Prognostic power of pre- and postoperative B-type natriuretic peptide levels in patients undergoing abdominal aortic surgery.

OBJECTIVES: The first aim of the present study was to evaluate the pre- and postoperative B-type natriuretic peptide (BNP) levels in patients undergoing surgery for repair of an infrarenal abdominal aortic aneurysm (AAA) and analyze their power as a predictor of in-hospital cardiac events. The second aim was to evaluate the association among pre- and postoperative BNP levels, postoperative patient complications, and length of hospital stay. DESIGN: Prospective observational study. SETTING: A university hospital. PARTICIPANTS: Forty-five patients undergoing elective surgery for an abdominal aortic aneurysm. INTERVENTIONS: The plasma BNP level was assessed just before surgery and then on postoperative day 1. Cardiac troponin I levels were measured postoperatively on arrival to the intensive care unit (time 0) and then 12, 48, and 72 hours later. MEASUREMENTS AND MAIN RESULTS: The preoperative BNP concentration in patients who developed an acute myocardial infarction was 209 (IQR 84-346) pg/mL compared with 74 (IQR 28-142) pg/mL in those who did not. The difference between groups was statistically significant (p = 0.04). The Spearman correlation showed that postoperative BNP levels correlated significantly with preoperative BNP levels (r = 0.73, p = 0.0001), length of hospital stay (r = 0.35, p = 0.04), and troponin I concentration at 0 hour (r = 0.42, p = 0.02), 12 hours (r = 0.51, p = 0.0052), and 48 hours (r = 0.40, p = 0.033). In contrast, preoperative BNP levels correlated with troponin I at only 12 hours (r = 0.34, p = 0.02). Postoperative BNP levels were influenced significantly by transfusions (p = 0.035) and cross-clamping times (p = 0.038). CONCLUSIONS: The present results confirm the high negative predictive value of preoperative BNP levels; and postoperative BNP levels showed a better correlation with postoperative troponin levels, blood transfusion, and postoperative cardiac events.

Prothrombin complex concentrate such as therapy and prophylaxis in factor X-deficient patient (Friuli variant).

BACKGROUND: Factor X (FX) deficiency is a serious, rare bleeding disorder, with 1 in 500 000 affected people. Hemorrhages, hematuria, epistaxis, and other bleeding complications are frequent. CASE REPORT: Now, we report a case of a well-known 77-year-old FX-deficient patient (Friuli variant, level <1%, mutation Pro(343)→Ser, exon VIII) with hypertension, chronic obstructive pulmonary disease (COPD), and chronic gastritis, admitted many times to hospital due to surgical complications after aortic abdominal aneurysm (AAA) repair. Use of prothrombin complex concentrate (PCC) such as hemostatic therapy during surgeries and prophylaxis after discharge is shown in this article. Three consecutive surgeries were considered. First, endoleak postendoprosthesis; second, AAA breakage; and third, planned surgery, a new endovascular prosthesis positioning and femur-femoral bypass. No adverse events due to PCC were found by local physicians. DISCUSSION: We discuss the methods commonly used in the treatment and prophylaxis of patients with FX deficiency to reduce hemorrhagic risk and to improve their quality of life. CONCLUSION: Waiting for specific therapeutic options for FX deficiency, currently, the best treatment is represented by PCC. Its correct use permits an improvement in life quality and a reduction in bleeding frequency in FX-deficient patients.

Wake-up test decrease shunts insertion during carotid endarterectomy under general anesthesia.

OBJECTIVE: The use of locoregional anesthesia versus general anesthesia (GE) in carotid endarterectomy (CEA) has been a debatable issue in clinical studies for the past several years. In our study, GE with wake-up tests (WUTs) during carotid cross-clamping was used instead of stump pressure (SP) to directly assess the neurological status of the patient to determine whether shunting was needed. Our study assessed the percentage of patients under light sedation and mechanically ventilated needing shunting based on WUT compared to a systolic stump pressure (SPs) cutoff value of

American College of Cardiology/American Heart Association perioperative assessment guidelines for noncardiac surgery reduces cardiologic resource utilization preserving a favourable clinical outcome.

OBJECTIVES: The American College of Cardiology (ACC) and the American Heart Association (AHA) provided perioperative evaluation and management guidelines for assessing cardiac risk in noncardiac surgery. Even if previously validated as safe and effective in risk stratification, there is often a gap between clinical practice and the recommendations of the ACC/AHA guidelines. We evaluated the impact of strict application of ACC/AHA guidelines for cardiac risk assessment of patients undergoing elective noncardiac vascular surgery in a consultant anaesthesiologist-led preoperative clinic. METHODS: One hundred and sixty-four consecutive patients who underwent elective vascular surgery after ACC/AHA guidelines implementation (from September 2004 to May 2005) were enrolled in the study and compared with a historical group of 166 patients operated from April 2002 to September 2002. Preoperative resources utilization (cardiologic consultations, non-invasive diagnostic tests, coronary angiograms, coronary revascularizations) and clinical events [all-cause death, acute myocardial infarction (AMI) and acute myocardial ischaemia] occurring within 30 days after surgical procedure were compared. RESULTS: Guidelines implementation reduced preoperative cardiologic consultations by 21% (P < 0.001) and preoperative non-invasive diagnostic testing by 11% (P = 0.01), and increased utilization of preoperative beta-blockers by 13% (P = 0.01). Preoperative coronary angiograms (2% versus 4%) and coronary revascularizations (3% versus 2%) and all-cause death (1% versus 2%), AMI (2% versus 1%) and acute myocardial ischaemia (4% versus 2%) during follow-up were similar in both groups. CONCLUSIONS: Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in a consultant anaesthesiologist-led preoperative clinic reduced preoperative resources utilization, improved medical treatment and preserved a low rate of perioperative cardiac complications.

Stent-grafting of the thoracic aorta: feasibility and early results in acute and chronic lesions.

BACKGROUND AND AIMS: Conventional surgery of the thoracic aorta is frequently associated with significant mortality and morbidity. Here we present treatment of surgical pathologies of the thoracic aorta using a less invasive endovascular approach. METHODS: From January 2000 to May 2004, 51 patients (mean age 62.7 +/- 12.8 years, 36 men) underwent endovascular repair of thoracic aortic lesions in our institution. All patients underwent computed tomography scan at discharge, 6 and 12 months and annually thereafter. Clinical follow-up was carried out by outpatient clinic visit or by telephone contact with the patients or their referring physicians. Mean follow-up was 15.8 months. RESULTS: The 30-day mortality rate was 3.8%, one death in the group of chronic (1.9%) and one in the group of acute lesion (1.9%). The survival rate in the follow-up period was 92.4% at 6 months. Computed tomography angiography confirmed exclusion of the lesion in 25 out of 27 chronic patients, whereas type I and II endoleaks were detected in two patients treated with a secondary procedure. In addition, two patients with an acute type B aortic dissection presented with early endoleaks. The overall rate of complications was 10%. No other endoleaks or deaths were observed at later follow-up. CONCLUSIONS: The early and mid-term results of endovascular stent-grafting for the treatment of chronic and acute thoracic aortic diseases showed a good outcome and low rate of complications. Stent-grafting of the thoracic aorta is still an investigational procedure that needs further validation.