Do Flow and Pulsatility Index within the Accepted Ranges Predict Long-Term Outcomes after Coronary Artery Bypass Grafting?

BACKGROUND: Transit-time flow measurement (TTFM) is the gold standard for intraoperative detection of graft failure. Several reports show that TTFM and distal coronary bed quality (DCBQ) may also be useful for midterm detection of graft failure. Nonetheless, there are no data regarding their predictive role on long-term outcomes. METHODS: Patients with three-vessel disease who underwent isolated coronary artery bypass grafting (CABG) in 2006 and received at least one graft to the left anterior descending artery (LAD) or to the first obtuse marginal (OM1) or posterior descending artery (PDA) were included. Baseline characteristics, mean graft flow, pulsatility index, and subjective impression of DCBQ for each coronary territory were collected. Long-term cardiovascular (CV) and overall survival, operative mortality, and new percutaneous coronary intervention (PCI) were evaluated. RESULTS: A total of 177 patients underwent isolated CABG. The OM1 was grafted in 131 patients, the LAD in 169 patients, and the PDA in 100 patients. Neither DQCB nor TTFM were predictors for new PCI. Independent predictors for overall survival were age, previous acute myocardial infarction (AMI), and DQCB of OM1 (odds ratio [OR] = 2.97; 95% confidence interval [CI]: 1.15-7.71). Age, previous AMI, and DCBQ of OM1 (OR = 2.5; 95% CI: 1.39-4.81) were independent predictors for CV survival. CONCLUSIONS: TTFM on patients with functioning grafts does not predict long-term survival or performance of new PCI. Subjective evaluation of distal coronary bed, especially of the OM1, has a strong impact on long-term outcomes.

21. Sustitución valvular aórtica: ¿prótesis biológica o mecánica? Estudio comparativo de sobrevida a largo plazo

Antecedentes: la elección del tipo de prótesis valvular en los pacientes sometidos a sustitución valvular aórtica (SVA) es de gran relevancia. Buscamos evaluar si es el tipo de prótesis valvular aórtica un predictor de mortalidad operatoria y sobrevida a largo plazo. Objetivo: el objetivo del trabajo es comparar el impacto de la colocación de prótesis valvulares mecánicas y biológicas en la mortalidad operatoria y sobrevida a largo plazo. Material y método: se identificaron en la base de datos de la institución aquellos pacientes sometidos a SVA entre enero de 2006 y diciembre de 2016. Se extrajeron y compararon las variables demográficas, intraoperatorias y posoperatorias. Se compararon las mismas entre aquellos que recibieron bioprótesis y prótesis mecánica mediante chi cuadrado (variables categóricas) y test de t (variables continuas). Se utilizó Kaplan-Meier y log-rank test para comparación de sobrevida. Mediante regresión logística y Cox se identificó el valor predictivo del tipo protésico en los resultados. Resultados: en dicho período se operaron 1.826 pacientes por SVA. Recibieron bioprótesis 1.450 pacientes (78,3%). Estos eran de mayor edad (72,7±8,5 versus 53,7±11,9, p<0,05), con mayor incidencia de CFNYHA III-IV, mayor requerimiento de revascularización asociada y mayor Euroscore (10,5±0,1 versus 7,7±0,1, p<0,05). Pacientes con prótesis mecánica presentaban mayor incidencia de tabaquismo, endocarditis y requerimiento de sustitución de aorta ascendente. No hubo diferencias en las variables intraoperatorias a excepción de menor tamaño de prótesis en el grupo de bioprótesis (22,1±2,0 versus 23,1±2,3, p<0,05). Pacientes con bioprótesis presentaron mayor incidencia de FA, accidente isquémico transitorio y requerimiento de inotrópicos. No hubo diferencias significativas en la mortalidad operatoria. A diez años de seguimiento, el tipo protésico no fue predictor de sobrevida a largo plazo. Conclusiones: el tipo de prótesis valvular aórtica no es predictor de mortalidad operatoria ni sobrevida a largo plazo.

Early surgery after angiography in patients scheduled for valve replacement.

Background There are limited data regarding the risks of cardiac surgery early after coronary angiography in patients scheduled for isolated aortic and/or mitral valve replacement. Our aim was to evaluate the risk of early surgery after coronary angiography in these patients. Methods We retrospectively analyzed data of 1044 patients who underwent isolated aortic and/or mitral valve replacement from 2006 to 2014. Baseline, operative, and postoperative variables were collected. The patients were divided into 3 groups based on the interval between coronary angiography and surgery: ≤3 days ( n = 216), 4-7 days ( n = 109), and ≥8 days ( n = 719). We evaluated hospital mortality and postoperative acute kidney injury. Subgroup analysis was performed according to preoperative creatinine clearance. Results Postoperative creatinine clearance was lower in patients who underwent surgery ≤3 days after coronary angiography (63.57 ± 38.52 mL min-1) compared to ≥8 days after coronary angiography (74.56 ± 54.25 mL min-1, p = 0.015). Patients who underwent surgery ≤3 days after coronary angiography had higher hospital mortality when preoperative creatinine clearance was ≤60 mL min-1 (12% vs. 4% for creatinine clearance ≤and >60 mL min-1, respectively; p = 0.039). Predictors of hospital mortality were New York Heart Association class and postoperative creatinine clearance. Conclusion Hospital mortality was higher in patients with decreased preoperative renal function who underwent surgery within the first 3 days after coronary angiography. Delaying surgery in this subgroup of patients could be a good strategy.

