Pneumonia in a cardiothoracic intensive care unit: incidence and risk factors.

OBJECTIVE: The purpose of this study was to determine the incidence, risk factors, and pathogens causing pneumonia in a cardiothoracic intensive care unit (CTICU). DESIGN: A prospective study. SETTING: "Civili Hospital," Brescia, Italy. PARTICIPANTS: One hundred forty consecutive patients in the CTICU for more than 24 hours from October 1, 2006, to September 30, 2007. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic variables and intrinsic and extrinsic risk factors were analyzed with univariate and multivariate analysis. One hundred forty patients were studied, 128 (91.4%) were surgical and 12 (8.5%) were medical. Cumulative incidence of pneumonia was 28.6% (n = 40); 62.5% (n = 25) had ventilator-associated pneumonia (VAP) and 37.5% (n = 15) had non-VAP. The most common isolated pathogens were Pseudomonas aeruginosa (n = 15), Staphylococcus aureus (n = 5), Escherichia coli (n = 4), and Klebsiella pneumoniae (n = 3). Mortality was 22.2% (n = 31), with 54.8% (n = 17) of patients with pneumonia leading to mortality during CTICU stay (p = 0.0006). On multivariate analysis, independent risk factors for pneumonia were each point of the Sequential Organ Failure Assessment score at CTICU admission (p = 0.006, odds ratio [OR] = 1.39, confidence interval [CI] = 1.09-1.76), every day of mechanical ventilation (p = 0.049, OR = 1.08, CI = 1.00-1.18), noninvasive mechanical ventilation (NIMV) (p = 0.014, OR = 4.83, CI = 1.37-17.03), and bronchoscopy (p = 0.002, OR = 8.14, CI = 2.10-31.55). CONCLUSIONS: Pneumonia is a common complication in the CTICU, and the authors recommend the following: the removal of the endotracheal tube as soon as possible, the minimal use of a bronchoscope and only in cases of bronchial obstruction, and the use of NIMV.

Heart valve surgery in a very high-risk population: a preliminary experience in awake patients.

BACKGROUND AND AIM OF THE STUDY: Heart valve surgery in high-risk patients is associated with considerable morbidity and mortality. Epidural anesthesia without mechanical ventilation has been proposed to reduce invasiveness. An analysis was conducted in very high-risk heart valve patients of mid-term survival free from complications, and patient satisfaction of regional anesthesia use, without mechanical ventilation. METHODS: A prospective follow up study was conducted in 50 patients (24 females, 26 males; mean age 74 +/- 10 years; range: 43-89 years) who underwent heart valve surgery with epidural anesthesia without endotracheal intubation. Preoperatively, all patients were in NYHA class III or IV; eight patients (16%) had undergone a previous cardiac procedure. The median Additive and Logistic EuroSCORE were 14.5 and 52%, respectively. Twenty-seven patients underwent aortic valve replacement, 10 mitral valve replacement, 10 mitral valve repair, two double valve replacement, and one patient ascending aorta replacement. Associated surgical procedures included coronary artery bypass grafting in 12 patients (24%), ascending aorta replacement in three (6%), and left ventricle reshaping in two (4%). Radiofrequency ablation to treat chronic atrial fibrillation (AF) was performed in 15 patients (30%). All patients were prospectively followed up, and a six-month quality of life assessment was performed in all survivors. RESULTS: Procedures were performed without mechanical ventilation in completely awake and conscious patients. There were two in-hospital and two long-term deaths (8%). Three patients had had previous cardiac surgery (two double valve replacements, two complex mitral valve surgery). Among survivors, 34 (71%) had an uneventful postoperative outcome, except for AF in nine cases. Eight patients required revision for bleeding; two of these were redo cases. The most consistent postoperative complication was acute renal failure in 16 patients, five of whom had previous chronic renal failure. Three patients required mechanical ventilatory support, and none had a cerebrovascular accident. Patients were discharged home after a mean of 10 +/- 5 days (including ICU stay; median 9 h). At follow up, all patients were in NYHA class I/II, and all survivors expressed their satisfaction with epidural anesthesia. CONCLUSION: Heart valve surgery while on cardiopulmonary bypass is feasible and safe using epidural anesthesia. By maintaining autonomic ventilation, a low mid-term morbidity and mortality was observed in patients in whom there was an unacceptable operative risk.

