Sequential organ failure assessment score predicts mortality after coronary artery bypass grafting

Background

Mortality after coronary artery bypass grafting (CABG) is generally associated with underlying disease and surgical factors overlooked in preoperative prognostic models. Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores are widely used in intensive care units for outcome prediction. This study investigated the accuracy of these models in predicting mortality.

Methods

Between January 2010 and April 2013, 483 patients who underwent isolated CABG were enrolled. The clinical characteristics, outcomes, and prognostic model scores of the patients were collected. Discrimination was assessed using the area under the curve approach.

Results

Both SOFA and APACHE II scores were effective for predicting in-hospital mortality. Among the organ systems examined in the SOFA, the cardiac and renal systems were the strongest predictors of CABG mortality. Multivariate analysis identified only the SOFA score as being an independent risk factor for mortality.

Conclusion

In summary, the SOFA score can be used to accurately identify mortality after isolated CABG.

Extracorporeal membrane oxygenation support in post-traumatic cardiopulmonary failure: A 10-year single institutional experience

Patients with multiple traumas associated with cardiopulmonary failure have a high mortality rate; however, such patients can be temporarily stabilized using extracorporeal membrane oxygenation (ECMO), providing a bridge to rescue therapy. Using a retrospective study design, we aimed to clarify the prognostic factors of post-traumatic ECMO support.From March 2006 to July 2016, 43 adult patients (mean age, 37.3 ± 15.2 years; 7 females [16.3%]) underwent ECMO because of post-traumatic cardiopulmonary failure. Pre-ECMO demographics, peri-ECMO events, and post-ECMO recoveries were compared between survivors and nonsurvivors.The most common traumatic insult was traffic collision (n = 30, 69.8%), and involved injury areas included the chest (n = 33, 76.7%), head (n = 14, 32.6%), abdomen (n = 21, 48.8%), and fractures (n = 21, 48.8%). Fifteen patients (34.9%) underwent cardiopulmonary resuscitation and 22 (51.2%) received rescue interventions before ECMO deployment. The mean time interval between trauma and ECMO was 90.6 ± 130.1 hours, and the mode of support was venovenous in 26 patients (60.5%). A total of 26 patients (60.5%) were weaned off of ECMO and 22 (51.6%) survived to discharge, with an overall mean support time of 162.9 ± 182.7 hours. A multivariate regression analysis identified 2 significant predictors for in-hospital mortality: an injury severity score (ISS) >30 (odds ratio [OR], 9.48; 95% confidence interval [CI], 1.04-18.47; P = 0.042), and the requirement of renal replacement therapy (RRT) during ECMO (OR, 8.64; 95% CI, 1.73-26.09; P = 0.020). These two factors were also significant for the 1-year survival (ISS >30: 12.5%; ISS ≤30, 48.1%, P = 0.001) (RRT required, 15.0%; RRT not required, 52.2%, P = 0.006).Using ECMO in selected traumatized patients with cardiopulmonary failure can be a salvage therapy. Prompt intervention before shock-impaired systemic organ perfusion and acute renal failure, especially in high ISS patients, is crucial for both hospital and one-year survival.

Dynamic driving pressure associated mortality in acute respiratory distress syndrome with extracorporeal membrane oxygenation

Background

The survival predictors and optimal mechanical ventilator settings in patients with severe acute respiratory distress syndrome (ARDS) undergoing extracorporeal membrane oxygenation (ECMO) are uncertain. This study was designed to investigate the influences of clinical variables and mechanical ventilation settings on the outcomes for severe ARDS patients receiving ECMO.

Methods

We reviewed severe ARDS patients who received ECMO due to refractory hypoxemia from May 2006 to October 2015. Serial mechanical ventilator settings before and after ECMO and factors associated with survival were analyzed.

