Outcomes after surgical revascularization in diabetic patients.

OBJECTIVES: Patients with diabetes mellitus (DM) undergoing coronary artery bypass grafting (CABG) have been repeatedly demonstrated to have worse clinical outcomes compared to patients without DM. The objective of this study was to evaluate the impact of DM on 1-year clinical outcomes after isolated CABG. METHODS: The European DuraGraft registry included 1130 patients (44.6%) with and 1402 (55.4%) patients without DM undergoing isolated CABG. Intra-operatively, all free venous and arterial grafts were treated with an endothelial damage inhibitor. Primary end point in this analysis was the incidence of a major adverse cardiac event (MACE), a composite of all-cause death, repeat revascularization or myocardial infarction at 1 year post-CABG. To balance between differences in baseline characteristics (n = 1072 patients in each group), propensity score matching was used. Multivariable Cox proportional hazards regression was performed to identify independent predictors of MACE. RESULTS: Diabetic patients had a higher cardiovascular risk profile and EuroSCORE II with overall more comorbidities. Patients were comparable in regard to surgical techniques and completeness of revascularization. At 1 year, diabetics had a higher MACE rate {7.9% vs 5.5%, hazard ratio (HR) 1.43 [95% confidence interval (CI) 1.05-1.95], P = 0.02}, driven by increased rates of death [5.6% vs 3.5%, HR 1.61 (95% CI 1.10-2.36), P = 0.01] and myocardial infarction [2.8% vs 1.4%, HR 1.99 (95% CI 1.12-3.53) P = 0.02]. Following propensity matching, no statistically significant difference was found for MACE [7.1% vs 5.7%, HR 1.23 (95% CI 0.87-1.74) P = 0.23] or its components. Age, critical operative state, extracardiac arteriopathy, ejection fraction ≤50% and left main disease but not DM were identified as independent predictors for MACE. CONCLUSIONS: In this study, 1-year outcomes in diabetics undergoing isolated CABG were comparable to patients without DM.

The fate of patients after failed epicardial ablation of atrial fibrillation.

BACKGROUND: Much debate is still going on about the best ablation strategy-via endocardial or epicardial approach-in patients with atrial fibrillation (AF), and evidence gaps exist in current guidelines in this area. More specifically, there are no clear long-term outcome data after failed surgical AF ablation. METHODS: Since June 2008, 549 surgical AF ablation procedures through a right minithoracotomy were performed at our institution. From 2008 to 2011, a unipolar radiofrequency device was used (151 patients), whereas from 2011 to 2020 a bipolar radiofrequency device was used (398 patients). Patients were scheduled for surgery on the basis of the following criteria: recurrent episodes of paroxysmal or persistent lone AF refractory to maximally tolerated antiarrhythmic drug dosing and at least one failed cardioversion attempt. Besides the recommended follow-up by the local cardiologist, starting from 2021, surviving patients were asked to undergo assessment of left ventricular function and to complete a questionnaire addressing quality of life and predisposing factors for recurrent AF. RESULTS: At a mean follow-up of 77 months, the rate of AF recurrence was 20.7% (n = 114). On multivariate analysis, impaired left ventricular ejection fraction (58 patients, 51%, p = 0.002), worsening of European Heart Rhythm Association (EHRA) symptom class (37 patients, 32%, p = 0.003) and cognitive decline or depression (23 patients, 20%, p = 0.023) during follow-up were found to be significantly associated with AF recurrence. CONCLUSIONS: Surgical AF ablation through a right minithoracotomy is safe, but a better outcome could be achieved using a hybrid approach. Patients after initial failed surgical AF ablation show worsening of cardiac function, clinical status and quality of life at follow-up compared to patients with successful AF ablation.

Novel biomarkers in cardiovascular surgery.

Cardiovascular disease includes health problems related to the heart, arteries and veins and is a significant healthcare problem worldwide. Cardiovascular disease may be acute or chronic and relapses are frequent. Biomarkers involved in this field may help clinicians and surgeons in diagnosis and adequate decision making. Relevant articles searched in the following databases Medline, Scopus, ScienceDirect, were retrieved and analysed. Several biomarkers have been identified and we analyzed those of most importance from a clinical and surgical point of view. Biomarkers can better identify high-risk individuals, facilitate follow-up process, provide information regarding prognosis and better tailor the most appropriate surgical treatment.

