Association Between Shock Etiology and 5-Year Outcomes After Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: Outcomes of patients requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) vary greatly by etiology, but large studies that incorporate the spectrum of shock supported with ECMO are rare. OBJECTIVES: The purpose of this study was to describe the etiology-related outcome of patients with shock supported with peripheral VA-ECMO. METHODS: All consecutive adults with peripheral VA-ECMO between January 2015 and August 2018 at Pitié-Salpêtrière Hospital (Paris, France) were included in this retrospective observational study. The indication for VA-ECMO was cardiogenic shock. Rates of hospital death and neurological, renal, and pulmonary complications were evaluated according to etiology. RESULTS: Among 1,253 patients, hospital and 5-year survival rates were, respectively, 73.3% and 57.3% for primary graft failure, 58.6% and 54.0% for drug overdose, 53.2% and 45.3% for dilated cardiomyopathy, 51.6% and 50.0% for arrhythmic storm, 46.8% and 38.3% for massive pulmonary embolism, 44.4% and 42.4% for sepsis-induced cardiogenic shock, 37.9% and 32.9% for fulminant myocarditis, 37.3% and 31.5% for acute myocardial infarction, 34.6% and 33.3% for postcardiotomy excluding primary graft failure, 25.7% and 22.8% for other/unknown etiology, and 11.1% and 0.0% for refractory vasoplegia shock. Renal failure requiring hemodialysis developed in 50.0%, neurological complications in 16.0%, and hydrostatic pulmonary edema in 9.0%. CONCLUSIONS: Although the outcome differs depending on etiology, this difference is related more to the severity of the situation associated with the cause rather than the cause of the shock per se. Survival to 5 years varied by cause, which may reflect the natural course of the chronic disease and illustrates the need for long-term follow-up.

Analysis of a multicenter registry on evaluation of transit-time flow in coronary artery disease surgery.

Objective: The Evaluation of Transit-Time Flow in Coronary Artery Disease Surgery (EFCAD) registry aims to assess the influence of transit-time flow measurement (TTFM) in daily practice. Methods: EFCAD is a prospective, multicenter study involving 9 centers performing TTFM during isolated coronary artery bypass grafting. Primary end point was occurrence and risk factors of major adverse cardiac events, including perioperative myocardial infarction, urgent postoperative coronary angiogram and/or revascularization, and hospital mortality. Secondary end points were rate of graft revision during surgery and factors affecting graft flow. We respected the limit values set by the experts: mean graft flow >15 mL/minute and pulsatility index ≤5. Results: Between May 2017 and March 2021, 1616 patients were registered in the EFCAD database. After review, 1414 were included for analyses. Of those, 1176 were eligible for primary end point analysis. Graft revision, mainly due to inadequate TTFM values, occurred in 2% (29 patients). The primary end point occurred in 46 (3.9%) patients, and it was related with left anterior descending artery graft flow ≤15 mL/minute (odds ratio, 3.64; P < .001). Graft flow was related with number of grafts (3 vs 1-2, ß = -1.6; 4-6 vs 1-2, ß = -4.1; P < .001; ß > 0 indicates higher flow), and graft origin (aorta vs Y, ß = 9.2; in situ left internal thoracic artery vs Y, ß = 3.2; in situ right internal thoracic artery vs Y, ß = 2.3; P < .001). Conclusions: Data from EFCAD study suggest that TTFM is reliable to evaluate graft flow, and acceptance of inadequate flow on left anterior descending artery anastomosis influence postoperative outcomes. In our opinion, TTFM assessment should be routinely used in coronary artery bypass procedures, even if interpretation depends on learning curves.

Impact of transit-time flow measurement on early postoperative outcomes in total arterial coronary revascularization with internal thoracic arteries: a propensity score analysis on 910 patients.

