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OBJECTIVE: Risk-scoring systems for surgical aortic valve replacement (AVR) were largely derived from sternotomy cases. We evaluated the accuracy of current risk scores in predicting outcomes after minimally invasive AVR (mini-AVR). Because transcatheter AVR (TAVR) is being considered for use in low-risk patients with aortic stenosis, accurate mini-AVR risk assessment is necessary. METHODS: We reviewed 1,018 consecutive isolated mini-AVR cases (2009 to 2015). After excluding patients with Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) scores ≥4, we calculated each patient's European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, TAVR Risk Score (TAVR-RS), and age, creatinine, and ejection fraction score (ACEF). We compared all 4 scores' accuracy in predicting mini-AVR 30-day mortality by computing each score's observed-to-expected mortality ratio (O:E). Area under the receiver operating characteristic (ROC) curves tested discrimination, and the Hosmer-Lemeshow goodness-of-fit tested calibration. RESULTS: Among 941 patients (mean age, 72 ± 12 years), 6 deaths occurred within 30 days (actual mortality rate, 0.6%). All 4 scoring systems overpredicted expected mortality after mini-AVR: ACEF (1.4%), EuroSCORE II (1.9%), STS-PROM (2.0%), and TAVR-RS (2.1%). STS-PROM best estimated risk for patients with STS-PROM scores 0 to <1 (0.6 O:E), ACEF for patients with STS-PROM scores 2 to <3 (0.6 O:E), and TAVR-RS for patients with STS-PROM scores 3 to <4 (0.7 O:E). ROC curves showed only fair discrimination and calibration across all risk scores. CONCLUSIONS: In low-risk patients who underwent mini-AVR, current surgical scoring systems overpredicted mortality 2-to-3-fold. Alternative dedicated scoring systems for mini-AVR are needed for more accurate outcomes assessment.
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Estenosis de la Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Persona de Mediana Edad , Medición de Riesgo , Factores de Riesgo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del TratamientoRESUMEN
OBJECTIVES: Del Nido cardioplegia (DNC) has been shown to be safe in adults with normal coronary arteries who are undergoing valve surgery. This study compared the effects of DNC versus traditional blood-based cardioplegia on postoperative complications in patients who underwent coronary artery bypass grafting (CABG). METHODS: A retrospective analysis was performed on 863 patients who underwent CABG with DNC (n = 420) or control cardioplegia (CC) (n = 443) between 2014 and 2017. The full cohort of DNC and CC recipients, as well as propensity score-matched pairs, was compared regarding preoperative risk variables and outcomes. RESULTS: The DNC and CC groups showed no significant differences in mean cardiopulmonary bypass time (53.09 vs 52.10 min, P = 0.206) or aortic cross-clamp time (32.82 vs 33.28 min, P = 0.967). The groups also showed no difference in operative mortality (2.1% vs 2.5%, P = 0.734); however, DNC use resulted in lower rates of overall infections (1.7% vs 4.3%, P = 0.024), total sternal infections (0.9% vs 3.2%, P = 0.023), postoperative atrial fibrillation (23.8% vs 30.7%, P = 0.023) and postoperative ventricular tachycardia (0.5% vs 3.4%, P = 0.002). A propensity-matching analysis (n = 335 pairs) showed similar statistically significant decreases with DNC. CONCLUSIONS: In this large cohort of CABG patients, DNC was shown as a safe alternative to CC and was associated with lower postoperative dysrhythmia and infection rates. These findings show that DNC is safe and effective in patients whose operative interventions may require only single-dosing cardioplegia; its use in longer cases should be further explored given its low complication rate.
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Soluciones Cardiopléjicas/farmacología , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Vasos Coronarios/cirugía , Paro Cardíaco Inducido/métodos , Puntaje de Propensión , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Periodo Posoperatorio , Estudios RetrospectivosRESUMEN
BACKGROUND: The Genetics of Subsequent Coronary Heart Disease (GENIUS-CHD) consortium was established to facilitate discovery and validation of genetic variants and biomarkers for risk of subsequent CHD events, in individuals with established CHD. METHODS: The consortium currently includes 57 studies from 18 countries, recruiting 185 614 participants with either acute coronary syndrome, stable CHD, or a mixture of both at baseline. All studies collected biological samples and followed-up study participants prospectively for subsequent events. RESULTS: Enrollment into the individual studies took place between 1985 to present day with a duration of follow-up ranging from 9 months to 15 years. Within each study, participants with CHD are predominantly of self-reported European descent (38%-100%), mostly male (44%-91%) with mean ages at recruitment ranging from 40 to 75 years. Initial feasibility analyses, using a federated analysis approach, yielded expected associations between age (hazard ratio, 1.15; 95% CI, 1.14-1.16) per 5-year increase, male sex (hazard ratio, 1.17; 95% CI, 1.13-1.21) and smoking (hazard ratio, 1.43; 95% CI, 1.35-1.51) with risk of subsequent CHD death or myocardial infarction and differing associations with other individual and composite cardiovascular endpoints. CONCLUSIONS: GENIUS-CHD is a global collaboration seeking to elucidate genetic and nongenetic determinants of subsequent event risk in individuals with established CHD, to improve residual risk prediction and identify novel drug targets for secondary prevention. Initial analyses demonstrate the feasibility and reliability of a federated analysis approach. The consortium now plans to initiate and test novel hypotheses as well as supporting replication and validation analyses for other investigators.
