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Background: Postoperative Atrial Fibrillation (POAF) is a common complication in cardiac surgery. Despite its multifactorial origin, the left atrial (LA) size is closely linked to POAF, raising the question of a valid cut-off value and its impact on the long-term outcome. Methods: Patients without a history of AF who underwent coronary artery bypass grafting between 2014 and 2016 were selected for this retrospective study. LA size was preoperatively assessed using the left atrial anterior-posterior diameter (LAAPd). Correlation and logistic regression analyses were performed, following a receiver-operating characteristic (ROC) analysis. Propensity score matching (PSM) was applied to ensure group comparability, followed by a comparison analysis regarding the primary endpoint of POAF and the secondary endpoints of all-cause mortality and stroke during a five-year follow-up. Results: A total of 933 patients were enrolled in the study eventually revealing a significant correlation between LAAPd and POAF (cor = 0.09, p < 0.01). A cut-off point of 38.5 mm was identified, resulting in groups with 366 patients each after PSM. Overall, patients with a dilated LA presented a significantly higher rate of POAF (22.3% vs. 30.4%, p = 0.02). In a five-year follow-up, a slightly higher rate of all-cause mortality (9.8% vs. 13.7%, HR 1.4 [0.92-2.29], p = 0.10) was observed, but there was no difference in the occurrence of strokes (3.6% vs. 3.3%, p = 0.87). Conclusions: An LAAPd of >38.5 mm was found to be an independent predictor of POAF after coronary artery bypass grafting and resulted in a non-significant tendency towards a worse outcome regarding all-cause mortality in a five-year follow-up.
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Objectives: Clampless aortic anastomosis devices aim to lower stroke risk in off-pump coronary artery bypass grafting. Two main strategies for clampless anastomosis devices emerged with automated anastomosis punching and aortic sealing devices, prompting the question of perioperative outcome differences. Methods: All consecutive patients undergoing elective off-pump coronary artery bypass grafting with a clampless aortic anastomosis device between September 2014 and December 2021 in 2 centers were retrospectively included. Cohorts were divided by the use of an automated anastomosis punching device or an aortic sealing device to achieve proximal anastomosis on the ascending aorta. To reach group comparability propensity score matching was performed. The primary end point was defined as a composite of all-cause mortality, stroke and rethoracotomy. Secondary end points were perioperative outcome parameters. Results: A total of 3703 patients were enrolled of whom 575 and 3128 were included in the automated anastomosis punching and the aortic sealing device group, respectively. By propensity score matching a total of 1150 patients were included with 575 in each group. The primary composite endpoint showed no significant difference with 6.3% versus 5.9% events (odds ratio, 0.9; 95% confidence interval, 0.58-1.53, P = .81). All-cause mortality (P = .36), stroke (P = .81), and rethoracotomy (P = .89) also exhibit no disparity. Operation time was significantly longer in the aortic sealing device cohort with 220.0 ± 50.8 minutes and 204.6 ± 53.8 minutes (P < .01). Conclusions: Clampless aortic anastomosis strategies aortic sealing device and automated anastomosis punching did not differ in perioperative outcome parameters, whereas the implementation of aortic sealing devices were associated with a prolonged operation time without inducing any inferior clinical outcome.
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BACKGROUND: Recent data demonstrated the benefit of left atrial appendage (LAA)-amputation in patients with atrial fibrillation (AF). However, the long-term impact of LAA-amputation for patients with new-onset perioperative atrial fibrillation (POAF) is still unknown. METHODS: Patients with no history of AF undergoing coronary artery bypass grafting by off-pump technique (OPCAB) between 2014 and 2016 were retrospectively examined. Cohorts were divided by the concomitant execution of LAA-amputation. Propensity score (PS) matching was applied by all available baseline characteristics. The composite of all-cause mortality, stroke and rehospitalization in patients with POAF and patients maintaining sinus rhythm posed as the primary endpoint. RESULTS: A total of 1522 patients were enrolled, of whom 1208 and 243 were included in the control and the LAA-amputation group, respectively and were matched to 243 patients in each group. In total, patients with POAF without LAA-amputation showed a significantly higher rate of the composite endpoint (17.3% vs 32.1%, p = 0.007). However, patients with LAA-amputation showed no significant difference in the composite endpoint (23.2% vs 26.7%, p = 0.57). The significantly higher occurrence of the composite endpoint was driven by all-cause mortality (p = 0.005) and rehospitalization (p = 0.029). Subgroup analysis revealed a CHA2DS2-VASc-score of ≥ 3 to be associated with the high rate of the primary endpoint (p = 0.004). CONCLUSION: POAF is associated with a higher rate of the combined endpoint of all-cause mortality, stroke and rehospitalization. The composite endpoint in patients with LAA-amputation concomitant with OPCAB surgery developing new-onset POAF in a 5-year follow-up was not increased compared to a control cohort maintaining sinus rhythm. Five-year outcome of patients with POAF and LAA-amputation; 95% CI, 95% confidence interval, CPR, cardiopulmonary resuscitation, ECLS, extracorporeal life support, HR, hazard ratio, IABP, intra-aortic balloon pump, LAA, left atrial appendage, OPCAB, off-pump coronary artery bypass grafting, PAPs, systolic pulmonary artery pressure, SR, sinus rhythm, VT, ventricular tachycardia.
