Use of Preoperative Natriuretic Peptide in Predicting Mortality After Coronary Artery Bypass Grafting: A Systematic Review and Meta-analysis.

The objective of this systematic review was to evaluate the current evidence on the utility of preoperative B-type natriuretic peptide (BNP) and N-terminal-pro B-type natriuretic peptide (NT-proBNP) in predicting short-term and long-term mortality after coronary artery bypass grafting (CABG). OVID MEDLINE, EMBASE, SCOPUS, and PUBMED were searched from 1946 to August 2022 using the following terms: "coronary artery bypass grafting" and "BNP" and "outcomes." Eligible studies included observational studies reporting the association between preoperative BNP and NT-proBNP levels and short- and long-term mortality after CABG. Articles were selected systematically, assessed for bias, and, when possible, meta-analyzed using a random effect model. After retrieving 53 articles, 11 were included for qualitative synthesis and 4 for quantitative meta-analysis. Studies included in this review showed that elevated preoperative natriuretic peptide levels, despite variable cut-offs, have been consistently shown to be associated with short- and long-term mortality after CABG. The median BNP cut-off value was 145.5 pg/mL (25th-75th percentile 95-324.25 pg/mL), and the mean NT-proBNP value was 765 ± 372 pg/mL. Compared to patients with normal natriuretic peptide levels, patients with elevated BNP and NT-proBNP presented higher mortality rates after CABG (odds ratio 3.96, 95% confidence interval 2.41-6.52; p < 0.00001). Preoperative BNP level is a powerful predictor of mortality in patients undergoing CABG. The measurement of BNP can add significant value to these patients' risk stratification and therapeutic decision-making.

A traveler in transit: A case of an impending thrombus entrapped in a patent foramen ovale.

Thrombus across a patent foramen ovale (PFO), also referred to as a pending paradoxical embolus is a rare condition. We report a case of a 50-year-old male taxi driver who was diagnosed with a massive saddle pulmonary embolism, leg deep venous thromboembolism, and pending paradoxical embolus through a PFO with systemic embolization. The patient had an inferior vena cava (IVC) filter inserted immediately followed by surgical thromboembolectomy and closure of PFO. He was discharged home 1 month after surgery. Surgery is the treatment of choice for preventing systemic embolization particularly cryptogenic stroke and its sequelae from pending paradoxical embolus. Preoperative IVC filter is a useful adjunct to prevent ongoing thromboembolism in the perioperative period. The case report presented at the Annual Cardiothoracic Meeting, 10 November 2017, Royal Society of Medicine, London.

Permanent pacemaker insertion postmitral surgery: Do the atrial access and the origin of the sinoatrial node artery matter?

BACKGROUND AND AIM OF THE STUDY: To determine whether the type of atrial access to the mitral valve (left atriotomy, superior trans-septal, or limited trans-septal) influenced postoperative permanent pacemaker implantation and to investigate the effect of the sinoatrial (SA) node artery origin (right coronary or circumflex arteries) on the rate of pacemaker insertion. METHODS: We retrospectively reviewed consecutive cases of patients who had mitral valve surgery at the Trent Cardiac Centre (2008-2016). The primary outcome was the incidence of permanent pacemaker insertion. The data were analyzed using univariate then binary multivariate regression analysis. RESULT: Four hundred sixty nine patients had mitral valve surgery. The mean age was 66.5 ± 12.3 years and 47.5% were female. One hundred fifty patients (32%) had mitral valve surgery via the standard left atriotomy approach, while 226 (48.2%) and 93 (19.8%) cases were performed using the limited trans-septal and superior trans-septal approaches, respectively. Concomitant tricuspid valve surgery was carried out in 33 cases (7%). The overall rate of pacemaker implantation was 5.3%. On univariate analysis, only age (≥70 years old) and concomitant tricuspid valve surgery were significant predictors of postoperative pacemaker insertion, while on multivariate analysis only age (≥70 years old) remained as a predictor. The type of atrial incision and the origin of the SA node artery did not affect the rate of pacemaker implantation. CONCLUSION: The type of atrial approach to the mitral valve and the origin of the SA node artery did not influence the incidence of postoperative permanent pacemaker insertion.

Atrial approaches to the mitral valve: is there a difference in postoperative rhythm disturbance and permanent pacemaker implantation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether there was a difference in postoperative outcomes [namely permanent pacemaker (PPM) insertion, rhythm disturbance, reoperation for bleeding, hospital stay and in-hospital mortality] between trans-septal or superior (extended) trans-septal (STS) approaches in comparison with the conventional left atriotomy (LA) used in mitral valve surgery. Using the reported search strategy, 353 papers were found of which 11 represented the best evidence to answer the clinical question. The authors, journal, year and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Two papers compared all 3 atrial incisions with neither showing a difference in PPM implantation rate, whereas 2 papers compared just the trans-septal with the LA approach, again both finding no significant difference in PPM implantation. Seven studies compared the STS approach with the LA approach with regard to PPM implantation; 1 study showed that the STS approach was an independent risk factor for PPM implantation, PPM insertion was not necessary in 2 studies and there was no difference in PPM insertion in 4 studies. Postoperative junctional rhythm was studied in 5 papers that compared the STS approach with the LA approach; junctional rhythm was more prevalent in the STS approach in 2 studies, albeit transient, whereas 3 papers did not show a significant difference. Mortality, hospital stay and re-exploration for bleeding did not differ among the 3 groups.