OBJECTIVES: The aim of this study was to evaluate the impact of transit-time flow measurement (TTFM) on early postoperative outcomes in total arterial coronary revascularization. METHODS: A single-centre retrospective analysis was conducted on 910 patients undergoing isolated total arterial coronary artery bypass grafting with internal thoracic arteries (ITAs) at our institution, between January 2017 and February 2020. Complete arterial revascularization with bilateral ITAs with a Y-configuration, or single ITA, was planned for all patients. According to the surgeon preference, TTFM was assessed in 430 patients (TTFM group). They were compared with 480 patients without TTFM assessment (no TTFM group). Primary end point was the occurrence of in-hospital major cardiac adverse events (MACE). A propensity score analysis with an inverse probability weighting approach was performed to control for selection bias. RESULTS: TTFM was associated with longer cardiopulmonary bypass times (76.0 [62.0; 91.2] vs 79.0 [65.0; 94.0] min, P = 0.042). Six (1.4%) patients in the TTFM group versus no patient in the no TTFM group underwent intraoperative graft revision because of unsatisfying flow values (P = 0.011). MACE were significantly lower in the TTFM group (14, 3.3%) than in the no TTFM group (33, 6.9%, P = 0.014). At crude regression, TTFM was protective against MACE occurrence (odds ratios 0.46, 95% confidence interval 0.23-0.85, P = 0.016). Inverse probability weighting adjustment did not significantly displace P-values and odds ratios for MACE occurrence in the TTFM group 0.44, 95% confidence interval 0.28-0.69, P < 0.001. CONCLUSIONS: Even if associated with longer cardiopulmonary bypass times, intraoperative graft flow measurement with TTFM reduces MACE occurrence and it should be recommended for graft evaluation in arterial coronary artery bypass grafting surgery.

Long-term outcome of heart transplantation performed after ventricular assist device compared with standard heart transplantation.

BACKGROUND: Data on the long-term outcome of heart transplantation in patients with a ventricular assist device (VAD) are scarce. AIM: To evaluate long-term outcome after heart transplantation in patients with a VAD compared with no mechanical circulatory support. METHODS: Consecutive all-comers who underwent heart transplantation were included at a single high-volume centre from January 2005 until December 2012, with 5 years of follow-up. Clinical and biological characteristics, operative results, outcomes and survival were recorded. Regression analyses were performed to determine predictors of 1-year and 5-year mortality. RESULTS: Fifty-two patients with bridge to transplantation by VAD (VAD group) and 289 patients transplanted without a VAD (standard group) were enrolled. The mean age was 46±11 years in the VAD group compared with 51±13 years in the standard group (P=0.01); 17% of the VAD group and 25% of the standard group were women (P=0.21). Ischaemic time was longer in the VAD group (207±54 vs 169±60minutes; P<0.01). There was no difference in primary graft failure (33% vs 25%; P=0.22) or 1-year mortality (17% vs 28%; P=0.12). In the multivariable analysis, preoperative VAD was an independent protective factor for 1-year mortality (odds ratio 0.40, 95% confidence interval 0.17-0.97; P=0.04). Independent risk factors for 1-year mortality were recipient age>60 years, recipient creatinine, body surface area mismatch and ischaemic time. The VAD and standard groups had similar long-term survival, with 5-year mortality rates of 35% and 40%, respectively (P=0.72). CONCLUSIONS: Bridge to transplantation by VAD was associated with a reduction in 1-year mortality, leading critically ill patients to similar long-term survival compared with patients who underwent standard heart transplantation. This alternative strategy may benefit carefully selected patients.

Extracorporeal membrane oxygenation as treatment of graft failure after heart transplantation.

Heart transplantation (HTx) is a valuable option in eligible patients with end-stage heart failure. The most significant complication in the immediate post-operative period is early graft failure (EGF), with a mean incidence of 20-25%. EGF is a major risk factor for death and accounts for 40-50% of early mortality after HTx. Despite the use of inotropes, EGF may persist and require temporary mechanical circulatory support. Extracorporeal membrane oxygenation (ECMO) has been investigated over the years and has proved to be a reliable strategy in patients with EGF after HTx. This study aims to review the contemporary literature on this topic. Considering short-term outcomes, 45-80% of patients were discharged alive from hospital. Duration of support is variable, with a mean duration of 4-8 days. Cannulation strategy and device selection have no differences with respect to short-term outcomes. The main causes of death are multi-organ failure, bleeding, heart failure, stroke and sepsis. Considering long-term outcomes, ECMO survivors appear to have similar survival rates to HTx patients who did not experience EGF. Also, ECMO-treated EGF, among survivors, has no detrimental effect for graft function. In conclusion, ECMO is a reliable therapeutic option to support patients with severe graft failure after HTx, providing adequate support with either central or peripheral arteriovenous cannulation. Further studies will be needed to establish the correct threshold for ECMO support and to provide long-term results.