Results

A total of 158 severe ARDS patients received ECMO were finally analyzed. Overall intensive care unit (ICU) mortality was 55.1%. After ECMO initiation, tidal volume, peak inspiratory pressure and dynamic driving pressure were decreased, while positive end-expiratory pressure levels were relative maintained. After ECMO initiation, nonsurvivors had significantly higher dynamic driving pressure until day 7 than survivors. Cox proportional hazards regression model revealed that immunocompromised [hazard ratio 1.957; 95% confidence interval (CI) 1.216–3.147; p = 0.006], Acute Physiology and Chronic Health Evaluation (APACHE) II score (hazard ratio 1.039; 95% CI 1.005–1.073; p = 0.023), ARDS duration before ECMO (hazard ratio 1.002; 95% CI 1.000–1.003; p = 0.029) and mean dynamic driving pressure from day 1 to 3 on ECMO (hazard ratio 1.070; 95% CI 1.026–1.116; p = 0.002) were independently associated with ICU mortality.

Conclusions

For severe ARDS patients receiving ECMO, immunocompromised status, APACHE II score and the duration of ARDS before ECMO initiation were significantly associated with ICU survival. Higher dynamic driving pressure during first 3 days of ECMO support was also independently associated with increased ICU mortality.

Effect of dialysis dependence and duration on post-coronary artery bypass grafting outcomes in patients with chronic kidney disease: A nationwide cohort study in Asia

BACKGROUND

Chronic kidney disease (CKD) is associated with adverse outcomes in patients who undergo coronary artery bypass grafting (CABG). However, the impact of preoperative dialysis dependence and duration in CKD patients on outcomes after CABG has limited research.

OBJECTIVES

To evaluate the effect of preoperative dialysis dependence and duration on CABG outcomes in patients with CKD.

METHODS

A total of 33,920 patients without CKD and 2573 patients with CKD, all of whom underwent isolated CABG between 1998 and 2009, were identified using the Taiwan National Health Insurance Research Database. The patients with CKD were divided into non-dialysis (N=1167), dialysis<3years (N=749), and dialysis≥3years (N=657) groups. The primary outcomes were cumulative incidence of all-cause mortality, cardiovascular (CV) death, and myocardial infarction (MI) or repeat revascularization.

RESULTS

After adjustment of all covariates, a higher all-cause mortality was associated with dialysis≥3years than with dialysis<3years (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.35-1.80; P<0.001) and with non-dialysis (HR, 1.41; 95% CI, 1.20-1.66; P<0.001) after 2years of follow-up. Similar results were observed for CV death. In addition, both the dialysis groups had a higher risk of MI or revascularization than the non-dialysis group. Furthermore, subgroup analysis revealed that longer duration was associated with a higher risk of 30-day mortality (P for linear trend <0.001).

CONCLUSIONS

Among the CABG recipients, dialysis dependence is associated with a higher incidence of MI or repeat revascularization, and longer dialysis duration is associated with a higher risk of mortality.

Differential left-to-right atria gene expression ratio in human sinus rhythm and atrial fibrillation: Implications for arrhythmogenesis and thrombogenesis

BACKGROUND

Atrial fibrillation (AF) causes atrial remodeling, and the left atrium (LA) is the favored substrate for maintaining AF. It remains unclear if AF remodels both atria differently and contributes to LA arrhythmogenesis and thrombogenesis. Therefore, we wished to characterize the transcript profiles in the LA and right atrium (RA) in sinus rhythm (SR) and AF respectively.

METHODS

Paired LA and RA appendages acquired from patients receiving cardiac surgery were used for ion-channel- and whole-exome-based transcriptome analysis. The ultrastructure was evaluated by immunohistochemistry.

RESULTS

Twenty-two and twenty ion-channels and transporters were differentially expressed between the LA and RA in AF and SR, respectively. Among these, 15 genes were differentially expressed in parallel between AF and SR. AF was associated with increased LA/RA expression ratio in 9 ion channel-related genes, including genes related to calcium handling. In microarray, AF was associated with a differential LA/RA gene expression ratio in 309 genes, and was involved in atherosclerosis-related signaling. AF was associated with the upregulation of thrombogenesis-related genes in the LA appendage, including P2Y12, CD 36 and ApoE. Immunohistochemistry showed higher expressions of collagen-1, oxidative stress and TGF-β1 in the RA compared to the LA.

