Risk factor analysis of postoperative acute respiratory distress syndrome after type A aortic dissection repair surgery

To investigate the incidence, outcomes, and risk factors of postoperative acute respiratory distress syndrome (ARDS) in patients undergoing surgical repair for acute type A aortic dissection.This retrospective study involved 270 patients who underwent surgical repair for acute type A aortic dissection between January 2009 and December 2015. Data on clinical characteristics and outcomes were collected. Patients who immediately died after surgery and with preoperative myocardial dysfunction were excluded. The included patients were divided into the ARDS (ARDS patients who met the Berlin definition) and non-ARDS groups. Primary outcome was postoperative ARDS, according to the 2012 Berlin definition for ARDS and was reviewed by 2 qualified physicians with expertise in critical care and cardiac surgery. Outcomes of interest were the incidence and severity of risk factors for ARDS in this population, and perioperative outcomes and survival rates were compared with patients with or without ARDS.A total of 233 adult patients were enrolled into this study; of these, 37 patients (15.9%) had ARDS. Three, 20, and 14 patients had mild, moderate, and severe ARDS, respectively, according to the Berlin definition, with no significant difference in age, sex, and underlying disease. The ARDS group had lower mean oxygenation index (OI) than the non-ARDS group in the first 3 days post-surgery and demonstrated an improvement in lung function after the fourth day. Postoperative complication risks were higher in the ARDS group than in the non-ARDS group. However, no significant difference was observed in in-hospital mortality between the 2 groups (10.8% vs 5.6%, P = .268). Additionally, there was also no significant difference in the 3-year mortality rate between the 2 groups (P of log-rank test = .274). Postoperative hemoglobin level (odds ratio [OR]: 0.78; 95% confidence interval [CI]: 0.62-0.99) and perioperative blood transfusion volume (OR: 1.07; 95% CI: 1.03-1.12) were associated with ARDS risk.Postoperative ARDS after type A aortic dissection repair surgery was associated with risks of postoperative complications but not with risk of in-hospital mortality or 3-year mortality. A higher perioperative blood transfusion volume and a lower postoperative hemoglobin level may be risk factors for ARDS.

Prognostic value of endothelial biomarkers in refractory cardiogenic shock with ECLS: a prospective monocentric study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is often used in critical patients with severe myocardial failure. However, the mortality rate of patients on ECMO is often high. Recent studies have suggested that endothelial activation with subsequent vascular barrier breakdown is a critical pathogenic mechanism of organ damage and is related to the outcome of critical illness. This study aimed to determine whether endothelial biomarkers can be served as prognostic factors for the outcome of patients on ECMO.

METHODS

This prospective study enrolled 23 critically ill patients on veno-arterial ECMO in the intensive care units of a tertiary care hospital between March 2014 and February 2015. Serum samples were tested for thrombomodulin, angiopoietin (Ang)-1, Ang-2, and vascular endothelial growth factor (VEGF). Demographic, clinical, and laboratory data were also collected.

RESULTS

The overall mortality rate was 56.5%. The combination of Ang-2 at the time of ECMO support (day 0) and VEGF at day 2 had the ability to discriminate mortality (area under receiver operating characteristic curve [AUROC], 0.854; 95% confidence interval: 0.645-0.965).

CONCLUSIONS

In this study, we found that the combination of Ang-2 at day 0 and VEGF at day 2 was a modest model for mortality discrimination in this group of patients.

Long-term outcomes after extracorporeal membrane oxygenation in patients with dialysis-requiring acute kidney injury: A cohort study

Background

Acute kidney injury (AKI) is a common complication of extracorporeal membrane oxygenation (ECMO) treatment. The aim of this study was to elucidate the long-term outcomes of adult patients with AKI who receive ECMO.

Materials and methods

The study analyzed encrypted datasets from Taiwan’s National Health Insurance Research Database. The data of 3251 patients who received first-time ECMO treatment between January 1, 2003, and December 31, 2013, were analyzed. Characteristics and outcomes were compared between patients who required dialysis for AKI (D-AKI) and those who did not in order to evaluate the impact of D-AKI on long-term mortality and major adverse kidney events.

Results

Of the 3251 patients, 54.1% had D-AKI. Compared with the patients without D-AKI, those with D-AKI had higher rates of all-cause mortality (52.3% vs. 33.3%; adjusted hazard ratio [aHR] 1.82, 95% confidence interval [CI] 1.53–2.17), chronic kidney disease (13.7% vs. 8.1%; adjusted subdistribution HR [aSHR] 1.66, 95% CI 1.16–2.38), and end-stage renal disease (5.2% vs. 0.5%; aSHR 14.28, 95% CI 4.67–43.62). The long-term mortality of patients who survived more than 90 days after discharge was 22.0% (153/695), 32.3% (91/282), and 50.0% (10/20) in the patients without D-AKI, with recovery D-AKI, and with nonrecovery D-AKI who required long-term dialysis, respectively, demonstrating a significant trend (Pfor trend <0.001).

