The effects of ergonomic sleep mask use on sleep quality and comfort in intensive care patients.

This study was conducted to determine the effects of the use of ergonomic sleep mask on sleep quality and comfort in intensive care patients. This randomised controlled experimental study was completed with 128 surgical intensive care patients (control = 64, experimental = 64). During the second night of their stay in the unit, ergonomic sleep masks were given to the patients in the experimental group, and earplugs and eye masks were given to the patients in the control group. A Patient information form, Visual analogue scale for discomfort, and the Richard-Campbell sleep questionnaire were used to collect data. While 51.6% of the patients were female, the mean age of the patients was 63.87 ± 14.94 years. The highest rates of patients had undergone cardiovascular surgery (28.9%) and general anaesthesia (57.8%). It was determined that the sleep quality of the patients in the experimental group was statistically and clinically significantly higher after the intervention (50.86 ± 21.46 vs 37.64 ± 14.97, t = -5.355, Cohen's d = 0.450, p < 0.001). Likewise, the patients who used ergonomic sleep masks had a statistically significantly lower mean VAS for Discomfort score, and their comfort level was higher (p < 0.001), but the difference was not clinically significant (Cohen's d = 0.208). The results of this study showed that the use of ergonomic sleep masks in surgical intensive care patients had a more positive effect on both the sleep quality and comfort levels of patients compared with earplugs and eye masks. The use of an ergonomic sleep mask is recommended in the early period to facilitate sleep and rest in surgical intensive care patients.

BMI is not independently associated with coronary artery calcification in a large single-center CT cohort.

Objective: Obesity is associated with cardiovascular disease (CVD) and CVD mortality. However, previous reports showed a paradoxical protective effect in patients with known CVD referred as "obesity paradox". Therefore, the aim of the present study was to investigate the association of body mass index (BMI) with coronary artery calcification (CAC) in a large outpatient cardiac CT cohort. Methods: 4.079 patients who underwent cardiac CT between December 2007-May 2014 were analyzed. BMI and clinical risk factors (current smoking, diabetes mellitus type 2, family history, systolic blood pressure, lipid spectrum) were assessed. Missing values were imputed using multiple imputation. CAC extent was categorized as absent (0), mild (>0-100), moderate (>100-400) and severe (>400). Results: Multivariable multinomial logistic regression analysis, including all risk factors as independent variables, showed no association between BMI and CAC. Using absence of calcification as reference category, the odds ratios per unit increase in BMI were 1.01 for mild; 1.02 for moderate; and 1.00 for severe CAC (p-values ≥0.103). Conclusions: No statistically significant association was observed between BMI and CAC after adjustment for other risk factors.

Children's perioperative multidimensional anxiety scale: Turkish cross-cultural adaptation.

RATIONALE: The number of pediatric surgeries is constantly increasing. Evaluating anxiety levels in pediatric surgical patients is highly important in terms of preventing complications. AIMS AND OBJECTIVES: The purpose of this study is to cross-culturally adapt to the Turkish version, and to test the validity and reliability of Children's Perioperative Multidimensional Anxiety Scale (CPMAS). METHOD: This methodological study was carried out with 50 children aged 7-10 years who underwent surgery at Bartin Obstetrics and Pediatrics Hospital between September 2021 and May 2022. The self-reported CPMAS and Children's Anxiety Meter-State (CAM-S) were administered before the surgery, on the day of the surgery, and 1 month after the surgery to collect data. The internal consistency, test-retest reliability, parallel forms reliability, content validity, and construct validity of CPMAS were tested. RESULTS: Children's Perioperative Multidimensional Anxiety Scale showed a high level of internal consistency (Cronbach's alpha = 0.858, 0.916, 0.864). The item-total correlation values of CPMAS were found to be 0.58-0.71 before the surgery, 0.77-0.83 on the day of the surgery, and 0.60-0.80 1 month after the surgery. CPMAS was found to be a single-factor scale explaining 65% of the variance in the examined variable. The correlations between CPMAS and CAM-S (parallel forms) were found to be 0.474 before the surgery, 0.528 on the day of the surgery, and 0.599 1 month after the surgery. CONCLUSION: The CPMAS, which was developed by Chow et al. in English, had high validity and reliability levels for Turkey. It is recommended that the scale be used by healthcare professionals in Turkey in the assessment of surgery-related anxiety in children.

