Analysis of risk factors for in-hospital mortality in 177 patients who underwent isolated coronary bypass grafting and received intra aortic balloon pump.

BACKGROUND AND AIM OF THE STUDY: Intra-aortic balloon pump (IABP) is the most commonly used device for circulatory support of patients with heart disease. The aim of this study evaluated the risk factors for outcomes of patients who underwent isolated coronary bypass grafting and received IABP. METHODS: One hundred-seventy-seven patients underwent isolated coronary bypass grafting and received intraoperative IABP. All perioperative data were recorded. The primary end-point was in-hospital mortality, while the secondary end-points were the length of intensive care unit (ICU) stay and hospital length of stay (LOS). RESULTS: In-hospital mortality was 5.6% (10 patients). Multivariable logistic regression analysis showed that the risk factors for in-hospital mortality were preoperative plasma creatinine level and cardiopulmonary bypass (CPB) time (for both p < .05). Multivariable linear regression analysis showed that postoperative acute kidney injury (AKI), immediate plasma troponin after operation, numbers of grafts, and CPB time were predicted the hospital LOS, while postoperative AKI, preoperative left ventricular ejection fraction, and immediate plasma troponin after operation were predicted the lengths of ICU stay. CONCLUSION: Our analysis showed that increased preoperative plasma creatinine, postoperative renal dysfunction, and CPB time negatively affected the outcomes of patients who received intraoperative IABP insertion.

Antegrade and Retrograde Cerebral Perfusion During Acute Type A Aortic Dissection Repair in 290 Patients.

AIM: Hypothermia and selective brain perfusion is used for brain protection during an acute type A aortic dissection (ATAAD) correction. We compared the outcomes between antegrade and retrograde cerebral perfusion techniques after ATAAD surgery. METHOD: Between January 1995 and August 2017, 290 patients underwent ATAAD repair under deep hypothermic circulatory arrest/retrograde cerebral perfusion (DHCA/RCP) in 173 patients and moderate hypothermic circulatory arrest/antegrade cerebral perfusion (MHCA/ACP) in 117 patients. Outcomes of interest were: 30-day mortality, new-onset postoperative neurological complications, and length of intensive care unit (ICU) and in-hospital stays. RESULTS: No differences were observed between the preoperative details of both groups (p>0.05). Thirty-day (30-day) mortality did not differ between groups (RCP vs ACP, 22% vs 21.4%; p=0.90). New-onset postoperative permanent neurological dysfunctions and coma was similar in two group in 6.9% versus 10.3% of patients and 3.8% versus 6.8% patients of patients, respectively (p=0.69). The incidence of 30-day mortality and new postoperative neurological complications were similar in the RCP and ACP groups (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.39-2.83 [p=0.91] and OR, 1.7; 95% CI, 0.87-3.23 [p=0.11], respectively). There was no difference between length of stay in the ICU and overall stay in hospital between the RCP and ACP groups (p=0.31 and p=0.14, respectively). No difference in survival rate was observed between the RCP and ACP groups (hazard ratio, 1.2; 95% CI, 0.76-2.01 [p=0.39]). CONCLUSIONS: Thirty-day (30-day) mortality rate, new-onset postoperative neurological dysfunctions, ICU stay, and in-hospital stay did not differ between the MHCA/ACP and DHCA/RCP groups after ATAAD correction. Although the rates of 30-day mortality and postoperative neurological complications were high after ATAAD repair, ACP had no advantages over the RCP technique.

Current challenges in the diagnosis and treatment of cardiac myxoma.

Cardiac myxoma is the most common benign cardiac tumor. It is located in the left atrium and typically arises from the foramen ovale in approximately 75% of the general patient population, in the right atrium in 23%, and in the ventricles in only 2%. Symptoms depend on its size, mobility, and relation to surrounding cardiac structures. Neurological complications resulting from cardiac myxoma are seen in 20% to 25% of patients. Molecular genetic studies show that the condition can be inherited in Carney complex due to mutations of the PRKAR1A gene. Cardiac myxoma resection is a cardiac surgery with a low complication rate and the 30­day mortality of up to 10%. Recurrence may be observed months or years after surgery, and its rate is approximately 5%. Long­term follow­up with transthoracic echocardiography is needed in all patients after tumor resection. This review summarizes the available data on cardiac myxoma and, in particular, issues relating to diagnosis and treatment.