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Apéndice Atrial , Fibrilación Atrial , Puente de Arteria Coronaria Off-Pump , Accidente Cerebrovascular , Humanos , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Apéndice Atrial/cirugía , Estudios Retrospectivos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Amputación Quirúrgica , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control , Factores de RiesgoRESUMEN
AIMS: Evidence suggests that a high-dose statin loading before a percutaneous coronary revascularization improves outcomes in patients receiving long-term statins. This study aimed to analyse the effects of such an additional statin therapy before surgical revascularization. METHODS AND RESULTS: This investigator-initiated, randomized, double-blind, and placebo-controlled trial was conducted from November 2012 to April 2019 at 14 centres in Germany. Adult patients (n = 2635) with a long-term statin treatment (≥30 days) who were scheduled for isolated coronary artery bypass grafting (CABG) were randomly assigned to receive a statin-loading therapy or placebo at 12 and 2 h prior to surgery using a web-based system. The primary outcome of major adverse cardiac and cerebrovascular events (MACCE) was a composite consisting of all-cause mortality, myocardial infarction (MI), and a cerebrovascular event occuring within 30 days after surgery. Key secondary endpoints included a composite of cardiac death and MI, myocardial injury, and death within 12 months. Non-statistically relevant differences were found in the modified intention-to-treat analysis (2406 patients; 1203 per group) between the statin (13.9%) and placebo groups (14.9%) for the primary outcome [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.74-1.18; P = 0.562] or any of its individual components. Secondary endpoints including cardiac death and MI (12.1% vs. 13.5%; OR 0.88, 95% CI 0.69-1.12; P = 0.300), the area under the troponin T-release curve (median 0.398 vs. 0.394 ng/ml, P = 0.333), and death at 12 months (3.1% vs. 2.9%; P = 0.825) were comparable between treatment arms. CONCLUSION: Additional statin loading before CABG failed to reduce the rate of MACCE occuring within 30 days of surgery.
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Enfermedad de la Arteria Coronaria , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Infarto del Miocardio , Intervención Coronaria Percutánea , Adulto , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Resultado del Tratamiento , Puente de Arteria Coronaria/métodos , Infarto del Miocardio/prevención & control , Infarto del Miocardio/etiología , Intervención Coronaria Percutánea/métodos , MuerteRESUMEN
OBJECTIVES: Since recent data demonstrated the benefit of the amputation of the left atrial appendage (LAA) in patients with atrial fibrillation, the long-term impact of LAA amputation on stroke rate and mortality in patients with no history of atrial fibrillation is still unknown. METHODS: Patients with no history of atrial fibrillation who underwent coronary artery bypass grafting by the off-pump technique between 2014 and 2016 were examined retrospectively. Cohorts were divided by the concomitant execution of LAA amputation, and propensity score matching was applied by baseline characteristics. The stroke rate in a 5-year follow-up served as the primary end point. Secondary end points were the mortality rate and rehospitalization in the same time span. RESULTS: A total of 1,522 patients were enrolled, of whom 1,267 and 255 were included in the control group and in the LAA amputation group, respectively. These were matched to 243 patients in each group. In total, patients with an LAA amputation showed a significantly lower rate of stroke in a 5-year follow-up [7.0% vs 2.9%, hazard ratio, 0.41; 95% confidence interval (0.17; 0.98), p = 0.045]. However, there was no difference in all-cause mortality (P = 0.23) or rehospitalizations (P = 0.68). Subgroup analysis revealed LAA amputation in patients with a CHA2DS2VASc [congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 and sex category (female)] score of ≥3 to be associated with a reduction of stroke [9.4% vs 3.1%, hazard ratio, 0.33; 95% confidence interval [0.12; 0.92], P = 0.034]. CONCLUSIONS: LAA amputation concomitant with cardiac surgery reduces the stroke rate in patients with no history of atrial fibrillation and a high CHA2DS2VASc score (≥3) in a 5-year follow-up.