Pericardial fat and its influence on cardiac diastolic function.

BACKGROUND: Pericardial fat (PF) has been suggested to directly act on cardiomyocytes, leading to diastolic dysfunction. The aim of this study was to investigate whether a higher PF volume is associated with a lower diastolic function in healthy subjects. METHODS: 254 adults (40-70 years, BMI 18-35 kg/m2, normal left ventricular ejection fraction), with (a)typical chest pain (otherwise healthy) from the cardiology outpatient clinic were retrospectively included in this study. All patients underwent a coronary computed tomographic angiography for the measurement of pericardial fat volume, as well as a transthoracic echocardiography for the assessment of diastolic function parameters. To assess the independent association of PF and diastolic function parameters, multivariable linear regression analysis was performed. To maximize differences in PF volume, the group was divided in low (lowest quartile of both sexes) and high (highest quartile of both sexes) PF volume. Multivariable binary logistic analysis was used to study the associations within the groups between PF and diastolic function, adjusted for age, BMI, and sex. RESULTS: Significant associations for all four diastolic parameters with the PF volume were found after adjusting for BMI, age, and sex. In addition, subjects with high pericardial fat had a reduced left atrial volume index (p = 0.02), lower E/e (p < 0.01) and E/A (p = 0.01), reduced e' lateral (p < 0.01), reduced e' septal p = 0.03), compared to subjects with low pericardial fat. CONCLUSION: These findings confirm that pericardial fat volume, even in healthy subjects with normal cardiac function, is associated with diastolic function. Our results suggest that the mechanical effects of PF may limit the distensibility of the heart and thereby directly contribute to diastolic dysfunction. Trial registration NCT01671930.

Agatston score of the descending aorta is independently associated with coronary events in a low-risk population.

Objectives: A standard coronary artery calcium scan includes part of the aorta. This additional information is often not included in routine analyses. We aimed to determine the feasibility of assessing the Agatston score of the descending aorta calcification (DAC) on standard coronary calcium scans and the association of this score with coronary events in a low-risk study population. Methods: Between January 2008 and March 2011, 390 consecutive patients who were referred for cardiac CT as part of work-up for pulmonary vein isolation (n=115) or assessment of presence of coronary artery disease (n=275) were included. At baseline, all patients were free of a history of cardiovascular disease. Two independent observers determined the Agatston score of the ascending aorta and descending aorta. Results: A total of 16 patients (4.1%) developed coronary events (acute coronary syndrome (n=6) and symptomatic significant coronary artery disease requiring treatment (n=10)) during a follow-up of 67±12 months, with more events in patients with calcifications in the descending aorta than in those without (8.4% vs 3.7 %; p=0.08). Multivariable Cox regression, corrected for Framingham Risk Score (FRS) and coronary Agatston score (CAC), revealed that DAC was independently associated with coronary events (per 100 units; HR: 1.06, 95% CI 1.02 to 1.09; p=0.001). DAC furthermore increased the identification of patients that will experience a coronary event (area under the curve: 0.68 for FRS only, 0.75 for FRS+CAC and 0.78 for FRS+CAC+DAC). Conclusions: The Agatston score of the descending aorta could be included in the standard analysis of cardiac CT scans of low-risk patients since it holds valuable information for the prediction of coronary events.

The role of standard non-ECG gated chest CT in cardiac assessment: design and rationale of the Cardiac Pathologies in standard chest CT (CaPaCT) study.