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Enfermedad Coronaria/patología , Adulto , Factores de Edad , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Modelos de Riesgos Proporcionales , Factores de Riesgo , Factores Sexuales , FumarRESUMEN
BACKGROUND: Genetic variation at chromosome 9p21 is a recognized risk factor for coronary heart disease (CHD). However, its effect on disease progression and subsequent events is unclear, raising questions about its value for stratification of residual risk. METHODS: A variant at chromosome 9p21 (rs1333049) was tested for association with subsequent events during follow-up in 103 357 Europeans with established CHD at baseline from the GENIUS-CHD (Genetics of Subsequent Coronary Heart Disease) Consortium (73.1% male, mean age 62.9 years). The primary outcome, subsequent CHD death or myocardial infarction (CHD death/myocardial infarction), occurred in 13 040 of the 93 115 participants with available outcome data. Effect estimates were compared with case/control risk obtained from the CARDIoGRAMplusC4D consortium (Coronary Artery Disease Genome-wide Replication and Meta-analysis [CARDIoGRAM] plus The Coronary Artery Disease [C4D] Genetics) including 47 222 CHD cases and 122 264 controls free of CHD. RESULTS: Meta-analyses revealed no significant association between chromosome 9p21 and the primary outcome of CHD death/myocardial infarction among those with established CHD at baseline (GENIUS-CHD odds ratio, 1.02; 95% CI, 0.99-1.05). This contrasted with a strong association in CARDIoGRAMPlusC4D odds ratio 1.20; 95% CI, 1.18-1.22; P for interaction <0.001 compared with the GENIUS-CHD estimate. Similarly, no clear associations were identified for additional subsequent outcomes, including all-cause death, although we found a modest positive association between chromosome 9p21 and subsequent revascularization (odds ratio, 1.07; 95% CI, 1.04-1.09). CONCLUSIONS: In contrast to studies comparing individuals with CHD to disease-free controls, we found no clear association between genetic variation at chromosome 9p21 and risk of subsequent acute CHD events when all individuals had CHD at baseline. However, the association with subsequent revascularization may support the postulated mechanism of chromosome 9p21 for promoting atheroma development.
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Cromosomas Humanos Par 9 , Enfermedad de la Arteria Coronaria/patología , Estudios de Casos y Controles , Enfermedad de la Arteria Coronaria/genética , Femenino , Frecuencia de los Genes , Predisposición Genética a la Enfermedad , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/genética , Infarto del Miocardio/patología , Oportunidad Relativa , Factores de RiesgoRESUMEN
OBJECTIVE: The effects of having a lower left ventricular end-diastolic dimension before HeartMate II (Thoratec Corp, Pleasanton, Calif) left ventricular assist device implantation remain unclear. We analyzed our single-center data on HeartMate II implantation to determine whether having a lower left ventricular end-diastolic dimension preoperatively was associated with inferior outcomes. METHODS: From November 2003 to March 2016, 393 patients with chronic heart failure underwent primary HeartMate II implantation. We compared the preoperative left ventricular end-diastolic dimension and associated survival outcomes of these patients to determine the left ventricular end-diastolic dimension cutoff for worse overall survival. Then, we compared the preoperative demographics, stroke rate, and mortality of patients with a left ventricular end-diastolic dimension above the cutoff for worse survival with those of patients with a left ventricular end-diastolic dimension below the cutoff. RESULTS: A Cox multivariate regression model showed that low left ventricular end-diastolic dimension was an independent predictor of mortality (hazard ratio, 1.49; P = .02). The Contal and O'Quigley method showed that overall survival postimplantation was decreased in patients with a left ventricular end-diastolic dimension less than 6.0 cm (n = 91). Kaplan-Meier analysis confirmed that the left ventricular end-diastolic dimension less than 6.0 cm group had lower overall survival than the left ventricular end-diastolic dimension 6.0 cm or greater group (P = .04). Furthermore, a competing-risk analysis showed that postoperative stroke was more common in the left ventricular end-diastolic dimension less than 6.0 cm group than in the left ventricular end-diastolic dimension 6.0 cm or greater group (P < .01). CONCLUSIONS: Overall survival was decreased and postoperative stroke was increased in HeartMate II recipients with a preoperative left ventricular end-diastolic dimension less than 6.0 cm. Future research should determine the left ventricular end-diastolic dimension cutoff values for safely implanting other support devices, and device designs should be improved to better accommodate the needs of patients with a limited left ventricle size.
