomoses (p = 0.005), and hence a significantly shorter cardiopulmonary bypass time (p = 0.045) and shorter aortic cross-clamping time. Surgical mortality was similar between the two groups. The durations of intensive care unit stay and hospitalization were also similar. The discriminatory power of the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was lower in both group. CONCLUSIONS: Prior coronary stenting does not affect short-term mortality in patients subsequently undergoing CABG surgery. The EuroSCORE does not predict perioperative mortality well for the patients who undergo coronary stenting before CABG.

Short-term intensive training attenuates the exercise-induced interaction of mono-1/2 cells and platelets after coronary bypass in cardiac patients.

The interaction between platelets and monocytes plays a critical role in the pathogenesis and progression of cardiovascular diseases. This study investigated how short-term intensive training (SIT) influences monocyte subset characteristics and exercise-induced monocyte and platelet aggregates (MPAs) following elective coronary bypass (CABG) in cardiac patients. Forty-nine patients hospitalised for CABG were randomised into SIT (N=26) and conventional training (CT, N=23) groups. The SIT subjects underwent supervised aerobic training at 80~120 % of the ventilatory anaerobic threshold based on sub-maximal exercise tests performed 7 days post-CABG for 20 sessions with two sessions/day and 30 min/session, which were completed within four weeks after surgery. The CT subjects performed light-intensity conditioning exercise for ≤4 sessions. Resting and maximal exercise-mediated monocyte characteristics and MPA were determined before and following intervention. The SIT group had a larger improvement in ventilation efficiency and anaerobic threshold than the CT group; the SIT group exhibited larger reductions in blood monocyte subtypes 1 and 2 (Mono1 and 2) counts at rest than the CT group; the SIT group but not the CT group exhibited attenuated formation of Mono1/platelet hetero-aggregation (MPA1) and CD42b expression on Mono1/2 caused by strenuous exercise; and plasma levels of macrophage inflammatory protein-1ß and soluble P-selectin showed similar trends as Mono1/2 and MPA1, respectively. In conclusion, SIT modestly improved aerobic capacity in patients following CABG. Moreover, SIT simultaneously ameliorated the CD42b expression of Mono1/2 cells and maximal exercise-induced MPA1, which may reduce the risk of inflammatory thrombosis.

Is There a Preinterventional Mechanical Ventilation Time Limit for Candidates of Adult Respiratory Extracorporeal Membrane Oxygenation.

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a useful life support in severe acute respiratory distress syndrome (ARDS). Although prolonged mechanical ventilation (MV) before institution of ECMO is known to be a poor prognostic factor for outcomes of VV-ECMO, a reasonable deadline for this period has not been defined yet. To discover the answer, we reviewed a 9 year institutional experience of adult respiratory ECMO in VV configuration and investigate the relationship between the MV time before ECMO and in-hospital mortality. This retrospective study included 129 adult patients receiving VV-ECMO for ARDS in a single institution from 2007 to 2016. Important demographic and clinical data before ECMO intervention were collected for analyses of in-hospital mortality. The MV time before ECMO independently predicted hospital death in adult respiratory ECMO here. While compared to the patients receiving MV for 7 days or less, the patients receiving MV for more than 7 days before ECMO showed a higher in-hospital mortality rate (77% vs. 38%, p < 0.001). They also experienced a more significant deterioration in respiratory function during MV before the institution of ECMO. Therefore, from the clinical observation, we thought that a 7 day period might be an acceptable limit on MV time before institution of VV-ECMO. Integrating other respiratory parameters into the current PaO2/FiO2 (PF) ratio-based inclusion criteria of adult respiratory ECMO might be helpful to reduce the risk of prolonged MV in selected patients.