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Apéndice Atrial , Fibrilación Atrial , Procedimientos Quirúrgicos Cardíacos , Accidente Cerebrovascular , Humanos , Femenino , Anciano , Apéndice Atrial/cirugía , Estudios Retrospectivos , Procedimientos Quirúrgicos Cardíacos/métodos , Fibrilación Atrial/complicaciones , Fibrilación Atrial/epidemiología , Fibrilación Atrial/cirugía , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Amputación QuirúrgicaRESUMEN
OBJECTIVES: Left atrial appendage (LAA) amputation concomitant to coronary artery bypass grafting (CABG) has become an increasingly performed technique in patients with atrial fibrillation (AF) or with sinus rhythm and a CHA2DS2-VASc score ≥2. However, LAA amputation has come under suspicion to cause postoperative atrial fibrillation (POAF) due to left atrial (LA) dilation. This study aims to assess this assumption in patients undergoing CABG in off-pump technique with and without amputation of the LAA. METHODS: Patients who underwent isolated CABG in off-pump technique without history of AF were retrospectively examined. Cohorts were divided according to the concomitant execution of LAA amputation. LA volume was measured by transthoracic echocardiography and rhythm was analyzed by electrocardiography, medication protocol, and visit documentation. Propensity score (PS) matching was performed based on 20 preoperative risk variables to correct for selection bias. RESULTS: A total of 1,522 patients were enrolled, with 1,267 in the control group and 255 in the LAA amputation group. Occurrence of POAF was compared in 243 PS-matched patient pairs. Neither the unmatched cohort (odds ratio [OR] 0.82; 95% confidence interval or CI [0.61; 1.11], p = 0.19) nor the PS-matched cohort (OR 0.94; 95% CI [0.62; 1.41], p = 0.75) showed significant differences in POAF occurrence. Subgroup analysis of sex, use of ß-blockers, pulmonary disease, ejection fraction, and CHA2DS2-VASc-Score also showed no tendencies. LA volume did not change significantly (p = 0.18, 95% CI [-0.29; 1.51]). CONCLUSION: Surgical amputation of the LAA concomitant to CABG did not lead to LA dilation and has no significant impact on the occurrence of POAF.
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Apéndice Atrial , Fibrilación Atrial , Humanos , Apéndice Atrial/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Puente de Arteria Coronaria/efectos adversos , Amputación Quirúrgica , Factores de RiesgoRESUMEN
Patients suffering retrograde type A aortic dissection after TEVAR for type B dissection are at higher risk of mortality than their spontanous counterparts and the kind of optimal therapy remains obscure. We present a case of successful open surgical repair where distal open anastomosis was accomplished by cutting off the un-covered stent portion and suturing a vascular prosthesis to the dissected distal aortic arch including the covered stent part. The clinical course was regular. Immediate and radical repair in the aortic arch may be the adequate response in such instances.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Disección Aórtica/etiología , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/complicaciones , Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/métodos , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Stents/efectos adversos , Resultado del TratamientoRESUMEN
OBJECTIVES: Recent data suggested that off-pump coronary artery bypass (OPCAB) may carry a higher risk for mortality in the long term when compared to on-pump coronary artery bypass (ONCAB). We, therefore, compared long-term survival and morbidity in patients undergoing ONCAB versus OPCAB in a large single-centre cohort. METHODS: A total of 8981 patients undergoing isolated elective/urgent coronary artery bypass grafting between January 2009 and December 2019 were analysed. Patients were stratified into 2 groups (OPCAB n = 6649/ONCAB n = 2332). The primary end point was all-cause mortality. Secondary endpoints included repeat revascularization, stroke and myocardial