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Ventrículos Cardíacos/patología , Corazón Auxiliar/efectos adversos , Disfunción Ventricular Izquierda/mortalidad , Diástole/fisiología , Femenino , Humanos , Masculino , Modelos de Riesgos Proporcionales , Implantación de Prótesis/mortalidad , Estudios Retrospectivos , Análisis de Supervivencia , Disfunción Ventricular Izquierda/patología , Disfunción Ventricular Izquierda/cirugía , Función VentricularRESUMEN
BACKGROUND: We performed a single-center retrospective analysis to determine whether preoperative serum albumin levels were associated with postoperative adverse events and short- and long-term survival in patients who underwent continuous-flow left ventricular assist device (CF-LVAD) implantation. METHODS: From November 2003 through March 2016, 526 patients underwent CF-LVAD implantation. Patients whose preoperative serum albumin level was normal (≥3.5 g/dL) were compared to patients with preoperative hypoalbuminemia (<3.5 g/dL), which was further categorized as moderate (2.5-3.5 g/dL) or severe (<2.5 g/dL). These groups were compared regarding preoperative demographics, incidence of postoperative complications, and long-term survival. RESULTS: Patients with hypoalbuminemia had higher serum levels of liver enzymes (P < 0.05) and total bilirubin (P < 0.001) and significantly lower platelet counts (P = 0.02) and prealbumin levels (P < 0.001) than patients with normal preoperative albumin levels. Survival in patients with moderate and severe preoperative hypoalbuminemia was significantly decreased compared with patients with normal preoperative serum albumin levels (P < 0.001). Preoperative hypoalbuminemia was also associated with higher incidences of postoperative infection, gastrointestinal bleeding, neurological dysfunction, and acute kidney injury (P ≤ 0.01 for all) but did not affect the success of bridge to transplantation or survival after transplantation. CONCLUSIONS: Our data demonstrated that there is a significant association of preoperative low serum albumin levels with postoperative adverse outcomes and lower survival rates. This highlights the importance of a patient's preoperative nutritional status on postoperative outcomes after CF-LVAD implantation.
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Corazón Auxiliar , Hipoalbuminemia/diagnóstico , Estado Nutricional , Complicaciones Posoperatorias/etiología , Implantación de Prótesis/mortalidad , Albúmina Sérica , Lesión Renal Aguda/etiología , Adulto , Anciano , Biomarcadores/sangre , Femenino , Hemorragia Gastrointestinal/etiología , Ventrículos Cardíacos , Humanos , Hipoalbuminemia/complicaciones , Incidencia , Infecciones/etiología , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/etiología , Valor Predictivo de las Pruebas , Periodo Preoperatorio , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Preoperative statin administration is associated with reduced mortality risk after a coronary artery bypass graft operation. However, the optimal dose and timing are unknown. METHODS: We retrospectively reviewed data from 3,025 primary isolated coronary artery bypass graft surgery patients at our institution. Patients were divided into three groups, according to timing of their preoperative statin: 24 hours or less (n = 1,788), 24 to 72 hours (n = 452), or more than 72 hours before operation or no dose (n = 781). We then grouped patients by preoperative dose: no statin (n = 739), 20 mg or less (n = 920), or more than 20 mg (n = 1,284) atorvastatin or equivalent. Primary outcome was 30-day all-cause postoperative mortality. RESULTS: Thirty-day all-cause mortality was significantly lower for patients taking a statin 24 hours or less preoperatively (1.7%) compared with 24 to 72 hours (2.9%), more than 72 hours, or no dose (3.8%). Multivariate analysis of a propensity-matched cohort showed taking statins 24 hours or less preoperatively was associated with reduced 30-day all-cause mortality (odds ratio 0.52, 95% confidence interval: 0.28 to 0.98, p = 0.04) versus more than 24 hours or no dose. For preoperative statin dose, 30-day all-cause mortality was significantly lower when taking 20 mg or less(1.8%) or more than 20 mg atorvastatin or equivalent (2.1%) than when taking none (3.8%). In multivariate analysis of the propensity-matched cohort, more than 20 mg preoperative dose was associated with a 68% reduction of 30-day all-cause mortality (odds ratio 0.32, 95% confidence interval: 0.13 to 0.82, p = 0.02) compared with no preoperative statin. However, a 20 mg or less preoperative dose showed no mortality reduction. CONCLUSIONS: Both statin use 24 hours or less preoperatively and preoperative statin dose of more than 20 mg were independently associated with decreased 30-day all-cause mortality after coronary artery bypass graft surgery.
