Atrial fibrillation - Can HbA1c levels really predict the risk?

BACKGROUND: Diabetes is associated with higher mortality and worse post-operative outcomes in patients undergoing coronary artery bypass grafting and HbA1c levels have consistently been reported to be associated with adverse post-operative outcomes. However, the role of HbA1c still remains unclear with regards to the occurrence of atrial fibrillation. METHOD: Data for the patients undergoing off-pump coronary artery bypass grafting was analysed in a retrospective fashion. Patients were divided into-those with HbA1c < 6.5% and those with HbA1c ≥ 6.5% and the incidence of atrial fibrillation observed in these two groups. We also compared patient who developed atrial fibrillation in the post-operative period and compared them with those who did not. RESULTS: Of the 5259 patients included in the study HbA1c was <6.5 in 2808 (53.4%) patients and was ≥6.5 in 2451 (46.6%) patients; 623 (11.8%) patients in our study developed atrial fibrillation. Onset of atrial fibrillation in the post-operative period was seen most commonly 235 (38.3%) on between 24 and 48 h after the operation with more than half of them 338 (54.2%) occurring within the first 48 h. On multivariate analysis, HbA1c was not a risk factor for atrial fibrillation (odd's ratio 1.144, 95% confidence interval 0.967-1.354). Only increased age (odd's ratio 1.08; 95% confidence interval 1.069-1.091); EuroSCORE (odd's ratio 1.073; 95% confidence interval 1.048-1.099); history of recent MI (odd's ratio 0.768; 95% confidence interval 0.606-0.971) and peripheral vascular disease (odd's ratio 1.667; 95% confidence interval 1.091-2.517) were found to be independently associated with increased risk of atrial fibrillation in the post-operative period. CONCLUSIONS: After adjusting for confounders HbA1c levels do not independently predict risk of atrial fibrillation after off-pump coronary artery bypass grafting.

Benefits of Using High-Volume-Low-Pressure Tracheal Tube in Children Undergoing Congenital Cardiac Surgery: Evidence From a Prospective Randomized Study.

BACKGROUND: In the past 2 decades, usage of high-volume-low-pressure microcuffed tracheal tubes in smaller children has increased. However, there is paucity of evidence of its usage in smaller children undergoing congenital cardiac surgery. The aim of this study was to assess if microcuff endotracheal tubes in neonates and younger children undergoing congenital cardiac surgery is associated with better outcomes than uncuffed tubes. METHODS: We carried out this single-center, prospective, randomized study between June and November 2016. Eighty patients were randomized into those receiving microcuff tracheal tubes and conventional uncuffed tubes. Primary outcome was stridor postextubation. Secondary outcomes measured included number of tube changes, volume of anesthetic gases required, and cost incurred. RESULTS: The 2 groups were comparable in terms of baseline characteristics and duration of intubation. Incidence of stridor was significantly higher in conventional uncuffed tubes (12 [30%] vs 4 [10%]; P = .04) and so was the number of tube changes required (17/40 [42.5%] vs 2/40 [5%]; P ≤ .001). Tube change was associated with more than 3-fold risk of stridor (odds ratio = 3.92; 95% confidence interval = 1.23-12.43). Isoflurane (29.14 ± 7.01 mL vs19.2 ± 4.81 mL; P < .0001) and oxygen flow requirement ( P < .0001) and the resultant cost (7.46 ± 1.4 vs 5.77 ± 1.2 US$; P < .0001) were all significantly higher in the conventional uncuffed group. CONCLUSION: Microcuff pediatric tracheal tube is associated with significantly lower incidence of stridor, tube changes, and anesthetic gas requirement. This leads to significant cost reduction that offsets the higher costs associated with usage of a microcuff tracheal tube.

Preoperative Glycosylated Hemoglobin: A Risk Factor for Patients Undergoing Coronary Artery Bypass.

BACKGROUND: The prevalence of diabetes in the population of patients presenting with coronary artery disease continues to rise. The aim of this study was to assess whether high Glycosylated hemoglobin (HbA1c) was associated with adverse outcomes in patients undergoing elective coronary artery bypass grafting. METHODS: A retrospective observational study on prospectively collected data in 4,678 patients undergoing elective, isolated coronary artery bypass graft procedures in a single institution over a 4-year period was conducted. Patients were grouped into those with adequate preoperative control of hyperglycemia (HbA1c <6.5%) and those with suboptimal control (HbA1c ≥6.5%). Multivariable analysis using HbA1c as a binary independent variable was undertaken in the whole group. A subgroup analysis in diabetic patients and in nondiabetic patients was performed. The effect of HbA1c on outcomes at higher levels (HbA1c ≥8.0% and HbA1c ≥9.0%) was also assessed. RESULTS: A total of 4,678 patients (mean age, 58.8; male, 4,254) were included in the study. HbA1c was less than 6.5% in 2,476 (52.93%) patients and 6.5% or higher in 2,202 (47.07%) patients. On multivariate analysis, there was no difference in mortality rates between the groups (odds ratio, 1.36; 95% confidence interval [CI], 0.95 to 1.953; p = 0.08). Overall, an HbA1c of 6.5% or higher was an independent risk factor for respiratory complications (odds ratio, 1.05; 95% CI, 1.008 to 4.631; p = 0.01) and sternal dehiscence (odds ratio, 2.161; 95% CI, 1.008 to 4.63; p = 0.04). An association between HbA1c levels and adverse outcomes was not seen in nondiabetic patients. No additional adverse postoperative complications were seen with increasing HbA1c levels (HbA1c ≥8.0% and HbA1c ≥9.0%). CONCLUSIONS: An HbA1c level of 6.5% or higher in patients presenting for coronary artery bypass grafting was associated with a significant increase in the incidence of deep sternal wound infection and respiratory complications.