Conclusion

AKI is associated with an increased risk of long-term mortality and major adverse kidney events in adult patients who receive ECMO.

Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension at a Single Center in Taiwan

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) is classified as group IV pulmonary hypertension. This study aimed to report our institutional experience in managing CTEPH.

METHODS

We prospectively collected the data of 23 patients diagnosed with CTEPH between August 2001 and August 2017 in Linkou Chang Gung Memorial Hospital. Baseline characteristics including functional class (FC), 6-minute walk distance (6MWD), comorbidities, hematological and biochemical data, echocardiography, cardiac catheterization, and selective pulmonary angiography were recorded at diagnosis. All patients were referred to a cardiac surgeon for pulmonary endarterectomy (PEA) assessment.

RESULTS

The mean age at diagnosis was 48.4 ± 16.1 years. Nineteen patients (83%) underwent PEA with mean postoperative follow-up of 37.7 ± 42.8 months. The in-hospital mortality rate of PEA was 11%. The 1-, 2-, 3- and 5-year overall survival rates were 89%, 89%, 81%, and 50%, respectively. After 3 months of PEA, all patients had improvements in FC, 6MWD (from 326 ± 62 to 420 ± 63 m), B-type natriuretic peptide level (from 602 ± 599 to 268 ± 565 pg/mL), and systolic pulmonary artery pressure (from 79 ± 19 to 48 ± 19 mmHg). The patients with proximal disease (Jamieson type 1 or 2) had better survival than those with distal disease (Jamieson type 3 or 4), but there was no significant difference in mortality between FC III and IV. All of the four patients who did not undergo PEA survived for more than 3 years.

CONCLUSIONS

Significant improvements in symptoms, functional capacity, and hemodynamics were achieved in the CTEPH patients after PEA. However, the overall survival was still unsatisfactory.

Double arterial cannulation strategy for acute type A aortic dissection repair: A 10-year single-institution experience

Background

Repair of acute type A aortic dissection (ATAAD) is a complex and emergent cardiovascular surgery that is associated with high perioperative morbidity and mortality. Each cannulation strategy has different benefits and drawbacks during cardiopulmonary bypass. Using a retrospective study design, we aimed to clarify the safety and efficacy of right axillary artery cannulation in combination with femoral artery cannulation compared to single arterial cannulation for ATAAD repair.

Methods

From January 2007 to July 2017, 476 adult patients underwent ATAAD repair at a single institution. Patients were classified into groups according to their cannulation strategy: the double arterial cannulation (DAC) group (n = 377; 79.2%) or single arterial cannulation (SAC) group (n = 99; 20.8%). Preoperative demographics, surgical information, and postoperative recovery were compared between both groups. Survival and freedom from reoperation rates were analyzed using the Kaplan-Meier actuarial method.

Results

Demographics, comorbidities, and surgical procedures were generally homogenous between the two groups, except for sex, age, and rate of extensive aortic repair. Patients who underwent DAC had lower in-hospital mortality (13.5% vs. 25.3%; P = 0.005) and lower incidence of malperfusion-related complications (18.8% vs. 30.3%; P = 0.011) than those who underwent SAC. During multivariate analysis, SAC was identified as an in-hospital mortality predictor (odds ratio, 2.81; 95% confidence interval, 1.52–5.17; P = 0.001), as were preoperative ventilator support, intraoperative extracorporeal membrane oxygenation installation, and postoperative malperfusion-related complications. Three-year cumulative survival and freedom from reoperation rates were 74.8% and 85.3% for the DAC group and 62.6% and 81.1% for the SAC group, respectively (P = 0.010 and 0.430, respectively).

Conclusions

With acceptable short- and mid-term outcomes, DAC is effective and safe for establishing cardiopulmonary bypass during ATAAD repair.

Examining symptom trajectories that predict worse outcomes in post-CABG patients

BACKGROUND

Coronary artery bypass grafting is one of the most common interventional revascularisation procedures used to treat coronary artery disease worldwide. With a wide variability in postoperative cardiac symptoms, identification of symptom trajectories during the 3-month postoperative recovery period may improve clinicians' abilities to support symptom recovery.

AIMS

To identify distinct trajectories of cardiac symptoms seen over time in a cohort of patients during the 3-month post-coronary artery bypass grafting period, and determine clinical characteristics associated with different symptom trajectories postoperatively.

METHODS

A prospective trial used the cardiac symptom survey to determine patient symptoms at baseline prior to surgery, and at 1 week, 6 weeks and 3 months following coronary artery bypass grafting. A latent class growth model and multivariate logistic regression analyses were used.

