Designing a new scoring system (QualyP Score) correlating the management of cardiopulmonary bypass to postoperative outcomes.

AIM: The aim of this study was to ascertain if a score, directly derived from CPB records, could correlate to major postoperative outcomes. METHODS: An additive score (QualyP Score) was created from 10 parameters: peak lactate value during CPB, peak VCO(2)i, lowest DO(2)i/VCO(2)i, peak respiratory quotient, CPB time, cross-clamp time, lowest CPB temperature, circulatory arrest, ultrafiltration during CPB, number of packed red cells transfused intraoperatively. The PerfSCORE was calculated, as well. Multivariable logistic regression models were built to detect the independent predictors of: peak lactate >3 mmol/L during the first three postoperative days; the incidence of acute kidney injury network (AKIN) 1-2-3; respiratory insufficiency; mortality. RESULTS: The mean score was 4.8±2.6 (0-10). A QualyP Score ≥1 was predictive of postoperative acidosis (OR=1.595). A score ≥2 was predictive of AKIN 2 (OR=1.268) and respiratory insufficiency (OR=1.526). A score ≥5 was predictive of AKIN 3 (OR=1.848) and mortality (OR=1.497). CONCLUSIONS: QualyP Score may help to provide a quality marker of perfusion, emphasizing the need for goal-directed perfusion strategies.

Graft patency and late outcomes for patients with ST-segment elevation myocardial infarction who underwent coronary surgery.

OBJECTIVE: The aim of our study was to assess the long-term clinical outcomes and the grafts patency rates of patients with ST-segment elevation myocardial infarction (STEMI) who underwent urgent or emergency coronary artery bypass grafting (CABG). MATERIALS: Participants in two previous studies comprising 207 STEMI patients undergoing on-pump (145 patients) or off-pump (62 patients) coronary artery bypass graft (CABG) surgery in our institution were prospectively followed to assess late mortality, graft patency, and major adverse cardiac-related event (MACE) rates. Graft patency was evaluated by multi-detector computed tomography angiography 64-slice scan. Mean times of graft implantation were 38±16 months and 37±14 months in on-pump and off-pump, respectively. Follow-up data were obtained in all patients and was 100% complete. RESULTS: Late mortality rate was 7.4% (10 patients) in the on-pump and 6.5% (4 patients) in off-pump groups (p=0.45). Five-year overall survival rate (±SE) was 93.5±2.1% and 92.6±1.9% in the off-pump vs on-pump, respectively. Five years' freedom from cardiac-related death was 94.9±2.9% in the on-pump group vs 96.8±3.2% in the off-pump group (p=0.25). Five years' freedom from cardiac-related events was 89.7±1.6% in the on-pump group versus 93.5±1.8% in the off-pump group (p=0.32). In all patients, a total of 449/491 (91.5%) grafts were patent. Percentages of overall grafts classified as patent were similar in the on-pump group (90.7% - 322/355 conduits) versus the off-pump group (91% - 133/146 conduits). Graft patency rates were also similar between the two groups with regard to arterial and saphenous vein conduits, and with regard to different branches of the coronary arteries grafted. CONCLUSION: Our data suggest that off-pump CABG patients have the same late mortality, MACEs, and graft patency rates as conventional cardioplegic cardiac arrest CABG patients. In our opinion, urgent or emergency CABG for patients with STEMI can be done either way.

ECG-gated multidetector computed tomography for the assessment of the postoperative ascending aorta.