Computational fluid dynamics of a novel perfusion strategy during hybrid thoracic aortic repair.

BACKGROUND AND AIM: To mitigate the risk of perioperative neurological complications during frozen elephant trunk procedures, we aimed to computationally evaluate the effects of direct cerebral perfusion strategy through a left carotid-subclavian bypass on hemodynamics in a patient-specific thoracic aorta model. METHODS: Between July 2016 and March 2019, 11 consecutive patients underwent frozen elephant trunk operation using the left carotid-subclavian bypass with a side graft anastomosis and right-axillary cannulation for systemic and brain perfusion. A multiscale model realized coupling three-dimensional computational fluid dynamics was developed and validated with in vivo data. Model comparison with direct antegrade cannulation of all epiaortic vessels was performed. Wall shear stress, wall shear stress spatial gradient, and localized normalized helicity were selected as hemodynamic indicators. Four cerebral perfusion flows were tested (6 to 15 mL/kg/min). RESULTS: Direct cerebral perfusion of the left subclavian bypass resulted in higher flow rates with augmented speeds in all epiaortic vessels in comparison with traditional perfusion model. At the level of the left vertebral artery (LVA), a speed of 22.5 vs 21 mL/min and mean velocity of 3.07 vs 2.93 cm/s were registered, respectively. With a cerebral perfusion flow of 15 mL/kg, lower LVA wall shear stress (1.596 vs 2.030 N/m2 ), and wall shear stress gradient (1445 vs 5882 N/m3 ) were observed. A less disturbed flow considering the localized normalized helicity was documented. No patients experienced neurological/spinal cord damages. CONCLUSIONS: Direct perfusion of a left carotid bypass proved to be cerebroprotective, resulting in a more physiological and stable anterior and posterior cerebral perfusion.

Prior Percutaneous Coronary Intervention and Mortality in Patients Undergoing Surgical Myocardial Revascularization: Results From the E-CABG (European Multicenter Study on Coronary Artery Bypass Grafting) With a Systematic Review and Meta-Analysis.

BACKGROUND: The clinical impact of prior percutaneous coronary intervention (PCI) in patients requiring coronary artery bypass grafting (CABG) remains unsettled. We sought to determine whether prior PCI is associated with adverse outcome after CABG. METHODS AND RESULTS: Data from the prospective E-CABG (European Multicenter Study on Coronary Artery Bypass Grafting) conducted between January 2015 and March 2016 at 16 European centres were analyzed using propensity weighted methodology to adjust for confounding. A parallel systematic review/meta-analysis (MEDLINE, Embase, SCOPUS, and Cochrane Library) through September 2017 was accomplished. Of a total of 3641 adult patients included in the E-CABG study, 685 (19%) patients had a history of PCI. At multivariable level, prior PCI was not associated with an increased hospital mortality in both unweighted and weighted patient groups (odds ratio, 0.73; 95% confidence interval, 0.29-1.38; P=0.33 and odds ratio, 0.90; 95% confidence interval, 0.39-2.08; P=0.81, respectively). Subgroup analyses confirmed that prior PCI had no impact on hospital mortality and morbidity, including reexploration for bleeding, blood transfusion, hospital resource use, and neurological, renal, and cardiac complications. The systematic review provided a total of 71 366 individuals and showed a trend toward higher in-hospital/30-day mortality (adjusted odds ratio, 1.30; 95% confidence interval, 0.99-1.70; I2=43.1%) in patients with prior PCI. CONCLUSIONS: Our prospective multicenter study showed that prior PCI was not associated with an increased risk of mortality or other adverse outcomes in patients undergoing CABG. In light of a trend toward increased mortality observed in the meta-analysis, further studies are needed to ascertain the prognostic impact of prior PCI in the outcome after CABG. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02319083.