Percutaneous edge-to-edge mitral valve repair for the treatment of acute mitral regurgitation complicating myocardial infarction: A single centre experience.

BACKGROUND: Limited evidence is available about MitraClip therapy in patients with acute mitral regurgitation (MR) complicating myocardial infarction (MI). METHODS AND RESULTS: Among 80 consecutive patients undergoing MitraClip treatment, 5 (6.3%) had been admitted for acute MI complicated by severe MR. Mean age was 73±6years and 3 were males. At the time of admission they were in cardiogenic shock (80%) or pulmonary oedema (20%), with severe MR, left ventricular dysfunction and pulmonary hypertension. The indication to MitraClip treatment was based on severe hemodynamic instability with dependence on intravenous therapy and mechanical supports despite percutaneous coronary revascularization and on high surgical risk of 27.1±13% and 10.2±6% using Euroscore II and STS score respectively. MitraClip procedure was performed at 53±33days from admission. One or two clips were employed in 2 and 3 patients respectively. Procedural success (MR≤2+) was achieved in all patients without complications and with successful weaning from mechanical supports and intravenous drugs in all but one patient who underwent left ventricular assist device implantation at 60days from MitraClip procedure. MR recurrence occurred at 30-day follow-up in one patient who had concomitant aortic regurgitation. One patient died during follow-up for non-cardiovascular cause. However, recovery of hemodynamic balance with significant and persistent pulmonary pressure reduction and functional status improvement up to 2-year follow-up was observed in most of the patients. CONCLUSIONS: Critical patients with acute ischemic MR post-MI with persistence of hemodynamic instability after coronary revascularization may benefit from MitraClip therapy acutely with favourable long-term follow-up results.

Mitraclip therapy in patients with functional mitral regurgitation and missing leaflet coaptation: is it still an exclusion criterion?

AIMS: The aim of this study was to investigate the feasibility, safety, and efficacy of Mitraclip therapy in patients with functional mitral regurgitation (MR) and missing leaflet coaptation (MLC). METHODS AND RESULTS: Out of 62 consecutive patients with functional MR undergoing Mitraclip implantation, 22 had MLC defined as the presence of a 'gap' between two mitral leaflets or insufficient coaptation length (<2 mm), according to the EVEREST II criterion. Compared with the control group, the MLC population had a significantly higher effective regurgitant orifice area (0.67 ± 0.31 vs. 0.41 ± 0.13 cm2 ; P = 0.019) and sphericity index (0.80 ± 0.11 vs. 0.71 ± 0.10; P = 0.003). MLC patients were treated with pharmacological/mechanical support in order to improve leaflet coaptation and to prepare the mitral valve apparatus for grasping. Implantation of >1 clip and device time were comparable in patients with and without MLC (61.9% vs. 47.5%; P = 0.284 and 101 ± 39 vs. 108 ± 69 min; P = 0.646, respectively). No significant differences were observed between the two cohorts in technical success (95.5% vs. 97.5%, P = 0.667), 30-day device success (85.7% vs. 78.9%; P = 0.525), procedural success (81.8% vs. 75%; P = 0.842), and 1-year patient success (52.9% vs. 44.1%; P = 0.261), defined according to the MVARC (Mitral Valve Academic Research Consortium) criteria. The long-term composite endpoint of cardiovascular death and heart failure hospitalization was similar in the two groups (49.9% vs. 44.4%; P = 0.348). A significant improvement of MR and NYHA functional class and a lack of reverse remodelling were observed up to 2 years in both arms. CONCLUSION: The Mitraclip procedure could be extended to patients with functional MR who do not fulfil the coaptation length EVEREST II criterion and who would otherwise be excluded from this treatment.

Surgical treatment of lone atrial fibrillation in an awake patient.

Surgical treatment of atrial fibrillation recently gained new popularity since the introduction of different energy sources and the development of minimally invasive techniques as an alternative to the original "cut-and-sew" technique. However, closed-chest ablation procedures are not feasible in presence of pericardial or pleural adhesions. To our knowledge, this is the first report of surgical treatment of atrial fibrillation in a conscious patient by means of a high epidural anesthesia. Since evidence of fibrothorax was found, a conscious patient suffering from lone atrial fibrillation underwent a beating-heart pulmonary veins isolation with a microwave device through a standard sternotomic approach. At 6 months follow-up, the patient is in stable sinus rhythm, without any palpitation nor electrocardiographic evidence (Holter monitoring) of recurrent atrial fibrillation.