Tying the knot: An uncommon complication.

Cardiothoracic procedures require continuous hemodynamic monitoring and a fair proportion of these require the insertion of a pulmonary artery catheter, known also as Swan-Ganz catheter. Given, however, the invasive nature of these procedures, unforeseen complications may ensue. Early recognition and appropriate handling are essential to minimize adverse outcomes.

Multiple Giant Coronary Artery Aneurysms Surgically Treated with Bypass Grafting: A Challenging Rarity.

Coronary artery aneurysms are encountered in daily cardiology practise but multiple giant-sized coronary artery aneurysms are extremely rare. We present an illustrative case of multiple giant aneurysms located throughout the coronary system (left main stem and all left, right, and circumflex branches) in a 57-year-old male with acute coronary syndrome. The case was managed successfully with on-pump quadruple coronary artery bypass grafting. To our knowledge, few cases of multiple giant aneurysms in all coronary vessels have been reported.

Clinical presentation and treatment of cardiac myxoma in 153 patients.

Cardiac myxoma (CM) is the most common benign cardiac tumor. We retrospectively reviewed our single center experience in 153 patients with CM over a period 25 years.From November 1993 to May 2017, 153 patients were operated in our institution with diagnosis of a CM. In all patients preoperative, perioperative, and postoperative data were recorded including the long-term follow-up. All patients followed up in the outpatient's clinics and echocardiography at regular intervals.Mean age 59 ±â€Š12 years old. There were 104 women and 49 men. Preoperative clinical manifestations of the patients were hemodynamic consequences (47.7%), asymptomatic (46.4%), systemic embolism (4.5%), systemic manifestations-fever (0.7%), and hemoptysis (0.7%). The most common location of CM was in the left atrium in 82.4% patients. Mean tumors diameter was 4.5 ±â€Š1.9 cm. In addition, we were observed that the age of the patients have differences between sex groups women versus men, 60.3 and 54.8 years old respectively (P = .02). On the other hand the tumor size have not differences between the sex groups (P = .56). Combine operations were performed in 24 (15.7%) patients. New cerebrovascular accident was observed in 2 patients post-op. Mean in-hospital stay was 8.02 ±â€Š2.8 days. In-hospital mortality was 1 patient (0.7%) (from sepsis). During median follow-up 3.7 ±â€Š4.3 years CM recurrence was identified in 5 (3.3%) patients.Surgical resection of CMs contributes in an excellent prognosis and associated with low complications and recurrences rate. Regular long-term follow-up is recommended in all patients with CM.

Long-Term Results after Modified Bentall Operation in 200 Patients.

BACKGROUND: Composite graft replacement of the aortic root is the treatment of choice for an array of aortic root pathologies, such as annuloaortic ectasia, Marfan syndrome and acute or chronic aortic dissection type A. In this retrospective study of the authors' aortic surgery database, an exploration was made of factors related to early and long-term morbidity and mortality of patients who underwent this procedure. METHODS: Between 2000 and 2009, a total of 200 consecutive patients (male:female ratio 4:1; mean age 56.2 ± 11.66 years) underwent the modified Bentall operation at the authors' institution, with a composite graft (mechanical valve) being used to correct aortic root pathology. All preoperative, perioperative and postoperative data, as well as long-term follow up data, were retrieved from the authors' aortic surgery database. RESULTS: Preoperative characteristics of the patients included elective and emergency operations (83.1% and 15.9%, respectively). Intraoperative and 30-day mortalities were 2% and 3.5%, respectively, while the rate of postoperative cerebrovascular events was 1.5%. Long-term survival at a mean follow up of 110 months for the elective and emergency groups was 88.6% and 71.9%, respectively (p = 0.007). Moreover, during the same period new cerebrovascular events were observed in 5.8% of cases. Predictive factors for late survival were type of surgery (elective versus emergency; p = 0.023), conduit size (≤23 mm versus >23 mm; p = 0.053) , age >65 years (p = 0.001), intensive care unit stay (days; p <0.001) and postoperative creatinine level (p = 0.002). Survival rates at one, three, five and 10 years postoperatively were 93.5%, 92.5%, 91.5% and 85.9%, respectively. CONCLUSIONS: Patients who underwent the modified Bentall operation presented with minimal major adverse effects and demonstrated a good long-term survival.