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Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Complicaciones Posoperatorias/mortalidad , Cuidados Preoperatorios/métodos , Anciano , Atorvastatina/administración & dosificación , Causas de Muerte/tendencias , Enfermedad de la Arteria Coronaria/mortalidad , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Femenino , Estudios de Seguimiento , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Masculino , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Texas/epidemiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
Chronic tachycardia is a well-known cause of nonischemic cardiomyopathy. We hypothesized that nebivolol, a ß-blocker with nitric oxide activity, would be superior to a pure ß-blocker in preventing tachycardia-induced cardiomyopathy in a porcine model. Fifteen healthy Yucatan pigs were randomly assigned to receive nebivolol, metoprolol, or placebo once a day. All pigs underwent dual-chamber pacemaker implantation. The medication was started the day after the pacemaker implantation. On day 7 after implantation, each pacemaker was set at atrioventricular pace (rate, 170 beats/min), and the pigs were observed for another 7 weeks. Transthoracic echocardiograms, serum catecholamine levels, and blood chemistry data were obtained at baseline and at the end of the study. At the end of week 8, the pigs were euthanized, and complete histopathologic studies were performed. All the pigs developed left ventricular cardiomyopathy but remained hemodynamically stable and survived to the end of the study. The mean left ventricular ejection fraction decreased from baseline by 34%, 20%, and 20% in the nebivolol, metoprolol, and placebo groups, respectively. These changes did not differ significantly among the 3 groups (P =0.51). Histopathologic analysis revealed mild left ventricular perivascular fibrosis with cardiomyocyte hypertrophy in 14 of the 15 pigs. Both nebivolol and metoprolol failed to prevent cardiomyopathy in our animal model of persistent tachycardia and a high catecholamine state.
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Antagonistas de Receptores Adrenérgicos beta 1/farmacología , Cardiomiopatías/prevención & control , Metoprolol/farmacología , Nebivolol/farmacología , Taquicardia Ventricular/tratamiento farmacológico , Animales , Estimulación Cardíaca Artificial , Cardiomiopatías/etiología , Cardiomiopatías/patología , Cardiomiopatías/fisiopatología , Modelos Animales de Enfermedad , Fibrosis , Miocitos Cardíacos/efectos de los fármacos , Miocitos Cardíacos/patología , Volumen Sistólico/efectos de los fármacos , Sus scrofa , Taquicardia Ventricular/etiología , Taquicardia Ventricular/fisiopatología , Función Ventricular Izquierda/efectos de los fármacos , Remodelación Ventricular/efectos de los fármacosRESUMEN
PURPOSE: Magnetic resonance elastography (MRE) can estimate liver stiffness (LS) noninvasively. We prospectively assessed whether motion-encoding gradient (MEG) direction, slice position, or high-caloric food intake affects the repeatability of MRE measurements of LS. MATERIALS AND METHODS: Twenty healthy volunteers (8 women, 12 men; age, 48 ± 12 years) were imaged in a 3.0T scanner at four timepoints: twice after overnight fasting (B1 , B2 ) and twice after consuming a 1050-calorie standardized meal (A1 , A2 ; after 30 and 60 min, respectively). Each session comprised sequential MRE acquisitions in which MEG was applied in three orthogonal directions with three slices positioned over the liver for each. Between sessions, the participants were repositioned to assess test-retest reproducibility. RESULTS: The LS measurements before/after food intake were 3.36 ± 1.31 kPa/3.22 ± 1.03 kPa, 2.04 ± 0.33 kPa/2.27 ± 0.38 kPa, and 2.47 ± 0.50 kPa/2.64 ± 0.76 kPa for MEG superimposed along the anterior-posterior (AP), foot-head (FH), and right-left (RL) directions, respectively. Before and after food intake, LS estimates were lower and more reproducible (<10% coefficient of variation) when the MEG was in the FH direction, not the AP or RL direction. Liver stiffness estimates were significantly elevated after meal consumption when the MEG was in the FH direction (P < 0.05 for B1 vs. A1 , B1 vs. A2 , B2 vs. A1 , and B2 vs. A2 ). CONCLUSION: MRE estimates of LS were highly reproducible, particularly when MEG was applied in the FH direction, suggesting that this method could be used for long-term monitoring of antifibrotic therapy without repeated biopsies. High-caloric food intake resulted in slightly elevated LS on MRE.
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Diagnóstico por Imagen de Elasticidad , Interpretación de Imagen Asistida por Computador/métodos , Hígado/diagnóstico por imagen , Imagen por Resonancia Magnética , Adulto , Índice de Masa Corporal , Simulación por Computador , Módulo de Elasticidad , Femenino , Alimentos , Voluntarios Sanos , Humanos , Hígado/patología , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Movimiento (Física) , Presión , Estudios Prospectivos , Reproducibilidad de los Resultados , TransductoresRESUMEN
BACKGROUND: Heart failure (HF) patients have high rates of hospitalization and rehospitalization. METHODS AND RESULTS: A protocol-driven clinic staffed by an allied health care team was designed for patients discharged from the hospital with a diagnosis of congestive HF. The clinic provided follow-up visits 1 week and 4 to 6 weeks after hospital discharge. One-hundred and fourteen patients were observed at least 1 time, and 80% of these patients completed the 2-visit protocol. Clinical evaluations were provided by a nurse practitioner specializing in HF and a clinical pharmacist; these evaluations included physical examination, laboratory evaluation, medical education and reconciliation, medication adjustment and titration, and care coordination. Referrals to home health and appropriate services were provided. At visit 1, 25% of patients were hypervolemic and 13% were hypovolemic. At visit 2, 20% were hypervolemic and 13% were hypovolemic. Medicine reconciliation errors were common, with an average of 2.1 and 0.8 errors per person recorded for visits 1 and 2, respectively. Clinic participants showed a 44.3% reduction in 30-day readmission rates, as compared to the hospital's average 30-day readmission rates. CONCLUSIONS: Protocol-driven postdischarge transition care delivered by allied health staff addressed multiple transition issues and was associated with a dramatic reduction in readmission rates.