Illustration of the difficulty of identifying Streptococcus equi strains at the subspecies level through a case of endocarditis in an immunocompetent man.

We report a case of endocarditis caused by Streptococcus equi in an immunocompetent patient who was subsequently cured after appropriate antibiotherapy and cardiac surgery. However, it was challenging to identify the strain to the subspecies level, which highlights the necessity of developing reliable molecular tools to discriminate between the subspecies.

Unusual heart transplantation for iterative disinsertion of mitral prosthesis.

Heart transplantation is the gold standard of care for end-stage heart failure, usually associated with an impairment of left ventricular systolic function. We describe a case of heart transplantation in a 58-year-old man with normal left ventricular systolic function, because of recurrent mitral prosthesis disinsertion after multiple reoperations for infective endocarditis.

Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome: single-centre experience with 1-year follow-up.

OBJECTIVES: During 2009, pandemic influenza A (H1N1) affected France and several patients developed influenza A (H1N1)-associated acute respiratory distress syndrome. The use of extracorporeal membrane oxygenation (ECMO) could be advocated as therapeutic solution. We present our experience with ECMO utilized in patients with influenza A (H1N1)-associated respiratory failure. METHODS: We conducted a retrospective observational analysis of our experience with veno-venous ECMO for 2009 influenza A (H1N1)-associated respiratory failure. We have excluded from our study all not confirmed cases of influenza A (H1N1). Veno-venous ECMO was always instituted using a percutaneous cannulation technique. Mechanical circulatory support was maintained until respiratory function recovery. RESULTS: Between October 2009 and February 2010, we performed veno-venous ECMO support in 12 patients with influenza A (H1N1)-associated respiratory failure. Mean age was 33 ± 12 years (14-63 years) and there was a prevalence of female sex. Median time from influenza A (H1N1) onset to mechanical ventilation (MV) initiation was 6 days (1-17 days); median time from MV to veno-venous ECMO support was 3 days (1-20 days). Six patients (50%) suffered ventilator-associated pneumonia during ECMO support. Eight patients (66.6%) suffered significant haemorrhage requiring transfusion of more than 2 packed red cells. In two patients (16.6%), there was a thrombosis of the inferior vena cava and one of them experienced pulmonary embolism. Mean duration of ECMO support was 23 ± 14 days (3-47 days); mean duration of mechanical ventilatory support was 24 ± 21 days (6-70 days). ECMO was weaned in 10 patients (83.3%) and all these patients are still alive after a period of follow-up of 13.8 ± 1.12 months (11.03-14.83 months). Two patients (in-hospital mortality of 16.6%) died under ECMO support for refractory septic shock. CONCLUSIONS: Veno-venous ECMO for 2009 H1N1-associated respiratory failure gives good results with a very low mortality rate. The use of a mobile unit is a safe procedure and may improve survival of patients who might not be otherwise eligible for transfer to our institution. Larger studies are however required in order to optimize and refine the best treatment strategy in this subgroup of patients.

Reappraisal of a 20-year experience with the radial artery as a conduit for coronary bypass grafting.