Four-year clinical results of transcatheter self-expanding Medtronic CoreValve implantation in high-risk patients with severe aortic stenosis.

BACKGROUND: transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement for patients with severe aortic stenosis considered inoperable or at high operative risk, but the long-term outcome remains unknown. HYPOTHESIS: we assessed the 4-year clinical and echocardiographic outcomes of patients undergoing TAVI with the self-expanding Medtronic CoreValve prosthesis. METHODS: sixty-three patients (mean age 80 ± 6 years) with severe aortic stenosis (AS) at high risk for surgical aortic valve replacement (Logistic EuroSCORE 28.8 ± 10.9%) were included in this study. RESULTS: all-cause cumulative mortality at 1, 2, 3 and 4 years was 14.3, 25.4, 28.6 and 36.5%, respectively. The cumulative incidence of documented major stroke at 4 years was 6.3%. In survivors, there was a significant improvement in functional status at 4 years. Paravalvular leak (trivial/mild to moderate) was observed in the majority of patients post-TAVI with no case of progression to severe regurgitation at 4-year follow-up. In multivariate analysis, independent predictor for increased all-cause mortality was left ventricular ejection fraction <40% (HR: 5.347, 95% CI: 1.126-25.381, P = 0.035). CONCLUSION: our study demonstrated favourable long-term (4 years) outcomes after successful TAVI using the third-generation Medtronic CoreValve device.

Antegrade or Retrograde Cerebral Perfusion in Ascending Aorta and Hemiarch Surgery? A Propensity-Matched Analysis.

BACKGROUND: Over the years, numerous options have been proposed for surgical management of ascending aorta and aortic arch pathology in an attempt to minimize postoperative morbidity and probability of death. We present a propensity score-matching analysis of 259 patients from a single unit who were operated on under deep hypothermic arrest with retrograde cerebral perfusion (DHCA/RCP) or moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion (via common carotid artery) (MHCA/ACP). METHODS: Between 2006 and 2014 a total of 259 consecutive patients underwent ascending aorta and hemiarch correction under HCA. DHCA/RCP and MHCA/ACP were performed on 207 and 52 patients, respectively. Baseline patient characteristics accounted for in the propensity matching were age, sex, acute aortic dissection, emergency operation, re-operation, preoperative hemodynamic instability, preoperative kidney injury, and CA time. After propensity scoring 40 pairs (80 patients) were successfully matched (p = 0.732). Outcomes were defined as the incidence of postoperative neurologic complications, 30-day mortality, and all-cause midterm mortality. RESULTS: Surgical procedure that involved the MHCA/ACP technique was associated with 76.5% decreased risk (risk ratio, 0.235; 95% CI, 0.079 to 0.699) of postoperative neurologic complications (p = 0.009). In addition to MHCA/ACP in surgical procedure for acute aortic dissection a relevant trend was established for 30-day mortality (risk ratio, 0.333; 95% CI, 0.09 to 1.23). For midterm all-cause mortality, MHCA/ACP modestly decreased the number of deaths (p = 0.0456) in comparison with the DHCA/RCP technique. CONCLUSIONS: MHCA/ACP in aortic arch surgical procedure is associated with a decreased risk of all types of neurologic complications and a trend toward decreased 30-day and midterm mortality in comparison with DHCA/RCP.

Perioperative use of iloprost in cardiac surgery patients diagnosed with heparin-induced thrombocytopenia-reactive antibodies or with true HIT (HIT-reactive antibodies plus thrombocytopenia): An 11-year experience.