Body Mass Index and Mortality Among Adults Undergoing Cardiac Surgery: A Nationwide Study With a Systematic Review and Meta-Analysis.

BACKGROUND: In an apparent paradox, morbidity and mortality are lower in obese patients undergoing cardiac surgery, although the nature of this association is unclear. We sought to determine whether the obesity paradox observed in cardiac surgery is attributable to reverse epidemiology, bias, or confounding. METHODS: Data from the National Adult Cardiac Surgery registry for all cardiac surgical procedures performed between April 2002 and March 2013 were extracted. A parallel systematic review and meta-analysis (MEDLINE, Embase, SCOPUS, Cochrane Library) through June 2015 were also accomplished. Exposure of interest was body mass index categorized into 6 groups according to the World Health Organization classification. RESULTS: A total of 401 227 adult patients in the cohort study and 557 720 patients in the systematic review were included. A U-shaped association between mortality and body mass index classes was observed in both studies, with lower mortality in overweight (adjusted odds ratio, 0.79; 95% confidence interval, 0.76-0.83) and obese class I and II (odds ratio, 0.81; 95% confidence interval, 0.76-0.86; and odds ratio, 0.83; 95% confidence interval, 0.74-0.94) patients relative to normal-weight patients and increased mortality in underweight individuals (odds ratio, 1.51; 95% confidence interval, 1.41-1.62). In the cohort study, a U-shaped relationship was observed for stroke and low cardiac output syndrome but not for renal replacement therapy or deep sternal wound infection. Counter to the reverse epidemiology hypotheses, the protective effects of obesity were less in patients with severe chronic renal, lung, or cardiac disease and greater in older patients and in those with complications of obesity, including the metabolic syndrome and atherosclerosis. Adjustments for important confounders did not alter our results. CONCLUSIONS: Obesity is associated with lower risks after cardiac surgery, with consistent effects noted in multiple analyses attempting to address residual confounding and reverse causation.

Platelet-rich plasma inside the sternotomy wound reduces the incidence of sternal wound infections.

Despite the large choice of wide-spectrum antibiotic therapy, deep sternal wound infection (DSWI) following cardiac surgery is a life-threatening complication worldwide. This study evaluated that the use of platelet-rich plasma (PRP) applied inside the sternotomy wound would reduce the effect of sternal wound infections, both superficial and deep. Between January 2007 and January 2012, 1093 consecutive patients underwent cardiac surgery through median sternotomy. Patients were divided into two groups. Group B, the study group, included those who received the PRP applied inside the sternotomy wound before closure. Group A, the control group, included patients who received a median sternotomy but without the application of PRP. Antibiotic prophylaxis remained unchanged across the study and between the two groups. Occurrence of DSWI was significantly higher in group A than in group B [10 of 671 (1·5%) versus 1 of 422 (0·20%), P = 0·043]. Also, superficial sternal wound infections (SSWIs) were significantly higher in group A than in group B [19 of 671 (2·8%) versus 2 of 422 (0·5%), P = 0·006]. The use of PRP can significantly reduce the occurrence of DSWI and SSWI in cardiac surgery.

Resistance to secondary thrombosis of the On-X mitral prosthesis.

A 60-year-old man underwent aortic and mitral valve replacement with mechanical On-X prostheses, plus tricuspid annuloplasty ring and maze radiofrequency ablation. Two years later, he was admitted to hospital with severe orthopnea and hemolysis. Echocardiography revealed a blocked prosthetic mitral leaflet due to interference of the preserved subvalvular apparatus. Intraoperatively, one leaflet was found to be blocked by the native mitral apparatus, but no thrombus and/or pannus was present. Although, despite an abnormal blood flow, the On-X prosthesis is resistant to secondary thrombosis, even under adverse hemodynamic conditions, interference of the valve with cardiac structures remains a possibility.

Leukocyte filtration improves pulmonary function and reduces the need for postoperative non-invasive ventilation.