Modern high-performance computed tomography (CT) scanners with improved scan acquisition times now allow for routine assessment of cardiac pathologies on chest CTs, which can result in numerous incidental cardiac findings. The CaPaCT study, an observer blinded, single-centre study, aims to assess the visibility, management and possible clinical impact of incidental cardiac pathologies that are now becoming visible on standard chest CTs. A total of 217 consecutive patients referred for a chest CT on a high-performance third-generation dual-source CT scanner will be included. Tube voltage settings will be chosen via automated kV selection. Dedicated cardiac reconstructions will be added to the standard post-processing: 0.6-mm slice thickness, 0.4-mm increment and Bv36 kernel (iterative reconstruction/strength 3). Primary endpoints will be the presence and extent of coronary artery disease (CAD) assessed via a 17-segment model. These data will be collected and analysed by two experienced, blinded cardiac radiologists. Furthermore, information on aortic and mitral valve morphology/calcification and pericardial abnormalities will be collected. The CAD Reporting and Data System classification will subsequently be used to assess the management and possible clinical burden of any incidentally detected CAD. Additionally, objective and subjective image quality (attenuation, contrast-to-noise, signal-to-noise and 5-point Likert scale) of the obtained cardiac reconstructions will be assessed.

Vitamin K Antagonists, Non-Vitamin K Antagonist Oral Anticoagulants, and Vascular Calcification in Patients with Atrial Fibrillation.

Background Vitamin K antagonists (VKAs) are associated with coronary artery calcification in low-risk populations, but their effect on calcification of large arteries remains uncertain. The effect of non-vitamin K antagonist oral anticoagulants (NOACs) on vascular calcification is unknown. We investigated the influence of use of VKA and NOAC on calcification of the aorta and aortic valve. Methods In patients with atrial fibrillation without a history of major adverse cardiac or cerebrovascular events who underwent computed tomographic angiography, the presence of ascending aorta calcification (AsAC), descending aorta calcification (DAC), and aortic valve calcification (AVC) was determined. Confounders for VKA/NOAC treatment were identified and propensity score adjusted logistic regression explored the association between treatment and calcification (Agatston score > 0). AsAC, DAC, and AVC differences were assessed in propensity score-matched groups. Results Of 236 patients (33% female, age: 58 ± 9 years), 71 (30%) used VKA (median duration: 122 weeks) and 79 (34%) used NOAC (median duration: 16 weeks). Propensity score-adjusted logistic regression revealed that use of VKA was significantly associated with AsAC (odds ratio [OR]: 2.31; 95% confidence interval [CI]: 1.16-4.59; p = 0.017) and DAC (OR: 2.38; 95% CI: 1.22-4.67; p = 0.012) and a trend in AVC (OR: 1.92; 95% CI: 0.98-3.80; p = 0.059) compared with non-anticoagulation. This association was absent in NOAC versus non-anticoagulant (AsAC OR: 0.51; 95% CI: 0.21-1.21; p = 0.127; DAC OR: 0.80; 95% CI: 0.36-1.76; p = 0.577; AVC OR: 0.62; 95% CI: 0.27-1.40; p = 0.248). A total of 178 patients were propensity score matched in three pairwise comparisons. Again, use of VKA was associated with DAC ( p = 0.043) and a trend toward more AsAC ( p = 0.059), while use of NOAC was not (AsAC p = 0.264; DAC p = 0.154; AVC p = 0.280). Conclusion This cross-sectional study shows that use of VKA seems to contribute to vascular calcification. The calcification effect was not observed in NOAC users.

Optimizing contrast media application in coronary CT angiography at lower tube voltage: Evaluation in a circulation phantom and sixty patients.