RESULTS

Data were obtained from patients ( N=198) undergoing coronary artery bypass grafting in six medical centres of Taiwan, through patient medical records and interviews. Based on their frequency, trajectories were explored for the six most common postoperative symptoms including angina, dyspnoea, fatigue, depression, sleep problems and anxiety. We identified two to three distinct classes of trajectories for each symptom. Age, longer intensive care unit stay, fewer vessels bypassed, off-pump coronary artery bypass grafting, smoking history and lack of regular exercise were associated with worse symptom outcome trends over time.

CONCLUSIONS

Using this unique trajectories-based research method, we are able to achieve a better understanding of symptom recovery patterns over time among coronary artery bypass grafting patients. Recognising risk factors and potential recovery patterns prior to surgery may allow healthcare providers to deliver targeted discharge planning and individualised care after coronary artery bypass grafting.

Preoperative risk assessment improves biomarker detection for predicting acute kidney injury after cardiac surgery

Background

Although urinary neutrophil gelatinase-associated lipocalin (NGAL) has emerged as a promising biomarker for the early detection of kidney injury, previous studies of adult patients who underwent cardiac surgery have reported only moderate discrimination. The age, creatinine, and ejection fraction (ACEF) score is a preoperative validated risk model with satisfactory accuracy for predicting AKI following cardiac surgery. It remains unknown whether combining preoperative risk assessment through ACEF scores followed by urinary NGAL test in a population of high-risk individuals is an optimal approach with improved predictive performance.

Material and methods

A total of 177 consecutive patients who underwent cardiac surgery were enrolled. Clinical characteristics, prognostic model scores, and outcomes were assessed. Urinary NGAL were examined within 6 hours after cardiac surgery. Patients were stratified according to preoperative ACEF scores, and comparisons were made using the area under the receiver operator characteristic curve (AUROC) for the prediction of AKI.

Results

A total of 45.8% (81/177) of the patients had AKI. As expected, patients with ACEF scores ≥ 1.1 were older and more likely to have class III or IV heart failure. They were also more likely to have diabetes mellitus, myocardial infarction, and peripheral arterial disease. Urinary NGAL alone moderately predicted AKI, with an AUROC of 0.732. Risk stratification by ACEF scores ≥ 1.1 substantially improved the AUROC of urinary NGAL to 0.873 (95% confidence interval, 0.784–0.961; P < .001).

Conclusions

Risk stratification by preoperative ACEF scores ≥ 1.1, followed by postoperative urinary NGAL, provides more satisfactory risk discrimination than does urinary NGAL alone for the early detection of AKI after cardiac surgery. Future studies should investigate whether this strategy could improve the outcomes and cost-effectiveness of care in patients undergoing cardiac surgery.

Impact of reduced left ventricular function on repairing acute type A aortic dissection: Outcome and risk factors analysis from a single institutional experience

Preoperative left ventricular dysfunction is a risk factor for postoperative mortality and morbidity in cardiovascular surgeries with cardiopulmonary bypass, including thoracic aortic surgery. Using a retrospective study design, this study aimed to clarify the short- and mid-term outcomes of patients who underwent acute type A aortic dissection (ATAAD) repair with reduced left ventricular function.Between July 2007 and February 2018, a total of 510 adult patients underwent surgical repair of ATAAD in a single institution. The patients were classified as having left ventricular ejection fraction (LVEF) <50% (low EF group, n = 86, 16.9%) and LVEF ≥50% (normal group, n = 424, 83.1%) according to transesophageal echocardiographic assessment at the operating room. Preoperative demographics, surgical information, and postoperative complication were compared between the two groups. Three-year survival was analyzed using the Kaplan-Meier actuarial method. Serial echocardiographic evaluations were performed at 1, 2, and 3 years postoperation.Demographics, comorbidities, and surgical procedures were generally homogenous between the 2 groups, except for a lower rate of aortic arch replacement in the low EF group. The averaged LVEFs were 44.3 ± 2.5% and 65.8 ± 6.6% among the low EF and normal groups, respectively. The patients with low EF had higher in-hospital mortality (23.3% versus 13.9%, P = .025) compared with the normal group. Multivariate analysis revealed that intraoperative myocardial failure requiring extracorporeal membrane oxygenation support was an in-hospital mortality predictor (odds ratio, 16.99; 95% confidence interval, 1.23-234.32; P = .034), as was preoperative serum creatinine >1.5 mg/dL. For patients who survived to discharge, the 3-year cumulative survival rates were 77.8% and 82.1% in the low EF and normal groups, respectively (P = .522). The serial echocardiograms revealed no postoperative deterioration of LVEF during the 3-year follow-up.Even with a more conservative aortic repair procedure, the patients with preoperative left ventricular dysfunction are at higher surgical risk for in-hospital mortality. However, once such patients are able to survive to discharge, the midterm outcome can still be promising.

Sutureless aortic bioprosthesis replacement in elderly Asian patients with aortic stenosis: Experience in a single institution

BACKGROUND

Sutureless aortic valve replacement (SU-AVR) has emerged as a promising alternative for the treatment of patients with aortic valve stenosis. This study aims to assess the safety and efficacy of SU-AVR in an elderly Asian population.