OBJECTIVE: This study aimed at evaluating the clinical and angiographic results of the radial artery (RA) used as a coronary bypass graft over 20 years. METHODS: Clinical follow-up was obtained in 563 patients at 9.2 years. Angiographic follow-up was obtained in 351 patients with opacification of 1427 conduits, including 629 RA at 7.0 years. RESULTS: At 9.2 years, freedom from overall and cardiovascular death was 80.3% and 92.7%, respectively. Symptoms were: acute myocardial infarction: 2.1% (n=12); angina: 17.4% (n=98), and congestive heart failure 10.6% (n=60). Percutaneous revascularization was required in 13.5% (n=76) of cases on: native coronary (n=77), RA conduit (n=21), and other graft (n=7). Reoperation was needed in 2.3% (n=13) of cases for valve replacement (n=10) and redo coronary artery bypass grafting (CABG) (n=3). At 7.0 years, RA patency was 82.8% (521/629) and was lower than that of left internal mammary artery (IMA), 95.5% (491/514) (p<0.001); similar to right IMA, 87.9% (51/58, p=0.32); free IMA, 80.0% (44/55, p=0.60); and vein, 81.9% (140/171, p=0.77). RA patency was lower in the case of myocardial ischemia: 74.0% (174/235) versus 88.1% (347/394) in asymptomatics (p<0.001). RA patency was higher for diagonal (93.1% (95/102)) compared to circumflex (82.5% (274/332, p<0.01)) and right coronary (77.6% (146/188, p<0.001)). Calcium channel blockers had no impact on RA patency. Separating four groups at successive follow-up intervals, RA patency was: 86.2%, 81.9%, 81.4%, and 81.6% at 1.0, 5.4, 8.3, and 13.1 years, respectively. CONCLUSION: CABG with the RA offered long-lasting clinical benefit. Beyond the first postoperative year during which some attrition was observed, RA patency was remarkably stable for up to 20 years.

Structural deterioration of the cryopreserved mitral homograft valve.

OBJECTIVE: The aim of this study was to evaluate the long-term fate of the cryopreserved mitral homograft focusing on structural valve deterioration. METHODS: Homograft replacement of the mitral valve was performed in 106 patients. The causes of mitral disease were rheumatic disease (n=75), endocarditis (n=24), and others (n=7). There were 40 partial homografts and 66 total homografts. RESULTS: Mean follow-up was 9.3+4.7 years (up to 17.8 years). There were 5 early (<3 months) and 15 late deaths. There have been 5 early (<3 months) and 30 late reoperations. Five patients had endocarditis, and 5 patients had an ischemic/hemorrhagic event. Compared with baseline, follow-up echography showed progression of mitral regurgitation grade (from 0.4 to 1.3; P<.001) with stenosis (elevated gradient: from 3.9 to 7.0 mm Hg; P<.001) and decreased valve area (from 2.3 to 1.7 cm2, P<.001). Freedom from structural valve deterioration was 90%, 76%, and 65% at 5, 10, and 15 years, respectively. Structural valve deterioration was more frequent in total homografts (P=.018 vs partial homografts) and in case of pregnancy (P=.016 vs no pregnancy). Stenosis related to structural valve deterioration was more pronounced for age less than 40 years (P=.03) and ring size 30 mm or less (P=.002). Pathologic analysis of the explanted homografts almost invariably showed dense fibrosis with calcification and no cellularity. CONCLUSIONS: Mitral homografting was accomplished with early echographic results similar to those of valve repair. Structural valve deterioration produced mixed stenosis with insufficiency, and its incidence was comparable to that of bioprostheses structural valve deterioration. An improvement in the preservation mode of valvular homografts is warranted.

Predictive risk factors for primary graft failure requiring temporary extra-corporeal membrane oxygenation support after cardiac transplantation in adults.