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Insuficiencia Cardíaca/terapia , Alta del Paciente , Readmisión del Paciente/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Técnicos Medios en Salud , Protocolos Clínicos , Continuidad de la Atención al Paciente , Femenino , Humanos , Masculino , Persona de Mediana Edad , Alta del Paciente/estadística & datos numéricos , Pase de Guardia , Estudios Retrospectivos , Adulto JovenRESUMEN
OBJECTIVE: To determine whether preoperative aspirin-acetylsalicylic acid (ASA)-timing or dose independently affects 30-day all-cause mortality. BACKGROUND: Preoperative ASA administration is associated with reduced morbidity and mortality after coronary artery bypass graft (CABG). However, data are lacking regarding optimal timing and dosing of ASA. METHODS: We retrospectively reviewed data from 3018 consecutive patients who underwent CABG surgery between July 2005 and May 2011. Patients were assigned to 3 groups according to the time of the last preoperative ASA dose: (1) 24âhours or less preoperatively (nâ=â1173), (2) between 24 and 72âhours (nâ=â876), and (3) more than 72âhours or none (nâ=â969). In a separate analysis, patients were grouped according to ASA dose: 81âmg (nâ=â1285), 325âmg (nâ=â1004), and none (nâ=â543). The primary outcome was 30-day all-cause mortality. RESULTS: The 30-day mortality rate was significantly lower in patients who took ASA 24âhours or less preoperatively (1.5%) than in those who took it between 24 and 72âhours (3.2%) or more than 72âhours or none (2.9%). Multivariate analysis showed that ASA within 24âhours preoperatively was associated with reduced mortality (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.20-0.82; Pâ=â0.01). Moreover, mortality was significantly reduced for patients taking 81âmg of ASA (1.4%) compared with 325âmg (2.9%) or none (3.9%). Multivariate analysis demonstrated that 81âmg of ASA decreased mortality risk by 66% (OR, 0.34; 95% CI, 0.18-0.66; Pâ<â0.01), whereas 325âmg of ASA had no mortality benefit (OR, 0.74; 95% CI, 0.41-1.35; Pâ=â0.33) compared with no ASA. CONCLUSIONS: Low-dose ASA use within 24âhours of CABG is independently associated with decreased early postoperative mortality.
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Aspirina/administración & dosificación , Puente de Arteria Coronaria/mortalidad , Inhibidores de Agregación Plaquetaria/administración & dosificación , Complicaciones Posoperatorias/prevención & control , Cuidados Preoperatorios/métodos , Adulto , Anciano , Anciano de 80 o más Años , Aspirina/uso terapéutico , Esquema de Medicación , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Inhibidores de Agregación Plaquetaria/uso terapéutico , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Continuous-flow left ventricular assist devices (LVADs) expose blood cells to high shear stress, potentially resulting in the production of microparticles that express phosphatidylserine (PS+) and promote coagulation and inflammation. In this prospective study, we attempted to determine whether PS+ microparticle levels correlate with clinical outcomes in LVAD-supported patients. METHODS: We enrolled 20 patients undergoing implantation of the HeartMate II LVAD (Thoratec Corp, Pleasanton, CA) and 10 healthy controls who provided reference values for the microparticle assays. Plasma was collected before LVAD implantation, at discharge, at the 3-month follow-up, and when an adverse clinical event occurred. We quantified PS+ microparticles in the plasma using flow cytometry. RESULTS: During the study period, 8 patients developed adverse clinical events: ventricular tachycardia storm in 1, non-ST-elevation myocardial infarction in 2, arterial thrombosis in 2, gastrointestinal bleeding in 2, and stroke in 3. Levels of PS+ microparticles were higher in patients at baseline than in healthy controls (2.11% ± 1.26% vs 0.69% ± 0.46%, p = 0.007). After LVAD implantation, patient PS+ microparticle levels increased to 2.39% ± 1.22% at discharge and then leveled to 1.97% ± 1.25% at the 3-month follow-up. Importantly, levels of PS+ microparticles were significantly higher in patients who developed an adverse event than in patients with no events (3.82% ± 1.17% vs 1.57% ± 0.59%, p < 0.001), even though the 2 patient groups did not markedly differ in other clinical and hematologic parameters. CONCLUSIONS: Our results suggest that an elevation of PS+ microparticle levels may be associated with adverse clinical events. Thus, measuring PS+ microparticle levels in LVAD-supported patients may help identify patients at increased risk for adverse events.