PURPOSE: The purpose was to investigate optimal contrast media (CM) injection parameters for lower kVp settings, whilst maintaining diagnostic attenuation levels. METHODS AND MATERIALS: First, a circulation phantom with physiological parameters (BP 120/80mmHg, HR 60bpm) was used. A fixed CM injection protocol was used for each kVp setting (300mgI/ml [Iopromide], volume=45ml, flow rate=6.0ml/s, iodine delivery rate [IDR]=1.8gI/s, iodine load=13.5gI; at 120, 100, 80 and 70kVp). Then, IDR was decreased by steps of 0.2gI/s for each kVp setting, until diagnostically insufficient attenuation values were reached (<325HU). In order to keep injection time constant (7.5s), total iodine load (TIL) was reduced accordingly. Second, clinical applicability at 120 and 100kVp was evaluated in patients (n=60) referred for coronary CT angiography. A standard and reduced (12% less) CM protocol was used based on weight classes and scan duration ('high-pitch': 1s; 'adaptive sequence' and 'helical': 7s). Attenuation levels of the coronary arteries were measured and compared between protocols. RESULTS: Using a fixed CM injection at each kVp level resulted in the following HU values: 335HU±31 (120kVp); 425HU±30 (100kVp); 587HU±29 (80kVp); 666HU±27 (70kVp). Keeping diagnostic enhancement levels (353HU±28) CM could be reduced as follows: 12% for 100kVp; 45% for 80kVp and 56% for 70kVp. Diagnostic enhancement levels could be reproduced with concurrent CM reduction (-12% at 100kV) in the clinical setting (382HU±35). CONCLUSION: CM injection parameters can be substantially reduced at low kVp settings (up to 56% at 70kVp), whilst maintaining diagnostic attenuation levels. This may play an important role in CT imaging of the coronary arteries as well as cerebral and peripheral circulations in the future.

Patient Comfort During Contrast Media Injection in Coronary Computed Tomographic Angiography Using Varying Contrast Media Concentrations and Flow Rates: Results From the EICAR Trial.

PURPOSE: Pain sensation and extravasation are potential drawbacks of contrast media (CM) injection during computed tomographic angiography. The purpose was to evaluate safety and patient comfort of higher flow rates in different CM protocols during coronary computed tomographic angiography. METHODS: Two hundred consecutive patients of a double-blind randomized controlled trial (NCT02462044) were analyzed. Patients were randomized to receive 94 mL of prewarmed iopromide 240 mg I/mL at 8.3 mL/s (group I), 75 mL of 300 mg I/mL at 6.7 mL/s (group II), or 61 mL of 370 mg I/mL at 5.4 mL/s (group III), respectively. Iodine delivery rate (2.0 g I/s) and total iodine load (22.5 g I) were kept identical. Outcome was defined as intravascular enhancement, patient comfort during injection, and injection safety, expressed as the occurrence of extravasation. Patients completed a questionnaire for comfort, pain, and stress during CM injection. Comfort was graded using a 5-point scale, 1 representing "very bad" and 5 "very well." Pain was graded using a 10-point scale, 0 representing "no pain" and 10 "severe pain." Stress was graded using a 5-point scale, 1 representing "no stress" and 5 "unsustainable stress." RESULTS: Mean enhancement levels within the coronary arteries were as follows: 437 ± 104 Hounsfield units (HU) (group I), 448 ± 111 HU (group II), and 447 ± 106 HU (group III), with P ≥ 0.18. Extravasation occurred in none of the patients. Median (interquartile range) for comfort, pain, and stress was, respectively, 4 (4-5), 0 (0-0), and 1 (1-2), with P ≥ 0.68. CONCLUSIONS: High flow rates of prewarmed CM were safely injected without discomfort, pain, or stress. Therefore, the use of high flow rates should not be considered a drawback for CM administration in clinical practice.

High-Sensitivity Cardiac Troponin Concentrations in Patients with Chest Discomfort: Is It the Heart or the Kidneys As Well?

BACKGROUND: High-sensitivity cardiac troponins (hs-cTn) are the preferred biomarkers to detect myocardial injury, making them promising risk-stratifying tools for patients with symptoms of chest pain. However, circulating hs-cTn are also elevated in other conditions like renal dysfunction, complicating appropriate interpretation of low-level hs-cTn concentrations. METHODS: A cross-sectional analysis was performed in 1864 patients with symptoms of chest discomfort from the cardiology outpatient department who underwent cardiac computed tomographic angiography (CCTA). Serum samples were analyzed using hs-cTnT and hs-cTnI assays. Renal function was measured by the estimated glomerular filtration rate (eGFR), established from serum creatinine and cystatin C. On follow-up, the incidence of adverse events was assessed. RESULTS: Median hs-cTnT and hs-cTnI concentrations were 7.2(5.8-9.2) ng/L and 2.6(1.8-4.1) ng/L, respectively. Multivariable regression analysis revealed that both assay results were more strongly associated with eGFR (hs-cTnT:stß:-0.290;hs-cTnI:stß:-0.222) than with cardiac imaging parameters, such as coronary calcium score, CCTA plaque severity score and left ventricular mass (all p<0.01). Furthermore, survival analysis indicated lower relative risks in patients with normal compared to reduced renal function for hs-cTnT [HR(95%CI), 1.02(1.00-1.03) compared to 1.07(1.05-1.09)] and hs-cTnI [1.01(1.00-1.01) compared to 1.02(1.01-1.02)] (all p<0.001). CONCLUSION: In patients with chest discomfort, we identified an independent influence of renal function on hs-cTn concentrations besides CAD, that affected the association of hs-cTn concentrations with adverse events. Estimating renal function is therefore warranted when interpreting baseline hs-cTn concentrations.