OBJECTIVE: Primary graft failure (PGF) is a major risk factor for death after heart transplantation. We investigated the predictive risk factors for severe PGF that require extra-corporeal membrane oxygenation (ECMO) circulatory support after cardiac transplantation. METHODS: Between January 2003 and December 2008, 402 adult patients underwent isolated cardiac transplantation at our institution. PGF was defined as the need for ECMO support in the immediate postoperative period. Thirty-three recipient and 37 donor variables were analyzed for the risk of PGF occurrence. RESULTS: PGF occurred in 91 (23%) patients. Predictive risk factors for PGF occurrence were, in the recipient, being aged >60 years (odds ratio (OR) 2.11, p=0.01) and preoperative mechanical circulatory support (MCS) (OR 2.65, p=0.01); in the donor, they were mean norepinephrine dose (OR 2.02, p<0.01), trauma as the cause of death (OR 2.45, p<0.01), left-ventricle ejection fraction (LVEF) <55% (OR 2.72, p=0.02), and the ischemic time (OR 1.01, p<0.01). Weaning and discharge rates after ECMO support for PGF were, respectively, 60% (55/91 patients) and 46% (42/91 patients). The absence of PGF was correlated with improved long-term survival: 78% at 1 year and 71% at 5 years without PGF versus 39% at 1 year and 34% at 5 years with PGF (p<0.01). Surviving patients treated with ECMO for PGF have similar conditional 1-year survival rates as non-PGF patients: 93% at 3 years and 91% at 5 years without PGF versus 93% at 3 years and 84% at 5 years with PGF (p=0.46, NS). CONCLUSIONS: Occurrence of PGF is a multifactorial event that depends on both donor and recipient profiles. ECMO support is a reliable treatment for severe PGF; furthermore, surviving patients treated with ECMO have the same 1-year conditional survival rates as patients not having suffered a PGF.

Intentional and successful use of a marginal donor heart with surgically-corrected interventricular communication.

We describe a case of heart transplantation (HTX) performed using a heart from a 20-year-old donor who underwent surgical closure of a ventricular septal defect during childhood. Our 26-year-old patient was successfully discharged to a rehabilitation centre on day 20 post-transplantation. To our knowledge, this is the first report of an HTX performed with a 'redo' donor heart with previous surgical correction of a congenital heart defect. The widespread use of HTX as a therapeutic option is currently limited by the increase in number of patients listed annually for this procedure. The concomitant lack of organ donors has led to the concept of 'marginal donor' to broaden the classic standard criteria of donor suitability, but these extended criteria do not consider the possibility of using hearts that have undergone surgical correction of simple congenital heart defects. There has been a considerable increase in the grown-up congenital heart disease population over the past 20 years. We discuss the feasibility of using these hearts for transplantation and consider the limitations and precautions of such practice.

Extra-corporeal membrane oxygenation temporary support for early graft failure after cardiac transplantation.

OBJECTIVE: Early graft failure (EGF) is a major risk for death after heart transplantation. We studied the impact of an extra-corporeal membrane oxygenation (ECMO) temporary support on the operative mortality and the mean-term survival after EGF. MATERIALS AND METHODS: Between January 2000 and December 2006, 394 patients underwent orthotopic heart transplantation at our institution. EGF was observed in 90 (23%) patients. Fifty-four patients (14%) were treated with ECMO support, eight (2%) with other assisting devices, and 28 (7%) received maximal inotropic drug support only. RESULTS: The overall mortality was 21% (83 patients). EGF was a major risk for death: 13% (35 patients) without EGF versus 58% (49 patients) with EGF, p<0001. Among patients supported with ECMO, 36 (67%) were weaned from the assisting device and 27 (50%) were discharged from the hospital. Overall survival was 73% at 1 year and 66% at 5 years. Absence of EGF improved long-term survival: 78% at 1 year and 70% at 5 years without EGF versus 37% at 1 year and 35% at 5 years with EGF. Patients treated with ECMO have the same 1-year conditional survival as patients not having suffered EGF: 94% at 3 years. CONCLUSIONS: ECMO support is a reliable therapeutic option in severe EGF after cardiac transplantation; furthermore, patients treated with ECMO have the same 1-year conditional survival as patients not having suffered EGF.

Surgery for infective endocarditis on mitral annulus calcification.