METHODS

From June 2015 to May 2016, 15 adults with severe aortic stenosis (9 females) with a median age of 79 years underwent Perceval sutureless bioprosthesis (LivaNova, UK) implantation in a single Taiwanese institution; peri-operative recovery, clinical improvement, and valve performance were analyzed.

RESULTS

Three (20%) patients underwent concomitant procedures (coronary artery bypass grafting, 1 patient; maze, 2 patients) and 6/12 (50%) patients underwent J-ministernotomy for isolated SU-AVR. Median cardiopulmonary bypass and cross-clamp time were 105 min and 69 min, respectively. All sutureless bioprosthesis were implanted successfully without conversion to a traditional valve, but 2 patients (13.3%) need intraoperative valve repositioning because of paravalvular leakage. Median extubation time and intensive care unit stay were 5 h and 2 days, respectively. One patient experienced in-hospital mortality due to sudden collapse thought secondary to high degree atrioventricular block. Serial echocardiographic evaluations were performed preoperatively and at 1, 3, and 6 months postoperatively. The final echocardiographic exams showed nothing greater than mild aortic insufficiency and the median mean trans-valvular gradient was 13.2 (range, 6.0-26.3) mmHg.

CONCLUSIONS

By simplified procedure and improved hemodynamics, SU-AVR can be implanted safely in elderly Asian population with excellent valvular performance.

Changes in quality of life and health status in patients with extracorporeal life support: A prospective longitudinal study

Background

Extracorporeal life support (ECLS) provides emergency pulmonary and cardiac assistance for patients in respiratory or cardiac failure. Most studies evaluate the success of ECLS based on patients’ survival rate. However, the trajectory of health status and quality of life (QOL) should also be important considerations. The study’s aim was to explore changes in health status and QOL in adult patients weaned from ECLS who survived to hospital discharge over a one-year period.

Study design

A prospective longitudinal study was conducted from April 2012 to September 2014. A convenience sample of patients who had undergone ECLS was followed for one-year after hospital discharge. Heath status was measured with a physical activity scale, the Centre for Epidemiologic Studies Depression scale, and a social support scale; we assessed quality of life with the physical and mental component summary scales of the Short-Form 36 Health Survey. Changes in depression, social support, physical activity and QOL were analysed with generalized estimating equations at 3-month intervals; participants’ QOL at 12 months after discharge was compared with the general population.

Results

A total of 231 patients received ECLS during the study period. Sixty-five patients survived to hospital discharge (28% survival rate); 32 participants completed the study. Data showed scores for physical activity increased significantly over time (p < .001), while depression and social support significantly decreased (p < .05 and p < .001, respectively). Participants with veno-venous ECLS had higher scores for depression than participants with veno-arterial ECLS (p < .05). PCS scores significantly increased at 9, and 12 months after discharge (p < .05 and p < .001, respectively). There was no significant change in MCS scores.

Conclusions

This was a preliminary study of patients with ECLS following hospital discharge over a one-year period. One year following hospital discharge survivors of ECLS continued to experience physical complications and some continued to have depressive symptoms; the level of social support was significantly lower after hospital discharge. Healthcare professionals should understand the trajectory of health status and QOL after discharge, which can help developing evidence-based interventions and improve QOL for survivors of ECLS.

Cerebral desaturation in heart failure: Potential prognostic value and physiologic basis

Cerebral tissue oxygen saturation (SctO₂) reflects cerebral perfusion and tissue oxygen consumption, which decline in some patients with heart failure with reduced ejection fraction (HFrEF) or stroke, especially during exercise. Its physiologic basis and clinical significance remain unclear. We aimed to investigate the association of SctO₂ with oxygen transport physiology and known prognostic factors during both rest and exercise in patients with HFrEF or stroke. Thirty-four HFrEF patients, 26 stroke patients, and 17 healthy controls performed an incremental cardiopulmonary exercise test using a bicycle ergometer. Integrated near-infrared spectroscopy and automatic gas analysis were used to measure cerebral tissue oxygenation and cardiac and ventilatory parameters. We found that SctO₂ (rest; peak) were significantly lower in the HFrEF (66.3±13.3%; 63.4±13.8%,) than in the stroke (72.1±4.2%; 72.7±4.5%) and control (73.1±2.8%; 72±3.2%) groups. In the HFrEF group, SctO₂ at rest (SctO_2rest) and peak SctO₂ (SctO_2peak) were linearly correlated with brain natriuretic peptide (BNP), peak oxygen consumption (V˙O2peak), and oxygen uptake efficiency slope (r between -0.561 and 0.677, p < 0.001). Stepwise linear regression showed that SctO_2rest was determined by partial pressure of end-tidal carbon dioxide at rest (P_ETCO_2rest), hemoglobin, and mean arterial pressure at rest (MAP_rest) (adjusted R = 0.681, p < 0.05), while SctO_2peak was mainly affected by peak carbon dioxide production (V˙CO2peak) (adjusted R = 0.653, p < 0.05) in patients with HFrEF. In conclusion, the study delineates the relationship of cerebral saturation and parameters associated with oxygen delivery. Moreover, SctO_2peak and SctO_2rest are correlated with some well-recognized prognostic factors in HFrEF, suggesting its potential prognostic value.