Role of different vascular approaches on transcatheter aortic valve implantation outcome: a single-center study.

OBJECTIVE: To compare different vascular approaches on clinical outcome of patients undergoing transcatheter aortic valve implantation (TAVI) with self-expandable bioprosthesis. METHODS: We included all the patients undergoing CoreValve implantation at our institute between September 2007 and March 2014. They were divided into four groups based on the vascular approach: percutaneous transfemoral (pTF), cut-down transfemoral (cTF), transaxillary (TAx) and transaortic (TAo). Clinical outcomes were evaluated according to Valve Academic Research Consortium-2 recommendations. RESULTS: Out of 322 consecutive patients, 170 (53%) underwent pTF, 76 (23%) cTF, 32 (10%) TAx and 44 (14%) TAo approach. Although the TAx and TAo patients had a higher risk profile, they had a similar outcome compared with the pTF and cTF groups; in particular, there were no differences regarding cardiovascular and all-cause mortality at 30 days, 1 and 2 years, as well as stroke, myocardial infarction, bleeding, major vascular complications, permanent pacemaker implantation and acute kidney injury rates. The observed device success rate was higher in the TAo than in the other approaches (88.6 versus 65.9, 68.7 and 76.3% in the pTF, cTF and TAx groups, respectively; P = 0.019). No differences occurred regarding 30-day early safety and 1-year clinical efficacy across the four groups. Fluoroscopy time, amount of contrast medium used and minor vascular complications were significantly higher in pTF patients, as well as in-hospital stay in the TAo group. Atrial fibrillation and prosthetic valve regurgitation, but not the vascular approach, were independent predictors of all-cause mortality. CONCLUSION: A more invasive vascular approach, for CoreValve implantation, even in higher risk patients, does not affect early-term, mid-term and long-term outcomes.

Thoracoscopic epicardial pulmonary vein ablation for lone paroxysmal atrial fibrillation.

Surgical treatment of atrial fibrillation recently gained new popularity since the introduction of different energy sources for ablative therapy as an alternative to the original "cut-and-sew" techniques. However, most of the cases have been performed together with other cardiac surgical procedures and mainly through a standard median sternotomy approach. We report here the first European case of closed-chest thoracoscopic pulmonary vein isolation in a patient with lone paroxysmal atrial fibrillation.

Fenoldopam prophylaxis of postoperative acute renal failure in high-risk cardiac surgery patients.

BACKGROUND: Acute renal failure requiring replacement therapy occurs in 1% to 2% of patients who have undergone cardiac surgery with cardiopulmonary bypass and is associated with a very high mortality rate. The aim of this study was to determine if prophylactic treatment with fenoldopam mesylate of patients at high risk of postoperative acute renal failure reduced the incidence of this event. METHODS: This was a multicenter, prospective, cohort study in which 108 patients at high risk of postoperative acute renal failure and undergoing cardiac surgery with cardiopulmonary bypass were treated with fenoldopam mesylate (0.08 microg x kg(-1) x min(-1)) starting at the induction of anesthesia and throughout at least the next 24 hours. A homogeneous control group of 108 patients was created using a propensity-score analysis. RESULTS: Fenoldopam prophylaxis was significantly associated with a reduction in acute renal failure incidence (from 22% to 11%, p = 0.028), a less pronounced creatinine clearance decrease (p = 0.05), and a lower mortality rate (6.5% versus 15.7%, p = 0.03) by the univariate analysis, but these results were not confirmed by a multivariable analysis. Within the subgroup of patients who suffered a postoperative low output syndrome, fenoldopam prophylaxis was an independent protective factor for postoperative renal failure (odds ratio, 0.14; 95% confidence interval, 0.03 to 0.7; p = 0.017). CONCLUSIONS: Given the limitations of a nonrandomized prospective trial, our results support the hypothesis that fenoldopam may reduce the risk of acute renal failure in patients in whom endogenous and exogenous cathecolamines action may induce a renal vascular constrictive condition.