PURPOSE: This study was undertaken to define the role of electrocardiographically (ECG)-gated multidetector computed tomography (MDCT) in the assessment of the postoperative ascending aorta. MATERIALS AND METHODS: From November 2006 to June 2007, 21 patients, [11 men, ten women; age +/- standard deviation (SD): 62.7+/-10.8 years] with a history of ascending aorta replacement underwent ECG-gated MDCT and were prospectively included in our study. Ascending aorta replacement had been performed with different surgical techniques: Bentall-De Bono (four patients, 19%), Tirone-David (five patients, 23%), and modified Tirone-David with creation of aortic neosinuses (12 patients, 57%). Two patients were excluded from MDCT evaluation because they failed to fulfil the inclusion criteria. Transthoracic echocardiography was used as the reference standard. All patients provided informed consent. RESULTS: In all patients, ECG-gated MDCT provided a clear depiction of the aortic annulus, aortic root and ascending aorta, enabling accurate measurements in all cases. The aortic valve area (3.4+/-0.2 cm(2)), the diameter of the sinotubular junction (31.6+/-1.8 mm), the diameter of the neosinuses in the case of modified Tirone-David procedures (37.3+/-2.1 mm) and the distance between the cusps and the graft wall during systole (3.1+/-0.7 mm) fell within standard ranges and showed a good correlation (r=0.89) with the values obtained with transthoracic echocardiography. CONCLUSIONS: MDCT is currently considered a compulsory diagnostic step in patients with suspected or known aortic pathology. MDCT is a reliable technique for anatomical and functional assessment of the postoperative aortic root and provides cardiac surgeons with new and detailed information, enabling them to formulate a prognostic opinion regarding the outcome of the surgical procedure.

Factors influencing immediate and long-term results after button's technique.

BACKGROUND: Aim of this study was to evaluate the factors influencing immediate and long-term results in patients undergoing aortic root replacement with a composite graft. METHODS: Between January 1989 and February 1999, 105 patients (83 males, 22 females) who underwent Bentall technique were studied. Preoperative diagnosis was annulo-aortic ectasia in 54, aortic dissection in 27, atherosclerotic aneurysm in 21, and aortitis in 3 cases. Seventeen patients were affected by Marfan's syndrome. All cases, elective, urgent, and emergency were included. Button technique was performed and the associated surgical procedures were coronary artery bypass grafting in 21, total aortic arch replacement in 15, proximal hemi arch in 5, and mitral valve replacement in 5 cases. RESULTS: The overall hospital mortality rate was 7.6% (n=8). Univariate analysis using chi(2) and/or two-sample "t"-test showed that dissection, aortitis, aneurysm rupture into-pleura or pericardium, emergency status, redo, prolonged pump times and circulatory arrest, were predictors influencing in-hospital mortality. Coagulopathy, low cardiac output, stroke, perioperative myocardial infarction, surgical bleeding leading to reoperation, were significantly related to in-hospital mortality (by correlation analysis). A multivariate analysis showed that, emergency status (p=0.027), aortic dissection (p=0.029), perioperative myocardial infarction (p=0.0021), reoperation for bleeding (p=0.0023), and pump time >180 min (p=0.011), were significant. The actuarial survival rate at 10 years follow-up was 84.7%. There were 8 late deaths. The Kaplan-Meier showed significant differences when considering dissection vs non-dissection (p=0.018), but did not reach significance in Marfan vs non-Marfan groups (p=0.83). NYHA class IV (p=0.052), previous cardiac surgery procedure (p=0.041), concomitant CABG (p=0.021), total aortic arch reconstruction (p=0.001), and mitral valve replacement (p=0.016), were identified as significant by Log Rank test. CONCLUSIONS: The Bentall procedure for aortic root replacement is safe and durable; in hospital mortality in elective status it was 1.28%; early and long-term mortality higher in patients with acute dissection. Six late deaths were procedures related. Sixty-six patients (76.4%) were in NYHA I class at follow-up. The incidence of late outcomes, thromboembolism (1.03%), graft infection (2.06%), pseudoaneurysm (0%), reoperation in ascending aorta or aortic valve (3.1%), operations on the remaining aorta (6.7%), and hemorrhage due to anticoagulant therapy (1.03%), are very low.

Left ventricular thrombosis after blunt chest trauma.

A 22-year-old man was admitted to our observation with left ventricular thrombus arising after blunt chest trauma occurring during a ski accident one year before. None was obtained from a review of instrumental and laboratory data at trauma time. Transesophageal echocardiography showed an intraventricular thrombus and severe hypokinesia at the apex. Standard cardiac surgery procedure was performed and postoperative period was uneventful. Echocardiography controls at 6/12 months showed a normal apex kinesia. This case shows the importance of hospitalization, hemodynamics monitorization and late serial echocardiographic controls for timely diagnosis and management of myocardial contusion and consecutive ventricular thrombus formation to prevent life-threatening complications.

Arrhythmia prophylaxis after coronary artery bypass grafting: regimens of magnesium sulfate administration.