infarction. To adjust for potential selection bias, 1:1 nearest neighbour propensity score (PS) matching was performed resulting in 1857 matched pairs. Moreover, sensitivity analysis was applied in the entire study cohort using multivariable- and PS-adjusted Cox regression analysis. RESULTS: In the PS-matched cohort, 10-year mortality was similar between study groups [OPCAB 36.4% vs ONCAB 35.8%: hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.87-1.12; P = 0.84]. While 10-year outcomes of secondary endpoints did not differ significantly, risk of stroke (OPCAB 1.50% vs ONCAB 2.8%: HR 0.51, 95% CI 0.32-0.83; P = 0.006) and mortality (OPCAB 3.1% vs ONCAB 4.8%: HR 0.65, 95% CI 0.47-0.91; P = 0.011) at 1 year was lower in the OPCAB group. In the multivariable- and the PS-adjusted model, mortality at 10 years was not significantly different (OPCAB 34.1% vs ONCAB 35.7%: HR 0.97, 95% CI 0.87-1.08; P = 0.59 and HR 1.01, 95% CI 0.90-1.13; P = 0.91, respectively). CONCLUSIONS: Data do not provide evidence that elective/urgent OPCAB is associated with significantly higher risks of mortality, repeat revascularization, or myocardial infarction during late follow-up when compared to ONCAB. Patients undergoing OPCAB may benefit from reduced risks of stroke and mortality within the first year postoperatively.
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Puente de Arteria Coronaria Off-Pump , Enfermedad de la Arteria Coronaria , Puente de Arteria Coronaria/métodos , Puente de Arteria Coronaria Off-Pump/métodos , Enfermedad de la Arteria Coronaria/cirugía , Humanos , Puntaje de Propensión , Resultado del TratamientoRESUMEN
Our report presents a 73-year-old female patient with severe aortic stenosis who was admitted to our department for a surgical aortic valve replacement. After an uneventful surgery, a worsening low cardiac output syndrome with signs of myocardial ischemia occurred. Immediate angiography revealed a diffuse left coronary dissection starting from the ostium extending to the periphery of the left coronary system. The diffuse nature of the dissection ruled interventional management out and thus has been treated with urgent coronary bypass surgery. However, after an antecedent favorable course, the patient died 2 months later due to pneumonia resulting in septic shock.
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Advanced glycation endproducts (AGEs) are formed in a series of non-enzymatic reactions between reducing sugars and the amino groups of proteins and accumulate during aging, diabetes mellitus, chronic kidney disease and other chronic diseases. Accumulation of AGE-modifications alters protein structure and function, transforming these molecules into potential targets of the immune system, presumably triggering the production of autoantibodies against AGEs. In this study, we detected autoantibodies against AGE-modified proteins with ELISA in plasma samples of 91 patients with documented coronary artery disease (CAD), who underwent coronary artery bypass grafting (CABG) surgery. Patients with high levels of autoantibodies had a higher body mass index (BMI 28.6 vs 27.1 kg/m2; p = 0.046), were more likely to suffer from chronic obstructive pulmonary disease (COPD 30% vs 9.8%; p = 0.018), and more likely to need dialysis after the surgery (10% vs 0%; p = 0.037). Our findings show a weak link between the levels of autoantibodies against AGEs and diabetes mellitus (DM 44% vs 24.4%; p = 0.05). In a small subpopulation of patients, antibodies against native bovine serum albumin (BSA) were detected. A growing body of research explores the potential role of antibodies against AGE-modified proteins in pathogenesis of different chronic diseases; our data confirms the presence of AGE-autoantibodies in patients with CAD and that in parallel to the AGEs themselves, they may have a potential role in concomitant clinical conditions in patients undergoing CABG surgery. Further research is necessary to verify the molecular role of these antibodies in different pathological conditions.