Thrombocytopenia and thromboembolism(s) may develop in heparin immune-mediated thrombocytopenia (HIT) patients after reexposure to heparin. At the Onassis Cardiac Surgery Center, 530 out of 17,000 patients requiring heart surgery over an 11-year period underwent preoperative HIT assessment by ELISA and a three-point heparin-induced platelet aggregation assay (HIPAG). The screening identified 110 patients with HIT-reactive antibodies, out of which 46 were also thrombocytopenic (true HIT). Cardiac surgery was performed in HIT-positive patients under heparin anticoagulation and iloprost infusion. A control group of 118 HIT-negative patients received heparin but no iloprost during surgery. For the first 20 patients, the dose of iloprost diminishing the HIPAG test to ≤5% was determined prior to surgery by in vitro titration using the patients' own plasma and donor platelets. In parallel, the iloprost "target dose" was also established for each patient intraoperatively, but before heparin administration. Iloprost was infused initially at 3 ng/kg/mL and further adjusted intraoperatively, until ex vivo aggregation reached ≤5%. As a close correlation was observed between the "target dose" identified before surgery and that established intraoperatively, the remaining 90 patients were administered iloprost starting at the presurgery identified "target dose." This process significantly reduced the number of intraoperative HIPAG reassessments needed to determine the iloprost target dose, and reduced surgical time, while maintaining similar primary clinical outcomes to controls. Therefore, infusion of iloprost throughout surgery, under continuous titration, allows cardiac surgery to be undertaken safely using heparin, while avoiding life-threatening iloprost-induced hypotension in patients diagnosed with HIT-reactive antibodies or true HIT.

NT-proBNP in the mitral valve surgery.

BACKGROUND: Prognosis and severity of mitral valve disease in patients are reflected in their natriuretic peptide levels. Patients in the upper margin of this range with severe mitral valve dysfunction also present with a range of myocardial dysfunction and symptomatic progression. We investigated whether serial pre- and immediate postoperative measurements of N-terminal probrain natriuretic peptide (NT-proBNP) can serve as surrogate markers of these surgical patients' severity status and predictors of their immediate postoperative progress. METHODS: Clinical characteristics, echocardiographic indices, and preoperative and postoperative day 1, 5, 7 values of NT-proBNP were retrospectively recorded in a cohort of 75 patients who underwent mitral valve surgery. They were analyzed as a whole and separately for those suffering from severe mitral regurgitation. Correlations, multiple linear regression, logistic regression, and nonparametric receiver operating characteristic curve analyses were implemented. RESULTS: The patients' preoperative New York Heart Association class, presence of atrial fibrillation, and left ventricular function were strongly correlated with the preoperative NT-proBNP level. Specifically for those with severe mitral regurgitation, preoperative NT-proBNP was also correlated to their left ventricular end-diastolic diameter. NT-proBNP values increased respectively postoperatively in all patients and were related to the preoperative values, the patients' preoperative characteristics, and the operative times. Logistic regression analysis identified preoperative NT-proBNP as a predictor of postoperative optimal clinical outcome (P < 0.001). CONCLUSIONS: NT-proBNP is a valuable biomarker of the clinical presentation and immediate postoperative outcome in patients undergoing mitral valve surgery. The preoperative measurement of NT-proBNP can be used to predict an optimal postoperative clinical outcome.

Growth rate of an apical left ventricular myxoma using serial two dimensional echocardiographic and computed tomography observations over twelve months: a case report.

INTRODUCTION: Myxomas are the most common benign tumors of the heart. They vary widely in size, and little is known about their growth rate. The present case report is, we believe the first in bibliography that provides images of an apical left ventricular myxoma from transthoracic echocardiography and computed tomography scans taken a year apart. CASE PRESENTATION: We present the rare case of a 65-year-old asymptomatic Caucasian man with an apical left ventricular myxoma that grew over a 12-month period. Our patient underwent successful surgical excision of the tumor and had an uneventful postsurgical recovery period. CONCLUSIONS: Left ventricular myxomas are benign and curable tumors. They do not usually present with systemic symptomatology and most of them are diagnosed as sequelae of syncope caused by left ventricular outflow tract obstruction or systemic embolization. Because they are usually removed after diagnosis, the growth rate of myxomas is generally unknown. We present a rare case of the asymptomatic presentation of a left ventricular myxoma and its documented growth during a 12-month period.

Anesthetic management of patients undergoing transcatheter aortic valve implantation.