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess the characteristics of bacterial endocarditis complicating mitral annulus calcification, and to evaluate the surgical results. METHODS: Twenty-four patients (mean age 64 years) underwent surgery for mitral insufficiency secondary to mitral endocarditis with annulus calcification (acute, n = 18; healed, n = 6). Surgery was performed as an emergency in seven cases for septic (n = 3) or cardiogenic (n = 4) shock. An aortic prosthesis had previously been placed in three cases. Comorbidities noted included chronic renal insufficiency/dialysis (n = 8), cancer (n = 6), coronary disease (n = 6), and obstructive cardiomyopathy (n = 1). Nine patients suffered an embolic complication, such as stroke (n = 7, of which three had coma), splenic (n = 3), or lower limb (n = 1). The microorganism present was identified as Staphylococcus aureus (n = 9), Streptococcus/ Enterococcus sp. (n = 12), or others (n = 3). The left atrial diameter was 48 mm, the ejection fraction 63%, and the septal thickness 13 mm. RESULTS: The mean severity score of annulus calcifications (range: 1 to 5) was 1.9. The anatomical lesions included: vegetations (n = 16, of which eight were > 10 mm), leaflet perforation (n = 9), chordae rupture (n = 9), aortic abscess (n = 2) and mitral annular abscess (n = 9), and one fistulation into the pericardium. The valve was repaired in 15 cases, and replaced in nine (seven bioprostheses, two mechanical). Associated procedures included aortic valve replacement (n = 7) and coronary artery bypass (n = 3). The in-hospital mortality was 29% (n = 7); all patients who died were operated on during the acute phase. All patients who presented with septic shock or coma died. After a mean follow up of 46 months, six patients had died (overall survival was 46% at 33 months), and 11 were in NYHA class I/II. One recurrence of endocarditis was treated medically. CONCLUSION: Bacterial endocarditis complicating mitral annulus calcification has a poor prognosis due to the frequent comorbidity and severity of the infectious complications. Patients in septic shock or coma do not appear to be suitable candidates for surgery. Valve repair was possible in two-thirds of the present patients; otherwise, a bioprosthetic replacement was the option of choice.

Mitral annulus calcification: determinants of repair feasibility, early and late surgical outcome.

OBJECTIVE: The aim of this study was to determine the factors influencing the feasibility of valve repair and the surgical outcome in patients with mitral annulus calcification. METHODS: In 124 patients with mitral annulus calcification undergoing surgery, two entities were distinguished: Barlow disease (myxomatous leaflets, n=60) and fibroelastic deficiency (FED) (normal leaflets, n=64). The calcification score was lower (1.9 vs 2.8); the annulus was more dilated (ring 35 vs 32 mm) and ruptured chordae were more frequent (77% vs 37%) in Barlow than in FED (p<0.001). The clinical profile was different: age (60+/-14 vs 73+/-8 years, p<0.001), systemic hypertension (22% vs 70%, p<0.001), chronic renal insufficiency (5% vs 22%, p<0.01), cancer (7% vs 25%, p<0.01). Multifocal atherosclerosis was less frequent in Barlow than in FED: carotid disease (17% vs 54%, p<0.001), aortic atheroma (21% vs 51%, p<0.001) and coronary disease (22% vs 56%, p<0.01). Echocardiography showed two different patterns in Barlow and FED: aortic valve stenosis (1.7% vs 31%), left atrial diameter (54 vs 49 mm), left ventricular end-diastolic diameter (62 vs 54 mm), interventricular septal thickness (11 vs 13 mm), and systolic pulmonary pressure (40 vs 56 mmHg), respectively (p<0.001). Bacterial endocarditis was observed in 24 cases (19%). RESULTS: The surgical technique was a valve repair in 68% and a replacement in 32%. The repair rate depended upon the extent of annulus calcifications (p<0.001) and the type of degenerative disease (95% vs 44% in Barlow and FED p<0.001). In-hospital mortality was 14% (Barlow: 5% vs FED: 23%, p<0.01). The mean follow-up was 50+/-41 months. Overall 5-year year survival was 76% (Barlow: 90% vs FED: 64%, p<0.001) and survival free from cardiac event was 69% at 5 years (Barlow: 87% vs FED: 52%, p<0.001). Five-year survival was higher following repair than replacement (84% vs 64% p<0.001). Chronic renal insufficiency and bacterial endocarditis were two predictors of early and late death (p<0.01). CONCLUSIONS: The aetiopathogeny of the degenerative mitral disease responsible for annulus calcifications corresponded to distinct anatomical, clinical and echographic patterns. It was a main determinant of repair feasibility, early and late surgical outcome.

Strict glycemic control reduces EuroSCORE expected mortality in diabetic patients undergoing myocardial revascularization.