Evaluation of individually body weight adapted contrast media injection in coronary CT-angiography.

OBJECTIVES: Contrast media (CM) injection protocols should be customized to the individual patient. Aim of this study was to determine if software tailored CM injections result in diagnostic enhancement of the coronary arteries in computed tomography angiography (CTA) and if attenuation values were comparable between different weight categories. MATERIALS AND METHODS: 265 consecutive patients referred for routine coronary CTA were scanned on a 2nd generation dual-source CT. Group 1 (n=141) received an individual CM bolus based on weight categories (39-59 kg; 60-74 kg; 75-94 kg; 95-109 kg) and scan duration ('high-pitch: 1s; "dual-step prospective triggering": 7s), as determined by contrast injection software (Certegra™ P3T, Bayer, Berlin, Germany). Group 2 (n=124) received a standard fixed CM bolus; Iopromide 300 mgI/ml; volume: 75 ml; flow rate: 7.2 ml/s. Contrast enhancement was measured in all proximal and distal coronary segments. Subjective and objective image quality was evaluated. Statistical analysis was performed using SPSS (IBM, version 20.0). RESULTS: For group 1, mean attenuation values of all segments were diagnostic (>325 HU) without statistical significant differences between different weight categories (p>0.17), proximal vs. distal: 449 ± 65-373 ± 58 HU (39-59 kg); 443 ± 69-367 ± 81 HU (60-74 kg); 427 ± 59-370 ± 61 HU (75-94 kg); 427 ± 73-347 ± 61 HU (95-109 kg). Mean CM volumes were: 55 ± 6 ml (39-59 kg); 61 ± 7 ml (60-74 kg); 71 ± 8 ml (75-94 kg); 84 ± 9 ml (95-109 kg). For group 2, mean attenuation values were not all diagnostic with differences between weight categories (p<0.01), proximal vs. distal: 611 ± 142-408 ± 69 HU (39-59 kg); 562 ± 135-389 ± 98 HU (60-74 kg); 481 ± 83-329 ± 81 HU (75-94 kg); 420 ± 73-305 ± 35 HU (95-109 kg). Comparable image noise and image quality were found between groups (p ≥ 0.330). CONCLUSIONS: Individually tailored CM injection protocols yield diagnostic attenuation and a more homogeneous enhancement pattern between different weight groups. CM volumes could be reduced for the majority of patients utilizing individualized CM bolus application.

Unstable coronary plaque characteristics are associated with high-sensitivity cardiac troponin T and N-terminal Pro-Brain Natriuretic Peptide.