Nationwide cohort study of mitral valve repair versus replacement for infective endocarditis

OBJECTIVES

The feasibility and long-term outcomes of mitral valve (MV) repair in patients with infective endocarditis (IE) remain unclear.

METHODS

Using Taiwan's National Health Insurance Research Database, we identified 1999 patients who underwent MV surgery for IE during 2000 to 2013. The patients were more likely to have undergone valve replacement (1575 patients; 78.8%) than valve repair (424 patients; 21.2%). After 1:1 propensity score matching, 352 patients in each group were included for analysis. Perioperative outcomes and late composite end points, comprising all-cause mortality, MV reoperation, any stroke, major bleeding, and readmission for heart failure, were compared.

RESULTS

Patients who received MV repair had fewer perioperative complications, lower in-hospital mortality rates (6.3% vs 10.8%; P = .031), and lower risks of late mortality (hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.44-0.80), and composite end point (HR, 0.67; 95% CI, 0.52-0.87) during a mean follow-up of 4.8 years. Subgroup analysis revealed a trend in which the beneficial effect of MV repair was not apparent when surgeries were performed in hospitals within the lowest volume quartile (P for interaction = .091). In patients who underwent surgery during active IE, MV repair was also related to a lower rate of late mortality (HR, 0.64; 95% CI, 0.48-0.85).

CONCLUSIONS

Mitral repair for IE has better perioperative and late outcomes than mitral replacement. Mitral repair performed by an experienced team is recommended for IE patients instead of MV replacement whenever possible, even with an active infection status.

Effect of Anemia on Prognosis in Patients on Extracorporeal Membrane Oxygenation

Anemia is a component of the pathological triangle in cardiorenal anemia syndrome and is a risk factor for mortality in acute respiratory distress syndrome. This study assessed the predictive value of anemia for outcomes in critically ill patients receiving extracorporeal membrane oxygenation (ECMO) support. This retrospective study analyzed patients who received ECMO support at the cardiovascular surgery intensive care unit in the study institute between July 2003 and March 2012. Patient data, such as demographic information, etiologies of ECMO implementation, clinical parameters, and in-hospital and 6-month mortality rates, were statistically analyzed. The overall in-hospital mortality rate among the enrolled 295 patients was 55.6%. Multivariate logistical regression analysis indicated that age, albumin levels, sequential organ failure assessment (SOFA) score, and hemoglobin (Hb) level on ECMO day 1 exhibited independent prognostic significance for predicting in-hospital mortality rate. The SOFA score exhibited the highest areas under the receiver operating characteristic curve value (0.812 ± 0.025). The Hb level on ECMO day 1 exhibited satisfactory calibration and discriminatory power. The cumulative 6-month survival rates differed significantly between patients with Hb levels less than and more than 8.85 g/dL (30.6 vs. 54.0%, respectively, P < 0.001). This study indicated that old age, low albumin levels, low Hb levels, and higher SOFA scores on ECMO day 1 increased the risk of mortality. The Hb level is a readily measurable parameter and with good predictive power for critical patients on ECMO.

Surgical interventions of isolated active mitral valve endocarditis: Predisposing factors and impact of neurological insults on final outcome

The feasibility and durability of mitral valve (MV) repair in active infective endocarditis (IE) has been reported, but proper management of perioperative neurological complications and surgical timing remains uncertain and may crucially affect the outcome.In this single-center retrospective observational study, patients who underwent isolated MV surgery for active native IE in our institution between August 2005 and August 2015 were reviewed and analyzed. Patients who were operated on for healed IE or who required combined procedures were excluded from this study.A total of 71 patients were enrolled in the study with a repair rate of 53.5% (n = 38). Isolated posterior leaflet lesion was found in 15 patients (21%) and was related to higher reparability (86.7%, P = .004). The overall in-hospital mortality was 10 (14.1%): 3 (7.9%) in the repair group and 7 (21.2%) in replacement group (P = .17). Prognosis was not related to age, preoperative renal function, cerebral emboli, or duration of antibiotics. The only significant predictor was postoperative intracranial hemorrhage (ICH) [odds ratio 14.628 (1.649-129.78), P = .04]. At a mean follow-up period of 43.1 months, neither recurrent endocarditis nor late cardiac death was observed in both groups.Surgical timing and procedural options of MV surgery in active native IE did not make any difference, but occurrence of ICH after surgery jeopardized the final outcome. Routine preoperative brain imaging to detect silent ICH or mycotic aneurysm and aggressive treatment of these lesions may prevent catastrophe and optimize the results.