OBJECTIVE: To compare 2 anesthetic techniques, general anesthesia or monitored anesthesia care, performed by the same cardiac anesthesiologists for transcatheter aortic valve implantation in the authors' institution. DESIGN: A retrospective study. SETTING: A single specialized cardiac surgery center. PARTICIPANTS: Ninety-eight patients with severe aortic valve stenosis and a high logistic EuroSCORE considered not eligible to undergo conventional aortic valve replacement. INTERVENTION: General anesthesia or monitored anesthesia care. MEASUREMENTS AND MAIN RESULTS: General anesthesia was used in 57 and monitored anesthesia care in 41 patients. The authors compared the following parameters: Duration of procedure, transfusion requirements, cardiac indices, superior vena cava saturation (ScVO2) before and after the aortic valve implantation, hospital length of stay and 30-day mortality. The only significant differences between the groups concerned were the duration of anesthesia (p<0.001) and ScVO2 values. Anesthesia duration was prolonged significantly when general anesthesia was administered, and ScVO2 was significantly higher both before and after the valve implantation in the general anesthesia group. Thirty-day mortality was 5.3% in the general anesthesia group and 4.9% in the monitored anesthesia group. CONCLUSIONS: It would appear that both anesthetic techniques may be used for patients with a high logistic EuroSCORE undergoing transcatheter aortic valve implantation.

Outcomes after ascending aorta and proximal aortic arch repair using deep hypothermic circulatory arrest with retrograde cerebral perfusion: analysis of 207 patients.

OBJECTIVES: Correction of ascending aorta and proximal aortic arch pathology with numerous surgical techniques having been proposed over the years remains a surgical challenge. This study was undertaken to identify risk factors influencing outcome after aortic arch operations, requiring deep hypothermic circulatory arrest (DHCA). METHODS: Between 1993 and 2010, 207 consecutive patients were operated for ascending aorta and proximal arch correction with the use of deep hypothermic circulatory arrest with retrograde cerebral perfusion. All patients were followed up with regular out-patient clinics, transthoracic echocardiography and, when required, chest computed tomography. RESULTS: There were 102 (49.3%) emergencies (acute type A dissection) and 105 (50.7%) elective cases. Mean age: 63.5 ± 12 years. Mean circulatory arrest time was 25.4 ± 13 min. Unadjusted analysis of factors associated with 30-day mortality revealed emergency status, preoperative hemodynamic instability, acute dissection, reoperation, increased circulatory arrest time, postoperative bleeding, postoperative creatinine levels and presence of neurological dysfunction. Multi-adjusted analysis revealed duration of circulatory arrest as the only and main factor related to death. Thirty-day mortality was 2.4% for the elective and 7.2% for emergencies cases. Survival during long-term follow-up was 93, 82 and 53% at 1, 5 and 10 years, respectively. CONCLUSIONS: Ascending aorta and proximal aortic arch replacement with brief duration of deep hypothermic circulatory arrest combined with retrograde cerebral perfusion is a safe method with acceptable short- and long-tem results.

Repair of a penetrating aortic arch injury using deep hypothermic circulatory arrest and retrograde cerebral perfusion.

The traumatic rupture of the thoracic aorta is a severe and life-threatening entity. The incidence of penetrating trauma to the aortic arch is not known, because most patients die of haemorrhage even before they receive adequate treatment. Clinical signs of such injuries include external or internal haemorrhage, bruit, distal pulse deficit, neurological deficit and shock. We present a 42-year old female with a penetrating aortic arch injury successfully repaired using deep hypothermic circulatory arrest and retrograde cerebral perfusion.

Surgical treatment of primary intracardiac myxoma: 19 years of experience.

Cardiac myxoma is the most common benign tumor of the heart. It presents with a variety of clinical signs and symptomatology making diagnosis frequently quite a challenge. We review our experience with 41 patients who underwent surgical intervention for cardiac myxoma between 1994 and 2011. All patients' preoperative, intraoperative and postoperative characteristics were recorded. They all had a standard sternotomy and cardiopulmonary bypass with cardioplegic cardiac arrest and were followed up with clinical examination and echocardiography. The surgical goal was to remove not only the tumor but the whole area of attachment to prevent recurrence. Biatrial approach facilitated the complete excision of the tumor. Surgical excision of cardiac myxoma carries a low-operative risk and gives excellent short- and long-term results.

Transcatheter aortic valve implantation, patient selection process and procedure: two centres' experience of the intervention without general anaesthesia.