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Micropartículas Derivadas de Células , Insuficiencia Cardíaca/terapia , Trasplante de Corazón , Corazón Auxiliar/efectos adversos , Citometría de Flujo , Estudios de Seguimiento , Insuficiencia Cardíaca/sangre , Humanos , Proyectos Piloto , Estudios Prospectivos , Factores de Riesgo , Factores de TiempoRESUMEN
OBJECTIVE: Rapid decreases in serum sodium levels are associated with altered mental status, seizures, and coma. During cardiac surgery, serum sodium levels decrease rapidly when cardiopulmonary bypass is initiated because cardiopulmonary bypass causes hemodilution. However, whether this decrease influences neurologic outcome after cardiac surgery remains unclear. We investigated whether the average serum sodium level during cardiopulmonary bypass is independently predictive of postoperative stroke or 30-day all-cause mortality in patients who undergo primary coronary artery bypass grafting. METHODS: In a single-institution, retrospective cohort of 2348 consecutive patients who underwent primary, isolated coronary artery bypass grafting, sequential multivariate logistic regression was performed to determine the threshold below which the average serum sodium level during cardiopulmonary bypass independently predicts postoperative stroke or early death. To further test the validity of this threshold and to control for selection bias, stepwise multivariate logistic regression was also performed on propensity score-matched patients (n = 924). RESULTS: An average serum sodium level less than 130 mEq/L during cardiopulmonary bypass was independently predictive of stroke, both in the entire study cohort (1.44% vs 2.92%; odds ratio, 2.09; 95% confidence interval, 1.1-4.1; P = .03) and in the propensity-matched patients (0.9% vs 3.0%; odds ratio, 4.1; 95% confidence interval, 1.3-13.0; P = .02). The average serum sodium level during cardiopulmonary bypass was not independently associated with early death, regardless of what threshold value was used. CONCLUSIONS: An average serum sodium level of less than 130 mEq/L during cardiopulmonary bypass is independently associated with an increased risk of postoperative stroke in patients who undergo primary coronary artery bypass grafting.
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Puente Cardiopulmonar , Puente de Arteria Coronaria , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/epidemiología , Sodio/sangre , Accidente Cerebrovascular/sangre , Accidente Cerebrovascular/epidemiología , Anciano , Estudios de Cohortes , Femenino , Humanos , Periodo Intraoperatorio , Masculino , Pronóstico , Estudios Retrospectivos , Medición de RiesgoRESUMEN
It is not known whether genetic variants in the cholesteryl ester transfer protein (CETP) gene are associated with recurrent coronary heart disease events or mortality in secondary prevention patients. Among 3,717 patients with acute coronary syndrome or coronary artery bypass grafting (CABG) enrolled in a prospective genetic registry, we evaluated whether CETP gene variants previously shown to be associated with reduced CETP activity and high-density lipoprotein cholesterol increase ("A" allele for both TaqIB [rs708272] and rs12149545) are associated with a reduction in recurrent myocardial infarction (MI), recurrent revascularization, or death. At 4.5 years of follow-up, 439 recurrent MI, 698 recurrent revascularizations, and 756 deaths occurred. Using an additive model of inheritance, the "A" allele for rs708272 was not associated with recurrent MI (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.78 to 1.17 for AG; HR 0.89, 95% CI 0.67 to 1.19 for AA; compared with GG genotype), recurrent revascularization (HR 1.13, 95% CI 0.95 to 1.33 for AG; HR 1.05, 95% CI 0.84 to 1.32 for AA), or mortality (HR 1.02, 95% CI 0.86 to 1.19 for AG; HR 1.11, 95% CI 0.91 to 1.37 for AA) in the overall cohort. Similar results were seen for the "A" allele for rs12149545. In the CABG subgroup, AG genotype for rs708272 was associated with an increased mortality (HR 1.38, 95% CI 1.06 to 1.79) compared with GG genotype. Results remained consistent using dominant model of inheritance. In conclusion, genetic CETP variants were not associated with recurrent MI or recurrent revascularization in overall cohort with a possible mortality increase in patients who underwent CABG.