Comparison of right ventricular measurements by perioperative transesophageal echocardiography as a predictor of hemodynamic instability following cardiac surgery

BACKGROUND

The relationship between perioperative right ventricular (RV) performance and hemodynamic instability after cardiac surgery seemed less portrayed. Therefore, we sought to elucidate this relationship and compare the accuracy of different RV systolic indices in predicting outcome of cardiac surgery.

METHODS

This study enrolled consecutive patients referred for cardiac surgeries. Exclusion criteria were non-sinus rhythm or contraindications to transesophageal echocardiography (TEE). TEE exam and simultaneous pulmonary hemodynamics were recorded in two stages: after induction of anesthesia and before sternotomy (stage 1), and after sternal closure (stage 2). RV measurements performed offline included fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), peak systolic tricuspid annular velocity (RVS'), myocardial performance index (RVMPI), and global longitudinal strain (RVGLS). The end point was defined as prolonged use (>24 h) of postoperative inotropic agent in the intensive care unit (ICU).

RESULTS

The study population included 68 patients (mean age 61 ± 11 y; 49 men). Twenty-two of these patients (32%) were administered inotropic agents for a prolonged period with a mean duration of 63.9 ± 5.3 h, accompanied with significantly longer ventilator use (p = 0.006) and longer ICU stay (p = 0.001) than patients without a prolonged inotropic agent use. Multivariable analysis demonstrated that only RVGLS in either stage 1 (odds ratio [OR] 1.11, p = 0.048) or stage 2 (OR 1.15, p = 0.018) was significantly associated with the outcome, especially a RVGLS > -13.5% in stage 2 demonstrating high risk of prolonged inotropic agent use after cardiac surgery (OR 7.37, p = 0.016).

CONCLUSION

RVGLSs performed using perioperative TEE are reliably associated with hemodynamic instability following cardiac surgery. This finding adds substantial information to postoperative critical care.

Effect of different surgical type of coronary artery bypass grafting on kidney injury: A propensity score analysis

Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) is associated with a less favorable outcome. Off-pump surgery results in lower kidney dysfunction than conventional on-pump arrest surgery. On-pump arrest surgery results in a lower revascularization rate compared with off-pump surgery. On-pump beating heart (OPBH) CABG combines the advantages of beating heart surgery and cardiopulmonary bypass. This study compared the renal outcomes of 3 cardiac surgical methods. From January 2010 to December 2012, 373 patients who underwent on-pump CABG were enrolled. Propensity analysis was performed to compare the postoperative outcomes of postoperative AKI, renal replacement therapy (RRT), intensive care unit (ICU) stay, mortality, and extubating time. In total, 98 patients received conventional on-pump surgery, 160 received OPBH surgery, and 115 received off-pump surgery. The Society of Thoracic Surgeons scores of these 3 groups were 6.1 ± 13.6, 7.4 ± 13.6, and 5.6 ± 10.9, respectively. Propensity analysis revealed lower AKI incidence in the off-pump group than in the on-pump surgery group. No substantial differences were observed in mortality, RRT, and the ICU stay between the off-pump and OPBH surgery groups. Among the 3 surgical methods, off-pump surgery results in lower AKI incidence. The short-term outcome, including kidney function, of OPBH surgery is similar to that of the off-pump group. Therefore, OPBH surgery is a considerable choice for patients with a high surgical risk.

Safety and efficacy of endoscopic spray cryotherapy for esophageal cancer

Although surgery is traditionally the standard of care for esophageal cancer, esophagectomy carries significant morbidity. Alternative endoscopic therapies are needed for patients who are not candidates for conventional treatment. The objective of this study is to assess the safety, efficacy, and tolerability of spray cryotherapy of esophageal adenocarcinoma. This study includes patients with esophageal adenocarcinoma who had failed or were not candidates for conventional therapy enrolled retrospectively and prospectively in an open-label registry and patients in a retrospective cohort from 11 academic and community practices. Endoscopic spray cryotherapy was performed until biopsy proven local tumor eradication or until treatment was halted due to progression of disease, patient withdrawal or comorbidities. Eighty-eight patients with esophageal adenocarcinoma (median age 76, 80.7% male, mean length 5.1 cm) underwent 359 treatments (mean 4.4 per patient). Tumor stages included 39 with T1a, 25 with T1b, 9 with unspecified T1, and 15 with T2. Eighty-six patients completed treatment with complete response of intraluminal disease in 55.8%, including complete response in 76.3% for T1a, 45.8% for T1b, 66.2% for all T1, and 6.7% for T2. Mean follow-up was 18.4 months. There were no deaths or perforations related to spray cryotherapy. Strictures developed in 12 of 88 patients (13.6%) but were present before spray cryotherapy in 3 of 12. This study suggests that endoscopic spray cryotherapy is a safe, well-tolerated, and effective treatment option for early esophageal adenocarcinoma.