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Autoanticuerpos/inmunología , Enfermedad de la Arteria Coronaria/inmunología , Productos Finales de Glicación Avanzada/inmunología , Anciano , Especificidad de Anticuerpos , Autoanticuerpos/sangre , Biomarcadores/sangre , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/cirugía , Ensayo de Inmunoadsorción Enzimática , Femenino , Productos Finales de Glicación Avanzada/sangre , Humanos , MasculinoRESUMEN
BACKGROUND: Coronary artery bypass grafting is the first-line therapy for severe multivessel coronary artery disease. We aimed to investigate the clinical outcome in patients undergoing isolated off-pump surgery with the single or bilateral internal mammary artery (SIMA or BIMA) approach. METHODS: We performed a propensity score-matched analysis in 1,852 consecutive patients, aged 50 to 70 years, who underwent myocardial revascularization at our institution between July 2009 and August 2016. Primary end point was the probability of survival. RESULTS: Mean follow-up was 36.3 (range: 0.1-89.6) months. The probability of survival in the SIMA and BIMA groups was 98.6 and 99.0% at year 1, 92.0 and 92.5% at year 5, and 85.6 and 81.6% at year 7, respectively, with a hazard ratio (HR) of mortality for the BIMA group versus the SIMA group of 0.98 (95% confidence interval[CI]: 0.64-1.52; p = 0.94). There was evidence for interaction between diabetes and study group on mortality risk (HR = 2.59, 95% CI: 1.07-6.23; p = 0.034). Freedom from mediastinitis/wound infection was higher in the SIMA group than in the BIMA group (99.5 and 96.9%, respectively; HR of an event = 6.39, 95% CI: 2.88-14.18; p < 0.001). The corresponding values in the subgroups of diabetic patients were 98.6 and 90.9%, respectively (HR = 6.45, 95% CI: 2.24-18.58; p = 0.001). Mediastinitis/wound infection was associated with increased mortality risk (HR = 2.96, 95% CI: 1.29-6.78; p = 0.010). CONCLUSION: Overall, our data indicate similar probability of survival up to a maximum follow-up of 7 years by off-pump surgery with the SIMA or BIMA approach. However, in diabetic patients, the clinical outcome indicates caution regarding the use of the BIMA approach.
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Puente de Arteria Coronaria Off-Pump , Enfermedad de la Arteria Coronaria/cirugía , Anastomosis Interna Mamario-Coronaria , Anciano , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria Off-Pump/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/mortalidad , Femenino , Humanos , Anastomosis Interna Mamario-Coronaria/efectos adversos , Anastomosis Interna Mamario-Coronaria/mortalidad , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Puntaje de Propensión , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: Transcatheter aortic valve implantation (TAVI) has become standard therapy for aortic stenosis patients with intermediate or high operative risk. Treatment of patients with pre-existing mechanical mitral valve replacement (MVR) is challenging due to possible interference between the TAVI prosthesis and MVR. We present our single-center experience with this special patient cohort. METHODS: A total of 1960 patients underwent TAVI at our institution between 2009 and March 2018; of these, 16 patients had pre-existing mechanical MVR. Device success and adverse events were analyzed according to the Valve Academic Research Consortium (VARC)-2 criteria. Patients were followed for at least 12 months. RESULTS: Mean patient age was 81.5 ± 4.4 years. The patients had a mean logistic EuroScore of 37.1 ± 13.5% and STS score of 7.1 ± 3.2%. Successful valve deployment was achieved in all patients, peri-interventional stroke rate was 0.0%, and permanent pacemaker was implanted in 2 patients (12.5%). Two patients experienced major complications, with blockage of the MVR disc in 1 patient and annulus rupture in 1 patient. Hence, 30-day mortality was 12.5% and 1-year mortality was 25.0%. CONCLUSION: TAVI in patients with mechanical MVR is challenging and requires careful preparation and choice of TAVI device. Repositionable and retrievable devices seem to be a safer option.
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Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/diagnóstico , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/complicaciones , Diseño de Prótesis , Reoperación , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIMS: Peri-procedural transcatheter valve embolization and migration (TVEM) is a rare but potentially devastating complication of transcatheter aortic valve implantation (TAVI). We sought to assess the incidence, causes, and outcome of TVEM in a large multicentre cohort. METHODS AND RESULTS: We recorded cases of peri-procedural TVEM in patients undergoing TAVI between January 2010 and December 2017 from 26 international sites. Peri-procedural TVEM occurred in 273/29 636 (0.92%) TAVI cases (age 80.8 ± 7.3 years; 53.8% female), of which 217 were to the ascending aorta and 56 to the left ventricle. The use of self-expanding or first-generation prostheses and presence of a bicuspid aortic valve were independent predictors of TVEM. Bail-out measures included repositioning attempts using snares or miscellaneous tools (41.0%), multiple valve implantations (83.2%), and conversion to surgery (19.0%). Using 1:4-propensity matching, we identified a cohort of 235 patients with TVEM (TVEMPS) and 932 patients without TVEM (non-TVEMPS). In the matched cohort, all-cause mortality was higher in TVEMPS than in non-TVEMPS at 30 days (18.6% vs. 4.9%; P < 0.001) and after 1 year (30.5% vs. 16.6%; P < 0.001). Major stroke was more frequent in TVEMPS at 30 days (10.6% vs. 2.8%; P < 0.001), but not at 1 year (4.6% vs. 1.9%; P = 0.17). The need for emergent cardiopulmonary support, major stroke at 30 days, and acute kidney injury Stages 2 and 3 increased the risk of 1-year mortality, whereas a better renal function at baseline was protective. CONCLUSION: Transcatheter valve embolization and migration occurred in approximately 1% and was associated with increased morbidity and mortality.