INTRODUCTION: transcatheter aortic valve implantation (TAVI) is an emerging technique for the treatment of aortic stenosis. With the advent of percutaneous suture devices for the access point and prosthesis delivery systems of smaller diameter, TAVI has become a truly percutaneous procedure: percutaneous aortic valve replacement (PAVR). Thus, PAVR may be conducted without general anaesthesia (GA). METHODS: We report two centres' experience from PAVR without GA. CoreValve aortic bioprostheses were utilised. The patient selection process and PAVR procedure are described in detail. RESULTS: a total of 30 patients (pts) were treated with PAVR. In 4 pts correction of the initial malposition of the prosthesis required a special technique (2 pts: "snare"; 2 pts: "removing and reinserting"). At 1-month follow up, haemodynamic and clinical improvements were observed: left ventricular ejection fraction increased from 50.8 ± 9.3% to 54.3 ± 8.3% (p=0.02); peak aortic valve gradient decreased from 90.3 ± 26.4 mmHg to 14.8 ± 9.7 mmHg, (p<0.001); NYHA functional class decreased from 3.53 ± 0.93 to 1.45 ± 0.94 (p<0.001). Overall 1-month mortality was 3.3% (1 patient died). CONCLUSION: PAVR without general anaesthesia is a feasible technique, however the role of anaesthesiologists is still important.

Transcriptional regulation of TIMPs in ascending aorta aneurysms.

The events that result in the establishment and progression of aortic aneurysms are complex and multifactorial. However, degradation of the extracellular matrix (ECM) of aortic tunica media appears to be a consistent histopathological and biochemical feature. An increased local expression of matrix metalloproteinases (MMPs) as well as an imbalance between MMP expression and the expression of their natural tissue inhibitors (TIMPs) have been demonstrated in dilated aortic wall. We hypothesized that a distinct MMP and TIMP expression pattern underlies the development of ascending aorta dilation. To test our hypothesis, expression levels of 10 MMPs and 4 TIMPs were assessed by real-time PCR in dilated and normal aortic tissue derived from patients that underwent elective surgical repair of ascending aorta aneurysm (AAA) and coronary artery by-pass grafting, respectively. We found no statistically significant up- or down-regulation of any individual MMP. Surprisingly, the tissue inhibitor of metalloproteinases (TIMP)-3 was significantly more expressed in dilated aortic tissue compared to control tissue, thereby reflecting an effort to counteract MMP activity. Finally, when we evaluated the MMP and TIMP co-expression pattern in normal and dilated aortic tissue, we observed that in aortic aneurysms activation of the MMP system was characterised by the co-expression of more than one proteinase and the down-regulation of TIMP-1 and -2. The latter observation is the key regulatory point that leads to ECM degradation and, subsequently, to AAA formation.

Transcatheter aortic valve implantation: first Greek experience.

INTRODUCTION: Percutaneous aortic valve replacement represents an alternative to conventional open-heart surgery for selected high-risk patients without the need for sternotomy, aortotomy, or cardiopulmonary bypass. We present the first Greek series of transcatheter prosthetic aortic valve implantation procedures, performed in our centre. METHODS: All 12 patients (age 81 +/- 5 years) had severe, symptomatic, calcific aortic stenosis and were judged not to have a reasonable surgical option by a medical team including experienced cardiac surgeons. The patients' mean logistic EuroSCORE was 34 +/- 15% (min 11%, max 61%). Eight (8) of them underwent transfemoral (SAPIEN, Edwards 23 mm valve in 7 and 26 mm in 1 patient) and 4 transapical (26 mm in 2 and 23 mm in 2 patients) prosthetic aortic valve implantation, all in the cardiac catheterisation laboratory under general anaesthesia. RESULTS: The procedural, in-hospital and 2-month (mean follow up 50 days, min 17, max 122 days) mortality was 0%. The length of hospital stay was 8 +/- 2 days (min 5, max 12 days). The aortic valve area increased from 0.64 +/- 0.14 cm2 to 1.83 +/- 0.14 cm2 and the mean pressure gradient decreased from 57 +/- 23 mmHg to 10 +/- 3 mmHg post-implantation (p<0.001 for both). The patients' mean NYHA functional status improved from 2.8 +/- 0.7 to 1.3 +/- 0.5 at follow-up (p<0.001). CONCLUSIONS: Our initial experience with transcatheter prosthetic aortic valve implantation demonstrates that it can be performed safely and with excellent short and mid-term clinical outcomes.