Sustained local delivery of high-concentration vancomycin from a hybrid biodegradable, antibiotic-eluting, nanofiber-loaded endovascular prosthesis for treatment of mycotic aortic aneurysms

BACKGROUND

Endovascular repair for mycotic aortic aneurysm (MAA) is a less invasive alternative to open surgery, although the placement of a stent graft in an infected environment remains controversial. In this study, we developed hybrid biodegradable, vancomycin-eluting, nanofiber-loaded endovascular prostheses and evaluated antibiotic release from the endovascular prostheses both in vitro and in vivo.

METHODS

Poly(D,L)-lactide-co-glycolide and vancomycin were dissolved in 1,1,1,3,3,3-hexafluoro-2-propanol. This solution was electrospun into nanofibrous tubes, which were mounted onto commercial vascular stents and endovascular aortic stent grafts. In vitro antibiotic release from the nanofibers was characterized using an elution method and high-performance liquid chromatography. Antibiotic release from the hybrid stent graft was analyzed in a three-dimensional-printed model of a circulating MAA. The in vivo drug release characteristics were examined by implanting the antibiotic-eluting stents in the abdominal aorta of New Zealand white rabbits (n = 15).

RESULTS

The in vitro study demonstrated that the biodegradable nanofibers and the nanofiber-loaded stent graft provided sustained release of high concentrations of vancomycin for up to 30 days. The in vivo study showed that the nanofiber-loaded stent exhibited excellent biocompatibility and released high concentrations of vancomycin into the local aortic wall for 8 weeks.

CONCLUSIONS

The proposed biodegradable vancomycin-eluting nanofibers significantly contribute to the achievement of local and sustainable delivery of antibiotics to the aneurysm sac and the aortic wall, and these nanofibers may have therapeutic applications for MAAs.

Postoperative Renal Outcomes of On-Pump Beating-Heart versus Cardioplegic Arrest Coronary Artery Bypass Grafting

BACKGROUND

The aim of this investigation is to compare the postoperative renal outcomes after on-pump beating- heart versus conventional cardioplegic arrest coronary artery bypass grafting (CABG).

METHODS

Between January 2010 and December 2012, 254 patients who underwent isolated CABG were enrolled. The primary outcome was postoperative acute kidney injury (AKI) within 7 days [defined by the Kidney Disease Improving Global Outcome (KDIGO) Clinical Practice Guideline] and loss of kidney function at 1 year (defined as > 20% loss in estimated glomerular filtration rate from baseline preoperative creatinine level).

RESULTS

There was less AKI found for the on-pump beating-heart CABG (30.2% versus 46.3%; p = 0.010) group; with significant less stage I AKI (17.6% versus 29.5%; p = 0.035); a trend of less stage II AKI (4.4% versus 10.5%; p = 0.088) and no significant difference in stage III AKI (8.2% versus 6.3%; p = 0.587). The on-pump beating-heart group also had less patients who have lost their kidney function at 1 year (24.8% versus 41.2%; p = 0.021). Furthermore, multivariate analysis identified conventional arrest CABG is an independent risk factor for postoperative AKI and loss of kidney function at 1 year.

CONCLUSIONS

On-pump beating-heart CABG has superior short-term and mid-term renal outcomes than conventional cardioplegic arrest CABG.

Comparison of RIFLE, AKIN, and KDIGO classifications for assessing prognosis of patients on extracorporeal membrane oxygenation

BACKGROUND/PURPOSE

Acute kidney injury (AKI) developing during extracorporeal membrane oxygenation (ECMO) is associated with very poor outcome. The Kidney Disease: Improving Global Outcomes (KDIGO) group published a new AKI definition in 2012. This study analyzed the outcomes of patients treated with ECMO and identified the relationship between the prognosis and the KDIGO classification.

METHODS

This study examined total 312 patients initially, and finally reviewed the medical records of 167 patients on ECMO support at a tertiary care university hospital between March 2002 and November 2011. Demographic, clinical, and laboratory variables were retrospectively collected as survival predicators.

RESULTS

The overall mortality rate was 55.7%. In the analysis of the areas under the receiver operating characteristic curves, the KDIGO classification showed relatively higher discriminatory power (0.840 ± 0.032) than the Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage renal failure (RIFLE) (0.826 ± 0.033) and Acute Kidney Injury Network (AKIN) (0.836 ± 0.032) criteria in predicting in-hospital mortality. Furthermore, multiple logistic regression analysis showed that KDIGO, hemoglobin, and Glasgow Coma Scale score on the first day of patients on ECMO were independent predictors for in-hospital mortality. Finally, cumulative survival rates at 6-month follow-up after hospital discharge differed significantly for KDIGO stage 3 versus KDIGO stage 0, 1, and 2 (p < 0.001); and KDIGO stage 2 versus KDIGO stage 0 (p < 0.05).