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Proteínas de Transferencia de Ésteres de Colesterol/genética , Enfermedad de la Arteria Coronaria/genética , ADN/genética , Polimorfismo de Nucleótido Simple , Anciano de 80 o más Años , Proteínas de Transferencia de Ésteres de Colesterol/sangre , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Femenino , Estudios de Seguimiento , Genotipo , Humanos , Masculino , Pronóstico , Estudios Prospectivos , Recurrencia , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiologíaRESUMEN
Preoperative risk-prediction models are an important tool in contemporary surgical practice. We developed a risk-scoring technique for predicting in-hospital death for cardiovascular surgery patients. From our institutional database, we obtained data on 21,120 patients admitted from 1995 through 2007. The outcome of interest was early death (in-hospital or within 30 days of surgery). To identify mortality predictors, multivariate logistic regression was performed on data from 14,030 patients from 1995 through 2002 and risk scores were computed to stratify patients (low-, medium-, and high-risk). A recalibrated model was then created from the original risk scores and validated on data from 7,090 patients from 2003 through 2007. Significant predictors of death included urgent surgery within 48 hours of admission, advanced age, renal insufficiency, repeat coronary artery bypass grafting, repeat aortic aneurysm repair, concomitant aortic aneurysm or left ventricular aneurysm repair with coronary bypass or valvular surgery, and preoperative intra-aortic balloon pump support. Because the original model overpredicted death for operations performed from 2003 through 2007, this was adjusted for by applying the recalibrated model. Applying the recalibrated model to the validation set revealed predicted mortality rates of 1.7%, 4.2%, and 13.4% and observed rates of 1.1%, 5.1%, and 13%, respectively. Because our model discriminates risk groups by using preoperative clinical criteria alone, it can be a useful bedside tool for identifying patients at greater risk of early death after cardiovascular surgery, thereby facilitating clinical decision-making. The model can be recalibrated for use in other types of patient populations.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/mortalidad , Técnicas de Apoyo para la Decisión , Procedimientos Quirúrgicos Vasculares/mortalidad , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Curva ROC , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
OBJECTIVE: Selective antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest (HCA) provides cerebral protection during aortic arch surgery. However, the ideal temperature for HCA during ACP remains unknown. Clinical outcomes were compared in patients who underwent moderate (nasopharyngeal temperature, ≥ 20 °C) versus deep (nasopharyngeal temperature, <20 °C) HCA with ACP during aortic arch repair. METHODS: By using a prospectively maintained clinical database, we analyzed data from 221 consecutive patients who underwent aortic arch replacement with HCA and ACP between December 2006 and May 2009. Seventy-eight patients underwent deep hypothermia (mean lowest temperature, 16.8 °C ± 1.7 °C) and 143 patients underwent moderate hypothermia (mean, 22.9 °C ± 1.4 °C) before systemic circulatory arrest was initiated. Multivariate stepwise logistic and linear regressions were performed to determine whether depth of hypothermia independently predicted postoperative outcomes and blood-product use. RESULTS: Compared with moderate hypothermia, deep hypothermia was associated independently with a greater risk of in-hospital death (7.7% vs 0.7%; odds ratio [OR], 9.3; 95% confidence interval [CI], 1.1-81.6; P = .005) and 30-day all-cause mortality (9.0% vs 2.1%; OR, 4.7; 95% CI, 1.2-18.6; P = .02), and with longer cardiopulmonary bypass time (154 ± 62 vs 140 ± 46 min; P = .008). Deep hypothermia also was associated with a higher incidence of stroke, although this association was not statistically significant (7.6% vs 2.8%; P = .073; OR, 4.3; 95% CI, 0.9-12.5). No difference was seen in acute kidney injury, blood product transfusion, or need for surgical re-exploration. CONCLUSIONS: Moderate hypothermia with ACP is associated with lower in-hospital and 30-day mortality, shorter cardiopulmonary bypass time, and fewer neurologic sequelae than deep hypothermia in patients who undergo aortic arch surgery with ACP.
Asunto(s)
Aorta Torácica/cirugía , Trastornos Cerebrovasculares/prevención & control , Paro Circulatorio Inducido por Hipotermia Profunda , Hipotermia Inducida , Perfusión , Procedimientos Quirúrgicos Vasculares , Anciano , Transfusión Sanguínea , Puente Cardiopulmonar , Circulación Cerebrovascular , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/mortalidad , Trastornos Cerebrovasculares/fisiopatología , Distribución de Chi-Cuadrado , Paro Circulatorio Inducido por Hipotermia Profunda/efectos adversos , Paro Circulatorio Inducido por Hipotermia Profunda/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Hipotermia Inducida/efectos adversos , Hipotermia Inducida/mortalidad , Modelos Lineales , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Perfusión/efectos adversos , Perfusión/mortalidad , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
This present study investigated the influence of combined preoperative clopidogrel and aspirin (ASA) administration on adverse postoperative outcomes and bleeding risk in patients undergoing carotid endarterectomy (CEA). A retrospective cohort study of all consecutive patients undergoing isolated CEA (n = 1488) between 1998 and 2005 was performed. Patients were classified into three groups: patients receiving combined preoperative clopidogrel/ASA therapy (n = 315), patients receiving preoperative ASA only (n = 639) and patients receiving no preoperative antiplatelet therapy (n = 518). Multivariate logistic regression was performed to determine if combined preoperative clopidogrel and ASA therapy is independently associated with improved perioperative outcomes after CEA in the absence of significant bleeding risk. Clopidogrel/ASA therapy was independently associated with a five-fold increased risk of postoperative bleeding after CEA (odds ratios = 5.1; 95% confidence intervals: 1.814.2; P < 0.002). No increase in bleeding risk or reoperation was observed in patients receiving ASA alone. However, the postoperative length of hospital stay (PLOHS) was significantly shorter (P = 0.01) for patients receiving combined clopidogrel/ASA therapy (2.5 ± 2.3 days) versus those receiving no antiplatelet agents (3.2 ± 5.9 days). Preoperative clopidogrel/ASA therapy increases risk of postoperative bleeding after CEA, yet reduces overall PLOHS.