OBJECTIVES: Leukocyte depletion (LD) has been reported to reduce inflammatory damage during cardiopulmonary bypass (CPB). We evaluated the role of LD in pulmonary function and inflammatory response. METHODS: Seventy consecutive CABG patients were randomized (1:1) to receive LD on both arterial and cardioplegia lines (Filters) or standard arterial filters (Controls) during CPB. Estimates of pulmonary function, inflammatory and anti-inflammatory cytokines were collected pre-, intra- and postoperatively. RESULTS: Hospital mortality, intensive care and in-hospital lengths of stay were similar. Although duration of ventilation and incidence of pneumonia were comparable, leukodepleted patients showed higher PaO2/FiO2 (p-between groups = 0.005; ICU arrival p = 0.023; 24 hours p = 0.039; 48 hours p<0.001) and lower need for postoperative non-invasive ventilation (NIV), (p = 0.029). Moreover, Filters showed lower inflammatory burst at 24 hours (IL-6 p<0.001; IL-8 p = 0.002) and 48 hours (IL-6 p = 0.015). This was associated with a lower release of the anti-inflammatory IL-10 (p-between groups = 0.030; ICU admission p = 0.002; 24 hours p = 0.003). Furthermore, IL-2 concentration proved higher in Filters (p-between groups = 0.013; ICU arrival p = 0.029; 24 hours p = 0.040; 48 hours p = 0.021) in association with lower leukocyte and platelet counts at ICU admission. CONCLUSIONS: LD resulted in lower inflammatory burst and less need for release of anti-inflammatory cytokines. Although hospital outcomes were similar in terms of mortality and length of stay, improvements in pulmonary function and reduced need for postoperative NIV support the use of LD.

Intra-aortic balloon pumping recruits graft flow reserve by lowering coronary resistances.

BACKGROUND: The intra-aortic balloon pump (IABP) is used worldwide as an anti-ischemic strategy and to reduce myocardial workload. However, whether IABP augments coronary flow after coronary bypass via a passive increase in diastolic pressure or an active response of the coronary bed remains uncertain. METHODS: We analyzed transit-time flow measurements and the contemporary changes in coronary resistances obtained during 1:1 IABP and during its cessation in 144 consecutive patients receiving prophylactic IABP before isolated coronary artery bypass grafting (n=340 graft segments). RESULTS: Normally functioning grafts showed lower coronary resistances, greater percentage decrease in resistance, and greater increases in average maximum diastolic and mean flow during 1:1 IABP compared with IABP cessation (P<.001). Arterial and sequential saphenous vein grafts showed better flowmetry and greater reductions in coronary resistances compared with single venous grafts. Accordingly, graft flow reserve (defined as mean flow during 1:1 IABP/mean flow with IABP off) was recruited (graft flow reserve >1) during 1:1 IABP in all normally functioning grafts, with higher values in single arterial or sequential saphenous vein grafts than in single venous grafts (both P<.001). Coronary resistances were higher in 7 failed grafts versus normal-functioning grafts at baseline; these did not decrease during 1:1 IABP and showed worse transit-time flow results. CONCLUSIONS: IABP recruits graft flow reserve by lowering coronary resistance in functioning grafts. Arterial and sequential venous grafts showed greater reduction in coronary resistance compared with single saphenous grafts.

Unexpected embolization of Teflon pledget in the left main stem during: a Bentall operation.

We report the case of an 83-year-old man in whom acute left ventricular failure with ventricular arrhythmic storm developed during a Bentall operation. During re-exploration of the annular and coronary ostial anastomoses, no abnormality was seen, and none of the common sequelae of aortic root replacement was evident. The application of retrograde cardioplegia yielded a Teflon pledget that had migrated into the distal part of the left main stem. The pledget was removed, the anastomoses were reestablished, and the patient recovered uneventfully. This case suggests that left ostial anastomosis re-exploration should be carefully considered when no other cause of coronary insufficiency is obvious, and that retrograde cardioplegia may be useful to detect embolization in the left coronary system.

Preoperative statins improve recovery of renal function but not by an anti-inflammatory effect: observational study in 69 elderly patients undergoing cardiac surgery.