BACKGROUND: Unstable plaque characteristics on coronary CT angiography (CTA), serum high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal Pro-Brain Natriuretic Peptide (NT-proBNP) concentrations are associated with cardiovascular events. OBJECTIVE: To investigate the association between coronary CTA defined quantifiable plaque characteristics, hs-cTnT and NT-proBNP. METHODS: 81 consecutive stable chest pain patients with an intermediate-to-high risk were analyzed. Coronary CTA was performed using a 64-slice multidetector-row CT-scanner. Total coronary plaque volume, calcified volume, non-calcified volume, plaque burden, remodeling index (RI) and number of plaques were measured using dedicated software. A total plaque score ("Sum plaque score") incorporating total plaque volume, RI, plaque burden and number of plaques was defined. Hs-cTnT and NT-proBNP concentrations were measured in serum samples before coronary CTA. RESULTS: Univariate regression analysis demonstrated significant associations of hs-cTnT and NT-proBNP with total plaque volume (r hs-cTnT = .256; r NT-proBNP = .270), calcified volume (r hs-cTnT = .344; r NT-proBNP = .344), RI (r hs-cTnT = .335; r NT-proBNP = .342) and number of plaques (r hs-cTnT = .355; r NT-proBNP = .301) (all P values ≤ .021). Non-calcified plaque volume showed no association with hs-cTnT and NT-proBNP (r hs-cTnT = .050; r NT-proBNP = .087; P value = .660 and P value = .442). The "Sum plaque score" showed the highest correlation compared to other plaque parameters (r hs-cTnT = .362; r NT-proBNP = .409; P value = .001 and P value ≤ .001). CONCLUSION: Our data suggest that coronary plaque morphology parameters, derived by dedicated software, are associated with serum hs-cTnT and NT-proBNP concentrations.

Coronary CT angiography using low concentrated contrast media injected with high flow rates: Feasible in clinical practice.

PURPOSE: Aim of this study was to test the hypothesis that peak injection pressures and image quality using low concentrated contrast media (CM) (240 mg/mL) injected with high flow rates will be comparable to a standard injection protocol (CM: 300 mg/mL) in coronary computed tomographic angiography (CCTA). MATERIAL AND METHODS: One hundred consecutive patients were scanned on a 2nd generation dual-source CT scanner. Group 1 (n=50) received prewarmed Iopromide 240 mg/mL at an injection rate of 9 mL/s, followed by a saline chaser. Group 2 (n=50) received the standard injection protocol: prewarmed Iopromide 300 mg/mL; flow rate: 7.2 mL/s. For both protocols, the iodine delivery rate (IDR, 2.16 gI/s) and the total iodine load (22.5 gI) were kept identical. Injection pressure (psi) was continuously monitored by a data acquisition program. Contrast enhancement was measured in the thoracic aorta and all proximal and distal coronary segments. Subjective and objective image quality was evaluated between both groups. RESULTS: No significant differences in peak injection pressures were found between both CM groups (121 ± 5.6 psi vs. 120 ± 5.3 psi, p=0.54). Flow rates of 9 mL/s were safely injected without any complications. No significant differences in contrast-to-noise ratio, signal-to-noise ratio and subjective image quality were found (all p>0.05). No significant differences in attenuation levels were found in the thoracic aorta and all segments of the coronary arteries (all p>0.05). CONCLUSION: Usage of low iodine concentration CM and injection with high flow rates is feasible. High flow rates (9 mL/s) of Iopromide 240 were safely injected without complications and should not be considered a drawback in clinical practice. No significant differences in peak pressure and image quality were found. This creates a doorway towards applicability of a broad variety in flow rates and IDRs and subsequently more individually tailored injection protocols.

Contrast Enhancement of the Right Ventricle during Coronary CT Angiography--Is It Necessary?

PURPOSE: It is unclear if prolonged contrast media injection, to improve right ventricular visualization during coronary CT angiography, leads to increased detection of right ventricle pathology. The purpose of this study was to evaluate right ventricle enhancement and subsequent detection of right ventricle disease during coronary CT angiography. MATERIALS AND METHODS: 472 consecutive patients referred for screening coronary CT angiography were retrospectively evaluated. Every patient underwent multidetector-row CT of the coronary arteries: 128x 0.6mm coll., 100-120kV, rot. time 0.28s, ref. mAs 350 and received an individualized (P3T) contrast bolus injection of iodinated contrast medium (300 mgI/ml). Patient data were analyzed to assess right ventricle enhancement (HU) and right ventricle pathology. Image quality was defined good when right ventricle enhancement >200HU, moderate when 140-200HU and poor when <140HU. RESULTS: Good image quality was found in 372 patients, moderate in 80 patients and poor in 20 patients. Mean enhancement of the right ventricle cavity was 268HU±102. Patients received an average bolus of 108±24 ml at an average peak flow rate of 6.1±2.2 ml/s. In only three out of 472 patients (0.63%) pathology of the right ventricle was found (dilatation) No other right ventricle pathology was detected. CONCLUSION: Right ventricle pathology was detected in three out of 472 patients; the dilatation observed in these three cases may have been picked up even without dedicated enhancement of the right ventricle. Based on our findings, right ventricle enhancement can be omitted during screening coronary CT angiography.