¿Es seguro realizar la cirugía de revascularización miocárdica precozmente luego del cateterismo? / Is it safe to perform coronary artery bypass surgery early after catheterization?

Fundamentos y objetivos: existen reportes que vinculan la cirugía coronaria precoz luego de la coronariografía a falla renal aguda posoperatoria. Sin embargo, no existe evidencia concluyente acerca de la relación directa entre cirugía coronaria precoz y mortalidad posoperatoria. Nuestro objetivo fue evaluar la relación entre la cirugía coronaria precoz (dentro de las 24 horas de la coronariografía) y la evolución posoperatoria. Método: se seleccionaron pacientes sometidos a cirugía de revascularización coronaria aislada operados entre enero de 2006 y diciembre de 2014. Comparamos las características demográficas entre los pacientes sometidos a cirugía precoz versus no precoz. Evaluamos las siguientes variables evolutivas: mortalidad operatoria, tiempo de asistencia ventilatoria, uso de inotrópicos, tiempo de internación en cuidados intensivos y requerimiento de hemodiálisis. Resultados: se incluyeron un total de 2.039 pacientes (cirugía precoz en 382). Aquellos operados dentro de las 24 horas eran más jóvenes, con menor proporción de mujeres y con mayor incidencia de ángor inestable e inestabilidad hemodinámica. La cirugía precoz resultó ser predictora de mortalidad operatoria solo en aquellos pacientes con creatinina preoperatoria ³ 1,2 mg/dl (OR=2,81; IC 95% 1,03-7,68). No encontramos asociación con el resto de las variables evolutivas a excepción del mayor uso prolongado de inotrópicos/vasopresores en pacientes sometidos a cirugía precoz. Conclusiones: la cirugía de revascularización aislada realizada precozmente luego de la coronariografía en pacientes con cifras normales de creatinina (menor a 1,2 mg/dl) puede ser realizada de forma segura y no se asocia a mayor mortalidad operatoria.

Objectives: cardiac surgery performed early after coronariography has been associated with acute renal failure. Nonetheless, there is no solid evidence regarding its association with operative mortality. Our objective was to evaluate the association between early coronary surgery and postoperative outcomes. Methods: patients who underwent isolated coronary artery revascularization between January 2006 and December 2014 were selected from our database. Baseline characteristics were compared between patients who underwent surgery within 24h of coronariography and those in whom surgery was performed afterwards. The following postoperative outcomes were extracted and compared between both groups: operative mortality, time of assisted ventilation, inotrope use, stay in intensive care unit, stay in intensive care unit, and hemodyalisis requirement. Results: we included 2039 patients (early surgery in 382 patients). Patients operated early were younger, less frequently female and with higher incidence of unstable angina and hemodynamic instability. Early surgery was found to be an independent predictor for operative mortality only in patients with preoperative creatinine ³ 1.2 mg/dl (OR=2.81; IC 95% 1.03-7.68). No association was found between early surgery and other postoperative outcomes with the exception of greater use of inotropes. Conclusions: isolated coronary artery revascularization may be safely performed within 24 h of coronariography and does not increase operative mortality in patients with normal preoperative levels of creatinine.

Is patient-prosthesis mismatch a predictor of survival or a surrogate marker of co-morbidities in cardiac surgery?

BACKGROUND: Patient-prosthesis mismatch (PPM) has ignited much debate and no definite conclusions have been drawn on the outcome of these patients. Therefore, additional large studies with long-term follow-up are required to help the cardiologist and surgeon outline the best therapeutic strategy for patients with high risk for PPM. METHODS: Patients who underwent aortic valve replacement (AVR) from 2000 to 2013 were identified. Baseline and operative data was extracted and indexed effective orifice area calculated for each patient. The presence of PPM was defined in those patients with an iEOA ≤ 0.85 cm(2)/m(2). Regression analyses were performed to determine the association of PPM with operative mortality, post-operative complications and survival. Predictors for PPM were evaluated based on clinical and operative data. RESULTS: From 2023 patients who underwent AVR, PPM was present in 64.6%. These patients had increased age, more coronary artery bypass procedures, increased risk of diabetes, hypertension, higher creatinine values and higher Euroscore. Age, body surface area, prosthesis type and size were found to be predictors of mismatch. Operative mortality (8.1% vs 5.7%, p = 0.05), stroke (3.9% vs 2.4, p = 0.02) and acute kidney injury (47.6% vs 35.1%, p =< 0 .001) were more frequent in patients with PPM and mean 10-year survival was reduced (6.6 years, 95% CI: 6.3-6.8 vs 7.3, 95% CI: 6.9-7.2, p < 0.001). After adjusting for confounders, PPM was not found to be associated to either adverse outcome or survival. CONCLUSIONS: Patients with PPM have worse operative mortality, post-operative complications and survival mainly due to the fact that they represent a higher risk population based on age and co-morbidities.