RESUMO
AIM: To determine the clinical risk factors predictive of the 5--year mortality in patients with low cardiac output syndrome (LCOS) after cardiac surgery. In addition, to assess the influence of inflammation and myocardial dysfunction severity, as measured by C--reactive protein (CRP) and N--terminal pro--brain natriuretic peptide (NT--proBNP) concentrations, on outcome. METHODS: We studied 30 patients who underwent cardiac surgery and developed postoperative LCOS requiring inotropic support for longer than 48 hours after intensive care unit (ICU) admission. All patients received a 24--hour infusion of levosimendan after study enrolment. We measured the following at baseline, 24 h, 48 h and 7 days: clinical data, serum NT--proBNP and serum CRP levels. Patients were followed--up at 5 years for death by any cause. A risk--adjusted Cox proportional hazards regression model was used for statistical analysis. Hazard ratios and their 95% confidence intervals (CI) are presented. RESULTS: The 5--year mortality was 36.6% (n = 11). The predictors of 5--year mortality were the presence of dilated cardiomyopathy (HR = 36.909; 95% CI: 1.901-716.747; P = 0.017), a higher central venous pressure (CVP) at 48 hours (HR = 2.686; 95% CI: 1.383-5.214; P = 0.004), and lower CRP levels on day 7 (HR = 0.963; 95% CI: 0.933-0.994; P = 0.021). NT--proBNP levels showed a trend to higher initial levels in survivors without statistical significance, but were not associated with 5--year mortality. CONCLUSIONS: The presence of dilated cardiomyopathy, elevated CVP at 48 h and reduced CRP levels on day 7 predicted 5--year mortality in patients who developed postoperative LCOS after cardiac surgery. NT--proBNP levels in the first postoperative week were not predictors of long--term outcomes.
RESUMO
AIM: Little is known regarding the long-term outcome in cirrhotic patients undergoing cardiac surgery. The objective of this study was to identify preoperative and postoperative mortality risk factors and to determine the best predictors of long-term outcome. METHODS: Fifty-eight consecutive cirrhotic patients requiring cardiac surgery between January 2004 and January 2009 were prospectively studied at our institution. Seven patients (12%) died. A complete follow-up was performed in the whole survival group until November 2012 (mean 46±28 months). Variables usually measured on admission and during the first 24 h of the postoperative period were evaluated together with cardiac surgery scores (Parsonnet, EuroSCORE), liver scores (Child-Turcotte-Pugh, Model for End-Stage Liver Disease, United Kingdom End-Stage Liver Disease score), and ICU scores (Acute Physiology and Chronic Health Evaluation II and III, Simplified Acute Physiology Score II and III, Sequential Organ Failure Assessment). RESULTS: Twelve patients (23.5%) died during follow-up; six were Child class A and six class B. Comparing survivors vs. non-survivors using univariate analysis, variables associated with better long-term outcome were lower arterial lactate 24 h after admission (1.7±0.4 vs. 2.1±0.7 mmol·L(-1), P=0.03) and higher urine output in the first 24 h (2029±512 vs. 1575±627 mL, P=0.03). The receiver operating characteristic curve showed that the Simplified Acute Physiology Score III score had the best predictive value for long-term outcome (AUC: 77.4±0.76%; sensitivity: 83.3%; specificity: 64.9%, P=0.005). Multivariate analysis identified Simplified Acute Physiology Score III score (P=0.02) and urine output in the first 24 h (P=0.02) as independent factors associated with long-term outcome. Long-term survival was 82.4% for Child A, 47.6% for Child B and 33.3% for Child C (P=0.001). CONCLUSION: Long-term survival in cirrhotic patients requiring cardiac surgery is a more valuable prognostic measure than short-term survival. Urine output in the first 24 h may be a valuable predictor of long-term outcome in these patients. The Simplified Acute Physiology Score III is also useful.