Trends in the occurrence of new conduction abnormalities after transcatheter aortic valve implantation.

OBJECTIVES: The aim of the study was to investigate trends over time in the occurrence of left bundle branch block (LBBB) and permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) with the Medtronic CoreValve System (MCS) and Edwards SAPIEN Valve (ESV). BACKGROUND: TAVI-induced conduction abnormalities (TAVI-CAs) such as LBBB and the need for PPI are frequent postoperative complication. New techniques, procedural refinements, and increased awareness are focused on the reduction of these abnormalities. METHODS: Electrocardiograms of 549 patients without preprocedural LBBB and/or pacemaker were assessed to determine the frequency and nature of TAVI-CAs. To study the effect of experience, patients were subdivided per center into tertiles based on the number of procedures. Univariate and multivariate logistic regression was used to study predictors of TAVI-induced LBBB (TAVI-LBBB) and PPI. RESULTS: TAVI-LBBB occurred in 185 patients (33.7%) and significantly decreased over time, from 42.6% to 27.3% (P=0.006). This effect was only significant after implantation of the MCS (59.6% vs. 46.5% vs. 31.1%, P=0.001, ESV: 22.6% vs. 13.1% vs. 24.8%, P=0.11). Between tertiles there was no difference in the frequency of PPI after TAVI (n=73, 13.1% vs. 14.8% vs. 12%, P=0.74). Multivariate analysis revealed that, independent from valve type, depth of implantation was the only significant predictor of TAVI-LBBB (OR [95% C.I.]: 1.16 [1.10-1.24], P<0.001). In case of PPI pre-existing RBBB (OR [95% C.I.]: 7.22 [3.28-15.88], P<0.001) was the only significant predictor. CONCLUSIONS: Over time the frequency of LBBB after TAVI decreased significantly, especially in patients undergoing TAVI with the MCS. Experience and the subsequent reduction in depth of implantation seem responsible for this reduction. Contrary to TAVI-LBBB, the incidence of PPI remained unchanged over time and was not affected by experience. Although experience has led to a decrease in new CAs after TAVI, elucidation of pathophysiologic mechanisms underlying these CAs and subsequent changes in patient stratification, valve design and the procedure are needed to further reduce this complication.

Hemolysis is associated with acute kidney injury during major aortic surgery.

Hemolysis is an inevitable side effect of cardiopulmonary bypass resulting in increased plasma free hemoglobin that may impair tissue perfusion by scavenging nitric oxide. Acute kidney injury after on-pump cardiovascular surgery arises from a number of causes and severely affects patient morbidity and mortality. Here, we studied the effect of acute hemolysis on renal injury in 35 patients undergoing on-pump surgical repair of thoracic and thoracoabdominal aortic aneurysms of whom 19 experienced acute kidney injury. During surgery, plasma free hemoglobin increased, as did urinary excretion of the tubular injury marker N-acetyl-beta-D-glucosaminidase, in patients with and without acute kidney injury, reaching peak levels at 2 h and 15 min, respectively, after reperfusion. Furthermore, plasma free hemoglobin was independently and significantly correlated with the urine biomarker, which, in turn, was independently and significantly associated with the later postoperative increase in serum creatinine. Importantly, peak plasma free hemoglobin and urine N-acetyl-beta-D-glucosaminidase concentrations had significant predictive value for postoperative acute kidney injury. Thus, we found an association between increased plasma free hemoglobin and renal injury casting new light on the pathophysiology of acute kidney injury. Therefore, free hemoglobin is a new therapeutic target to improve clinical outcome after on-pump cardiovascular surgery.