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Embolia , Prótesis Valvulares Cardíacas/efectos adversos , Complicaciones Posoperatorias , Falla de Prótesis , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Anciano , Anciano de 80 o más Años , Embolia/epidemiología , Embolia/etiología , Embolia/mortalidad , Femenino , Humanos , Incidencia , Masculino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Falla de Prótesis/efectos adversos , Falla de Prótesis/etiología , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Resultado del TratamientoRESUMEN
BACKGROUND: Prompt revascularization is often required in acute coronary syndromes (ACS), whereas stable ischemic heart disease (SIHD) may allow for more measured procedural planning. Whether the acuity of presentation preferentially affects outcomes after coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with left main coronary artery disease (LMCAD) is unknown. We investigated whether the acuity of presentation discriminated patients who derived a differential benefit from PCI versus CABG in the randomized Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial. METHODS: We used multivariable Cox models to assess the interaction between the acuity of presentation, type of revascularization and outcomes in patients with low or intermediate SYNTAX scores enrolled in EXCEL. RESULTS: At baseline, 1151 patients (60.7%) presented with SIHD and 746 patients (39.3%) presented with an ACS. The acuity of presentation was not associated with the primary endpoint of all-cause death, MI, or stroke at 3 years (multivariable adjusted hazard ratio [HR] 0.94; 95% CI 0.70-1.26, Pâ¯=â¯.64). The primary endpoint rate was similar in patients assigned to PCI versus CABG whether they presented with SIHD (adjusted HR 1.04; 95% CI 0.73-1.48]) or with ACS (HR 0.82; 95% CI 0.54-1.26) (Pinteractionâ¯=â¯.34). CONCLUSIONS: The acuity of presentation did not predict outcomes in patients with LMCAD undergoing revascularization, nor did it discriminate patients who derive greater event-free survival from PCI versus CABG.
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Síndrome Coronario Agudo/cirugía , Puente de Arteria Coronaria , Isquemia Miocárdica/cirugía , Gravedad del Paciente , Intervención Coronaria Percutánea , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Supervivencia sin Progresión , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: The 30-day and 1-year follow-up analysis of the GOPCABE trial (German Off-Pump Coronary Artery Bypass Grafting in Elderly Patients) revealed no significant difference in the composite end point consisting of death, stroke, myocardial infarction, new renal replacement therapy, or repeat revascularization. The 5-year follow-up data of this trial are reported here. METHODS: From June 2008 to September 2011, a total of 2539 patients aged ≥75 years were randomly assigned to undergo off-pump or on-pump coronary artery bypass grafting (CABG) at 12 centers in Germany. The primary outcome was all-cause mortality at 5 years. The secondary 5-year outcomes were a composite of death, myocardial infarction, and repeat revascularization. Furthermore, the impact of complete versus incomplete revascularization was assessed. RESULTS: After a median follow-up of 5 years, 361 patients (31%) assigned to off-pump CABG and 352 patients (30%) assigned to on-pump CABG had died (hazard ratio off-pump/on-pump CABG, 1.03; 95% CI, 0.89-1.19; P=0.71). The composite outcome of death, myocardial infarction, and repeat revascularization occurred in 397 (34%) after off-pump and in 389 (33%) after on-pump CABG (hazard ratio, 1.03; 95% CI, 0.89-1.18; P=0.704). Incomplete revascularization occurred in 403 (34%) patients randomly assigned to off-pump and 354 (29%) patients randomly assigned to on-pump CABG ( P<0.001). Five-year survival rates were 72% (95% CI, 67-76) with incomplete versus 76% (95% CI, 74-80) with complete revascularization (log-rank test: P=0.02) after off-pump CABG and 72% (95% CI, 67-76) versus 77% (95% CI, 74-80) after on-pump CABG (log-rank test: P=0.03), respectively. Cox regression analysis revealed a hazard ratio incomplete/complete revascularization of 1.19 (95% CI, 1.01-1.39; P=0.04). CONCLUSIONS: In elderly patients ≥75 years of age, the 5-year survival rates and the combined outcome of death, myocardial infarction, and repeat revascularization, as well, were similar after on-pump and off-pump CABG. Incomplete revascularization was associated with a lower 5-year survival rate, irrespective of the type of surgery. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00719667.