CONCLUSION

For those patients with ECMO support, the KDIGO classification proved to be a more reproducible evaluation tool with excellent prognostic abilities than RIFLE or AKIN classification.

Risk analysis of dialysis-dependent patients who underwent coronary artery bypass grafting: Effects of dialysis modes on outcomes

Cardiovascular disease is the major morbidity and leading cause of mortality for dialysis-dependent patients. This study aimed to stratify the risk factors and effects of dialysis modes in relation to coronary artery bypass grafting (CABG) surgery among dialysis-dependent patients.This retrospective study enrolled dialysis-dependent patients who underwent CABG from October 2005 to January 2015. All data of demographics, medical history, surgical details, postoperative complications, and in-hospital mortality were analyzed, and patients were categorized as those with or without in-hospital mortality and those with preoperative hemodialysis (HD) or peritoneal dialysis (PD).Of 134 enrolled patients, 25 (18.7%) had in-hospital mortality. Multivariate analyses identified that older age [odds ratio (OR): 1.110, 95% confidence interval (CI): 1.030-1.197, P = .006], previous stroke history (OR: 5.772, 95% CI: 1.643-20.275, P = .006), PD (OR: 19.607, 95% CI: 3.676-104.589, P < .001), and emergent operation (OR: 8.788, 95% CI: 2.697-28.636, P < .001) were statistically significant risk factors for in-hospital mortality among dialysis-dependent patients with CABG surgery. Patients with PD had a higher in-hospital mortality rate (58.3% vs 14.8%, P < .001) and lower 1-year overall survival (33.3% vs 56.6%, P = .031) than did HD patients. The major in-hospital mortality cause was cardiac events among HD patients and septic shock among PD patients.Among dialysis patients who received CABG, those with older age, previous stroke history, PD, and emergent operation had higher risks. Those with PD were prone to poorer in-hospital outcomes after CABG surgery.

Short-term intensive training attenuates the exercise-induced interaction of mono-1/2 cells and platelets after coronary bypass in cardiac patients

The interaction between platelets and monocytes plays a critical role in the pathogenesis and progression of cardiovascular diseases. This study investigated how short-term intensive training (SIT) influences monocyte subset characteristics and exercise-induced monocyte and platelet aggregates (MPAs) following elective coronary bypass (CABG) in cardiac patients. Forty-nine patients hospitalised for CABG were randomised into SIT (N=26) and conventional training (CT, N=23) groups. The SIT subjects underwent supervised aerobic training at 80~120 % of the ventilatory anaerobic threshold based on sub-maximal exercise tests performed 7 days post-CABG for 20 sessions with two sessions/day and 30 min/session, which were completed within four weeks after surgery. The CT subjects performed light-intensity conditioning exercise for ≤4 sessions. Resting and maximal exercise-mediated monocyte characteristics and MPA were determined before and following intervention. The SIT group had a larger improvement in ventilation efficiency and anaerobic threshold than the CT group; the SIT group exhibited larger reductions in blood monocyte subtypes 1 and 2 (Mono1 and 2) counts at rest than the CT group; the SIT group but not the CT group exhibited attenuated formation of Mono1/platelet hetero-aggregation (MPA1) and CD42b expression on Mono1/2 caused by strenuous exercise; and plasma levels of macrophage inflammatory protein-1β and soluble P-selectin showed similar trends as Mono1/2 and MPA1, respectively. In conclusion, SIT modestly improved aerobic capacity in patients following CABG. Moreover, SIT simultaneously ameliorated the CD42b expression of Mono1/2 cells and maximal exercise-induced MPA1, which may reduce the risk of inflammatory thrombosis.

Impact of prior coronary stenting on the outcome of subsequent coronary artery bypass grafting

BACKGROUND

The percentage of patients referred for coronary artery bypass grafting (CABG) who have previously undergone percutaneous coronary interventions (PCIs) is increasing. The purpose of this study was to review the outcomes of patients who had received coronary stenting before CABG, and to examine the validity of a mortality risk stratification system in this patient group.

METHODS

From 2010 to 2012, 439 patients who underwent isolated CABG at our medical center were reviewed. The patients were divided into two study groups: those who had previously received coronary artery stenting (97 patients, 24.7%), and those who had not (342 patients, 75.3%). The patients who received balloon angioplasty were excluded.

RESULTS

There were no significant differences in baseline characteristics. The prior stenting group had a lower risk of mortality, although the difference was not significant. The prior stenting group had fewer graft anastomoses (p = 0.005), and hence a significantly shorter cardiopulmonary bypass time (p = 0.045) and shorter aortic cross-clamping time. Surgical mortality was similar between the two groups. The durations of intensive care unit stay and hospitalization were also similar. The discriminatory power of the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was lower in both group.

CONCLUSIONS

Prior coronary stenting does not affect short-term mortality in patients subsequently undergoing CABG surgery. The EuroSCORE does not predict perioperative mortality well for the patients who undergo coronary stenting before CABG.