OBJECTIVE: We sought to evaluate the effect of a strict glycemic control protocol on a series of diabetic patients undergoing surgical myocardial revascularization. METHODS: Between January 2003 and June 2004, 300 diabetic patients undergoing myocardial revascularization received a local protocol of insulin administration (protocol, group P). Patients were divided into 2 risk classes, according to their additive EuroSCORE value: low-moderate risk (0-4) and moderate-high risk (>4). The logistic EuroSCORE algorithm was used to calculate the expected probability of death. A control group was selected, including a series of 300 consecutive diabetic patients (no protocol group, group NP) who underwent coronary artery bypass grafting between March 2001 and September 2002, just before the introduction of the protocol. A propensity analysis was performed to control for selection bias. RESULTS: Both groups showed similar EuroSCORE risk profiles: mean additive and logistic EuroSCORE values were 4.16 and 4.29 in group P versus 3.93 and 3.91 in group NP. Observed and expected mortalities of group P were 0.6% versus 1.8% (low-moderate risk), 2.5% versus 8.0% (moderate-high risk, P = .03), and 1.3% versus 4.3% (entire group, P = .01). Observed and expected mortalities of group NP were 1.6% versus 1.9% (low-moderate risk), 8.3% versus 7.5% (moderate-high risk), and 4.0% versus 3.9% (entire group). Logistic regression confirmed observed mortality in group P to be significantly lower than the expected logistic EuroSCORE mortality. After risk adjustment, the protocol allowed us to reduce the mortality odds by 72% (odds ratio, 0.282; 95% confidence interval, 0.092-0.859; P < .03). Subgroup analysis for moderate- to high-risk patients showed the protocol to improve mortality (odds ratio, 0.24; P < .05), whereas no significant improvement was found in low- to moderate-risk patients. Addition of the propensity score to the multivariable analysis did not significantly displace P values and odds ratios. Sensitivity analysis of patients who underwent coronary artery bypass grafting without additional procedures showed the protocol to maintain its protective effect (odds ratio, 0.15; P < .05). CONCLUSION: Optimal glucose control highly reduces EuroSCORE expected mortality in diabetic patients undergoing myocardial revascularization, especially in moderate- to high-risk patients.

[Heart surgery interventions in chronic dialysis patients: short- and long-term results]. / Gli interventi cardiochirurgici nei pazienti in dialisi cronica: risultati a breve e lungo termine.

BACKGROUND: Chronic dialysis is a relevant risk factor for mortality and morbidity after cardiac surgery and cardiopulmonary bypass. The aim of this study was to evaluate the short- and long-term follow-up of patients in dialysis undergoing cardiac surgery. METHODS: We retrospectively reviewed 24 consecutive chronic hemodialysis adult patients (14 males, 10 females, mean age 63 +/- 12 years) who, over a 10-year period, underwent operative cardiac procedures in our Institution. Prior to surgery the mean duration of dialysis was 55 +/- 18 months (minimum 3 months). Surgery included isolated coronary artery bypass grafting in 18 patients, aortic valve replacement in 3, mitral valve replacement in 2, and double valve replacement (mitral and aortic) in 1. Sixteen operations were elective whereas 8 (33%) were performed in an emergency setting. RESULTS: Seven operative deaths occurred with an overall in-hospital mortality of 29%. Among the 16 patients in whom surgery was elective, only 2 died. Five of the 8 patients submitted to emergency procedures died. Hence, the operative mortality in this subgroup of patients was 62% (p < 0.005). A low cardiac output and multiorgan failure due to pulmonary infection were the most important causes of death. However 75% of patients experienced some major postoperative complications. All survivors were followed up for 6 to 108 months (mean 33.7 +/- 29.5 months). The overall functional status was significantly improved. Survival at 1, 2 and 5 years was 68, 63 and 45% respectively in coronary patients and 65, 58 and 42% in the overall study population. CONCLUSIONS: In dialysis-dependent patients major cardiac procedures can be carried out with an acceptable risk only in elective conditions even if the mortality is 4-5-fold higher than in the normal population and the life expectancy is similar to that of patients in chronic dialysis but without cardiac disease.