BACKGROUND: Older subjects, including those with normal renal function, have an increased risk of acute kidney injury. Preoperative statin therapy has been reported to improve renal outcome after cardiac surgery and to reduce inflammatory response to cardiopulmonary bypass. No study has hitherto evaluated whether the positive effect of pretreatment with statins on postoperative renal outcome is due to their positive effect on inflammatory burst in elderly patients undergoing myocardial revascularization using cardiopulmonary bypass. METHODS: Sixty-nine consecutive elderly patients to undergo isolated coronary artery bypass were enrolled and divided in two groups according to preoperative statin therapy (statin group n = 39) or not (no-statin group n = 30). Primary end-points of this study were the incidence of postoperative acute kidney injury defined by Acute Kidney Injury Network (AKIN) criteria, of acute renal failure needing renal replacement therapy, and the rate of complete recovery of kidney function. Secondary outcomes were perioperative changes of inflammatory and anti-inflammatory cytokines (IL-1ß, IL-2, IL-6, IL-8, IL-10 and TNF-α serum level). RESULTS: Incidence of acute kidney injury was similar between the two groups within 2 days after surgery (statin group 18/30 vs. no-statin group 18/39 P = 0.25). However, statin patients showed significantly higher glomerular filtration rate at 10th postoperative day than no-statin patients (statin group 80 ± 31.1 ml/min vs. no-statin group 59.2 ± 29.5 ml/min, P = 0.006). No significant difference in cytokine levels was observed, except for a higher IL-10 release in no-statin group at 24 h after surgery (statin group 130.22 ± 174.37 pg/ml vs. no-statin group 273.422 ± 351.52 pg/ml, P = 0.03). CONCLUSIONS: In elderly patients, preoperative statin treatment allows better recovery of renal function following cardiopulmonary bypass but not by an anti-inflammatory effect.

Leukocyte depletion during extracorporeal circulation allows better organ protection but does not change hospital outcomes.

BACKGROUND: Leukocyte filtration has been reported to reduce inflammatory damage during cardiopulmonary bypass. We evaluated the role of leukocyte filtration on hospital outcome and postoperative morbidity. METHODS: Eighty-two consecutive patients who underwent isolated coronary artery bypass grafting were randomly assigned (1:1) to receive leukocyte filters on both arterial and cardioplegia lines or standard arterial filters during cardiopulmonary bypass. Hospital outcome, postoperative markers of morbidity, and biochemical assays were compared. Data were collected preoperatively, intraoperatively, and postoperatively. Costs for patients receiving intraoperative leukofiltration were compared with control patients getting standard arterial filters. RESULTS: Hospital mortality and intensive care unit and hospital length of stay were similar. Although duration of ventilation and incidence of pneumonia were comparable, leukocyte-depleted patients showed a higher ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (p = 0.008) and lower need for postoperative noninvasive ventilation (p = 0.041). Control patients showed higher need for continuous furosemide infusion (p = 0.013) and for renal replacement therapy (p = 0.014), in association with higher serum creatinine (p = 0.038) and blood urea (p = 0.18) and lower glomerular filtration rate (p = 0.038). Leukocyte-depleted patients required lower doses of inotropic agents (p = 0.56), whereas troponin I leakage and incidence of postoperative atrial fibrillation were comparable. No differences were found in terms of postoperative cerebral dysfunction or neutrophil and platelet counts, as well as postoperative bleeding and need for transfusions. Finally, leukodepletion proved significantly cost-beneficial, with a 37% cost reduction. CONCLUSIONS: Although hospital outcomes were similar in terms of mortality and length of stay, the improvements in pulmonary, renal, and myocardial function, in association with the cost benefit, justify the use of leukocyte-depletion filters in the clinical practice.

Transmitral approach to monopolar radiofrequency ablation of inferior papillary muscle for refractory ischemic ventricular tachycardia.

Despite the proven effectiveness of antiarrhythmic drugs and automated implantable cardioverter-defibrillators for ischemic ventricular arrhythmias, ablative procedures still play a major role. Herein, we report the cases of 2 patients who had malignant ventricular arrhythmias secondary to ischemic heart disease. The arrhythmias were treated intraoperatively by means of surgical ablation through a transmitral approach.