BACKGROUND: Arrhythmias are common after open heart surgery and may be related to hypomagnesaemia due to cardiopulmonary bypass. Although perioperative prophylactic Mg2+ administration may prevent arrhythmias after coronary artery bypass grafting (CABG), clear indications as well as the timing of Mg2+ substitution and dose regimen need to be clarified. Aim of this study was to evaluate the antiarrhythmic effects of Mg2+ infusion in patients who underwent elective CABG. METHOD: Ninety-seven patients who underwent elective CABG were divided in four Groups. In Group A 1 g of magnesium sulfate was added to the pump prime, Group B received 1 g in the pump prime plus 5 mmol/L in the cardioplegic solution, Group C received 5 mmol/L in the cardioplegic solution, and Group D was a placebo control Group. Groups A, B, and C also received 24 h continuous infusion of magnesium sulfate at 10 mmol/L. Three-channel electrocardiogram (II-V5-V6) continuous monitoring was performed 12 hours preoperatively and 48 hours postoperatively. Blood samples were taken for subsequent Serum magnesium measurements, at five different time points before, during and after CBP. RESULTS: In all Groups serum Mg2+ levels were reduced during CPB (Time 2) and statistically significant differences from pre-anaesthesia levels (Time 1) were noted (p <0.05). In Groups A, B, and C Serum Mg2+ levels increased progressively from Time 3 to Time 5; in Group D serum Mg2+ levels were still much lower at Time 5. Significant differences (p<0.05) were noted for Groups B and C vs Groups A and D in atrial ectopics, atrial fibrillation, and ventricular arrhythmic events. CONCLUSION: Our results demonstrate that Mg2+ sulfate administration regimens used in Group B and C reduce postoperative arrhythmic events in patients undergoing CABG.

Effect of normothermic versus hypothermic cardiopulmonary bypass on cytokine production and platelet function.

BACKGROUND: Proinflammatory cytokines and platelets play a key role in the systemic inflammatory response associated with cardiopulmonary bypass (CPB). The aim of this study was to evaluate the effects of both hypothermic and normothermic CPB on platelet activation, cytokine production, as well as their possible correlations. METHODS: Twenty patients who underwent CABG were randomly assigned into two groups receiving hypothermic and normothermic CPB. Blood samples were obtained through a venous catheter at 6 time points. The following parameters were measured: in vitro platelet aggregation, in vivo platelet activation, complete and differential blood cell counts, plasma soluble P-selectin levels, plasma IL-6, IL-1beta and TNFalpha levels. RESULTS: The results demonstrated that platelet abnormalities could be observed to a greater extent during hypothermic rather than normothermic CPB. The occurrence of in vivo platelet activation was suggested by the presence of a significantly increased percentage of platelets expressing CD62P on their surface, as well as by a decreased in vitro platelet aggregation induced by different agonists. Complete and differential blood cell counts showed no substantial decrease in platelet number without differences between groups. The results obtained also showed the presence of a significant release of sP-selectin during CPB, as well as a more pronounced increase of plasma sP-selectin levels in patients undergoing hypothermic compared to normothermic CPB. A comparison of cytokine levels demonstrated a significant elevation of plasma IL-6 levels during either hypothermic or normothenmic CPB, paralleling the neutrophil rise, while no differences were observed for TNF-alpha levels. Conversely, plasma IL-1beta levels were significantly elevated during hypothermic, but not during normothermic CPB. CONCLUSIONS: Hypothermic CPB is responsible for a greater platelet activation and endothelial dysfunction than normothermic CPB, leading to more profound changes in the hemostatic and inflammatory systems, which, in turn, might be responsible for the higher incidence of postoperative complications reported during hypothermic CPB.

Repair of intramural hematoma of the ascending aorta without graft interposition.

A 68-year-old woman was admitted to hospital with a one-hour history of chest pain and syncopal episode. Transesophageal echocardiography showed an intramural aortic hematoma with cardiac tamponade. The patient underwent repair of the ascending aorta without graft interposition (resection and end-to-end anastomosis). The patient had an uneventful postoperative course and the 38-month follow-up was event-free. This case report shows that end-to-end anastomosis in patients with intramural hematoma and absence of intimal tearing, may provide good long-term results.