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Puente de Arteria Coronaria , Corazón Auxiliar , Infarto del Miocardio/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
Left ventricular assist device implantation following extracorporeal cardiopulmonary resuscitation has been associated with ambivalent results. In a series of patients who underwent left ventricular assist device implantation after extracorporeal cardiopulmonary resuscitation, we investigated whether the outcome can be predicted by preoperative risk factors or established risk scores. Primary endpoint was a composite of mortality and severe neurological disabling over 1 year of follow-up. To assess predictors of the primary endpoint, we performed univariate and multivariable Cox regression analyses. Of the 40 patients included, 24 patients (60%) experienced the primary endpoint. Renal replacement therapy and the Vasoactive-Inotropic Score were independently associated regarding the primary endpoint with a hazard ratio for renal replacement therapy of 2.50 (95% confidence interval: 1.09-5.70; P = 0.021) and for the Vasoactive-Inotropic Score of 1.02 per unit (95% confidence interval: 1.00-1.03; P = 0.040). The risk of experiencing an unfavorable outcome during follow-up in patients with a Vasoactive-Inotropic Score of 20 who needed renal replacement therapy or did not need renal replacement therapy was 78% and 54%, respectively. Our data indicate that a decision to implant a left ventricular assist device in patients requiring renal replacement therapy and revealing a high Vasoactive-Inotropic Score after extracorporeal cardiopulmonary resuscitation should be reached with caution.
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Reanimación Cardiopulmonar , Insuficiencia Cardíaca/terapia , Corazón Auxiliar , Complicaciones Posoperatorias , Implantación de Prótesis , Diálisis Renal , Reanimación Cardiopulmonar/efectos adversos , Reanimación Cardiopulmonar/instrumentación , Reanimación Cardiopulmonar/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/mortalidad , Pronóstico , Modelos de Riesgos Proporcionales , Implantación de Prótesis/efectos adversos , Implantación de Prótesis/instrumentación , Implantación de Prótesis/métodos , Diálisis Renal/métodos , Diálisis Renal/estadística & datos numéricos , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Choque Cardiogénico/terapia , Resultado del TratamientoRESUMEN
BACKGROUND/AIMS: We aimed to investigate the effect of a moderately high vitamin D dose on lipid parameters and biochemical markers of vascular calcification (VC) in patients with established cardiovascular disease. METHODS: We included in this pre-specified secondary analysis of a randomized controlled trial 161 patients with advanced heart failure and 25-hydroxyvitamin D (25OHD) concentrations < 75 nmol/L (vitamin D group: n = 80; placebo group: n = 81), who received a daily vitamin D3 supplement of 4,000 IU for 3 years. We assessed between-group differences of the lipid parameters total-cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, and triglycerides, and the VC markers fetuin-A and non-phosphorylated undercarboxylated matrix gla protein (MGP) at study termination, with adjustment for baseline values. RESULTS: Lipid parameters, the percentage of patients with dyslipoproteinemia, and VC markers did not differ significantly between groups at study termination (p values: 0.395-0.939). Likewise, vitamin D achieved no significant treatment effect on these markers in subgroup analyses in patients with 25OHD concentrations < 30 nmol/L, nonusers of lipid-lowering drugs, or diabetic patients (p values: 0.245-0.998). CONCLUSION: Our data indicate that vitamin D does not improve the lipid profile and does not influence the calcification inhibitors fetuin-A and non-phosphorylated undercarboxylated MGP in patients with advanced heart failure.