Asunto(s)
Aspirina , Endarterectomía Carotidea , Estudios de Cohortes , Humanos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Estudios RetrospectivosRESUMEN
BACKGROUND: There is a paucity of evidence on the association between preoperative diuretics use and outcomes following cardiac surgery. We hypothesized that diuretic use prior to cardiac surgery will be associated with adverse in-hospital clinical outcomes. METHODS: We evaluated patients undergoing cardiac surgery at a single institution between January 1, 2000, and December 31, 2011. Patients were grouped as follows: isolated coronary artery bypass grafting (CABG) (n = 8759), CABG plus valve surgery (n = 1188), and valve surgery only (n = 2646). A fourth group "All cardiac surgery" is comprised of patients from all three groups. Preoperative diuretic use was defined as patient on any diuretic till the day of surgery. Primary outcome was the incidence of major adverse events (MAEs) defined as the composite of mortality, postoperative renal dysfunction, myocardial infarction, stroke, and new-onset atrial fibrillation (AF). Logistic regression analysis and propensity score matching were performed. RESULTS: We included 12,593 patients [3546 on diuretic (28%)]. After logistic regression analyses, preoperative diuretic use was associated with an increased risk of the following: (1) MAE among all groups except the concomitant CABG and valve surgery group, (2) AF in "All cardiac surgery" and isolated CABG groups, (3) postoperative renal dysfunction in all groups. After propensity score matching (n = 3050 in each group), preoperative diuretic use was significantly associated with MAE (48% vs. 43%; P < 0.0001), postoperative renal dysfunction (19% vs. 14%; P < 0.0001), and AF (34% vs. 32%; P = 0.03) in the "All cardiac surgery" group. CONCLUSION: Preoperative diuretics use is associated with an increased incidence of MAEs after cardiac surgery.
Asunto(s)
Puente de Arteria Coronaria/efectos adversos , Diuréticos/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Anciano , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios RetrospectivosRESUMEN
BACKGROUND: Cerebrospinal fluid drainage, a well-established means of preventing paraplegia after thoracic aortic aneurysm surgery, can result in serious, sometimes lethal complications. In a large group of patients who underwent surgical thoracic aortic aneurysm repair with cerebrospinal fluid drainage, we examined the incidences of and potential risk factors for these outcomes. METHODS: The records were reviewed of 504 patients who underwent surgical thoracic aortic aneurysm repair with cerebrospinal fluid drainage at the Texas Heart Institute at St. Luke's Episcopal Hospital between February 2005 and December 2009. All historical data, inpatient records, and billing data were searched for evidence of complications. RESULTS: Of the 504 patients, 14 (2.8%) had intracranial hemorrhage, of whom 10 (72%) had subdural hematoma. Postdural puncture headache developed in 49 patients (9.7%), of whom 17 (34.6%) required epidural blood patch placement for resolution. Multivariable analysis identified having a connective tissue disorder (odds ratio, 3.08; 95% confidence interval, 1.33-7.13) as an independent predictor of postdural puncture headache, but not age less than 40 years (odds ratio, 0.97; 95% confidence interval, 0.94-0.99). CONCLUSIONS: Cerebrospinal fluid drainage, as performed by our method, seems to be associated with a modest rate of intracranial bleeding in patients who undergo surgical thoracic aortic aneurysm repair. In contrast, postdural puncture headache is not uncommon, particularly in patients with connective tissue disease. Clinicians caring for these patients should consider the likelihood of postdural puncture headache, and any such patient with postoperative headache should be assessed for epidural blood patch placement.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Líquido Cefalorraquídeo , Drenaje/efectos adversos , Cuidados Posoperatorios/efectos adversos , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: We determined whether pre-operative statin therapy is associated with a decrease in the incidence of infections after coronary artery bypass grafting (CABG). METHODS: A retrospective cohort study of 6253 patients undergoing isolated CABG, from the Texas Heart Institute Database from January 1, 2000 to December 31, 2010 (3869 receiving statins and 2384 not receiving statins) was conducted. Primary outcome was the development of any postoperative infection (composite of deep-sternal wound infection, leg harvest-site infection, pneumonia, or sepsis) after CABG. Secondary outcome was the association between pre-operative statin use and individual incidence of each aforementioned infection. Logistic regression analyses were performed. RESULTS: Incidence of any postoperative infection in patients who received statins pre-operatively was 6.5% compared to 8.3% in patients who did not receive statins. Pre-operative statin therapy was associated with a significant reduction in the primary outcome (odds ratio (OR) 0.74, 95% confidence interval (CI) 0.60-0.90) in adjusted models. Among individual secondary outcomes, pre-operative statin therapy was associated with a reduced incidence of sternal wound infections (2.5% vs. 3.2%, OR 0.6, 95% CI 0.5-0.8) and leg harvest site infections (0.6% vs. 1.3%, OR 0.46, 95% CI 0.2-0.8). Pre-operative statin therapy was not associated with a reduced incidence of pneumonia or sepsis. CONCLUSION: Pre-operative statin use is associated with a decrease in overall incidence of post-operative infections after CABG. We propose immunomodulatory effects of statins leading to a dampening of inflammatory cascade as the cause of our findings.