Myocardial infarction caused by compression of anomalous circumflex coronary artery after mitral valve replacement.

We report a case of myocardial infarction after mitral valve replacement occurring in a patient with the left cyrcumflex coronary artery arising from the right one. The patient underwent mitral valve replacement with a size 27 Carbomedics prosthesis and a tricuspidal annuloplasty was performed according to the De Vega technique. Patient died on the 20th postoperative day.

[Analysis of risk factors in patients undergoing closed heart mitral commissurotomy]. / Analisi dei fattori di rischio in pazienti sottoposti a commissurotomia mitralica a cuore chiuso.

The aim of this study was to analyse the risk factors in patients undergoing closed heart commissurotomy (CHC). From 1956 to 1978 a total of 630 patients with severe mitral stenosis underwent CHC at this Institute. The study was performed on a sample of 100 patients. Follow-up was performed using data taken from the Institute archives, questionnaires sent to the doctors in charge, telephone interviews or visits to outpatient clinics by the Institute's medical staff. The mortality rate 30 days after surgery was 2.9%. Re-CHC was necessary in 11 patients after a mean interval of 7.2 years. The overall probability of survival was 83%, 71%, 48% an 33% respectively at 10, 20, 30 and 40 years. Survival free from mitral re-operation at 10, 20, 30 and 40 years was 76%, 39%, 29% and 11% respectively. The probability of incidence for central and peripheral thromboembolism was 38%, 26%, 11% and 4% at 10, 20, 30 and 40 years. Mitral valve replacement surgery (MVR) was performed in a total of 64 patients. Operative mortality was 0.6% (1 patient). The mean duration of follow-up in patients undergoing post-CHC MVR was 10 years. The probability os survival in overall terms and free of cardiac decompensation was 79 and 53% respectively. From this study it is clear the CHC is a surgical procedure that offers excellent long-term results with a low incidence od thromboembolic events, very low costs and a good quality of life. CHC currently represents a valid alternative o mitral valve replacement in selected patients.

Return to work and quality of life measurement in coronary artery bypass grafting.

OBJECTIVE: Coronary bypass surgery (CABG) is effective in relieving angina and restoring expectation of life in patients with coronary artery disease. The aim of this work was to evaluate the effects of CABG on the quality of life (QL) and return to work (RW). Medical and non-medical variables influencing QL and RW were investigated. The results were compared with those of medically treated patients. METHODS: Five hundred fifty patients with chronic stable angina undergoing coronary angiography, were consecutively and prospectively enrolled in the study. Coronary lesions narrowing the lumen by more than 70% were considered significant. Questionnaire interviews were performed in hospital on admission and after at least 6 months follow-up. The QL interviews were based on quantitative evaluation of five conceptual dimensions: General Well-Being Schedule, Physical Symptoms Distress Index B, Sexual Satisfaction Unified Test, Social Participation and Work Performance and Satisfaction. Whether the patient had returned to work was recorded at each interview. Patients with significant coronary lesions were electively assigned to surgical (group A) or medical therapy (group B). The indications for surgical therapy were: triple-vessel disease, left main, ejection fraction (EF) less than 50%, angina resistant to medical therapy. Patients with non-significant coronary lesions, poor left ventricular function (EF < 25%) and combined valvular and coronary disease were excluded from the study. Patients scheduled for PTCA were also excluded. RESULTS: Two hundred forty-six patients were assigned to group A, 200 to group B, 26 had non-significant coronary lesions, 16 combined valve and coronary disease, 15 poor left ventricular function and 78 were scheduled for PTCA. The mean follow-up for the two groups was 38 +/- 6 months. At in-hospital admission group A patients had overall worse QL perception, while at follow-up control the improvement in QL test was statistically significant. The group A mean RW rate was statistically significant, subgroup analysis showed a higher RW rate in patients without angina, working before surgery, under 50 years old, literate and with a professional or executive employment before surgery. At follow-up group B QL perception showed a positive trend, but not statistically significant. The group B RW rate was higher than that of group A, subgroup analysis did not show statistically significant data. CONCLUSIONS: Our findings demonstrate that patients undergoing elective CABG surgery show early physical and psychological improvement. Specific rehabilitation programs can be useful in selected subgroups of patients.