CONCLUSIONS

AF was associated with differential LA-to-RA gene expression related to specific ion channels and pathways as well as upregulation of thrombogenesis-related genes in the LA appendage. Targeting the molecular mechanisms underlying the LA-to-RA difference and AF-related remodeling in the LA appendage may help provide new therapeutic options in treating AF and preventing thromboembolism in AF.

Comparison of contemporary preoperative risk models at predicting acute kidney injury after isolated coronary artery bypass grafting: a retrospective cohort study

OBJECTIVES

Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) is associated with short-term and long-term adverse outcomes. The European System for Cardiac Operative Risk Evaluation (EuroSCORE), EuroSCORE II, the Society of Thoracic Surgeons (STS) score and Age, Creatinine and Ejection Fraction (ACEF) score, have been widely used for predicting the operative risk of cardiac surgery. The aim of this study is to investigate the discriminant ability among current available models in predicting postoperative AKI.

METHODS

From January 2010 to December 2012, 353 patients who underwent isolated CABG were enrolled. The clinical characteristics, outcomes and scores of prognostic models were collected. The primary outcome was postoperative AKI, defined based on the Kidney Disease Improving Global Outcome (KDIGO) Clinical Practice Guideline for AKI, in 2012.

RESULTS

102 patients (28.9%) developed postoperative AKI. For AKI prediction, EuroSCORE II, STS score and ACEF score were all good tools for stage-3 AKI. The ACEF score was shown to have satisfied discriminant ability to predict postoperative AKI with area under a receiver operating characteristic curve: 0.781±0.027, (95% CI 0.729 to 0.834, p value <0.001). Multivariate logistic analysis identified that lower ejection fraction and higher serum creatinine were independent risk factors for AKI.

CONCLUSIONS

The simple and extremely user-friendly ACEF score can accurately identify the risk of postoperative AKI and has shown satisfactory discriminant ability when compared with other systems. The ACEF score might be the easiest tool for predicting postoperative AKI.

MMP9 Rs3918242 Polymorphism Affects Tachycardia-Induced MMP9 Expression in Cultured Atrial-Derived Myocytes but Is Not a Risk Factor for Atrial Fibrillation among the Taiwanese

Matrix metalloproteinase (MMP) plays an important role in the pathogenesis of atrial fibrillation (AF). The MMP9 promoter has a functional polymorphism rs3918242 that can regulate the level of gene transcription. This study recruited 200 AF patients and 240 controls. The MMP9 rs3918242 was examined by polymerase chain reactions. HL-1 atrial myocytes were cultured and electrically stimulated. Right atrial appendages were obtained from six patients with AF and three controls with sinus rhythm undergoing open heart surgery. The MMP9 expression and activity were determined using immunohistochemical analysis and gelatin zymography, respectively. Rapid pacing induces MMP9 secretion from HL-1 myocytes in a time- and dose-dependent manner. The responsiveness of MMP9 transcriptional activity to tachypacing was significantly enhanced by rs3918242. The expression of MMP9 was increased in fibrillating atrial tissue than in sinus rhythm. However, the distribution of rs3918242 genotypes and allele frequencies did not significantly differ between the control and AF groups. HL-1 myocyte may secrete MMP9 in response to rapid pacing, and the secretion could be modulated by rs3918242. Although the MMP9 expression of human atrial myocyte is associated with AF, our study did not support the association of susceptibility to AF among Taiwanese subjects with the MMP9 rs3918242 polymorphism.

Safety and efficacy of endoscopic spray cryotherapy for Barrett's dysplasia: results of the National Cryospray Registry

Retrospective series have shown the efficacy of endoscopic spray cryotherapy in eradicating high-grade dysplasia (HGD) in Barrett's esophagus (BE); however, prospective data are lacking, and efficacy for low-grade dysplasia (LGD) is unclear. The aim of this study was to assess the efficacy and safety of spray cryotherapy in patients with LGD or HGD. A multicenter, prospective open-label registry enrolled patients with dysplastic BE. Spray cryotherapy was performed every 2-3 months until there was no endoscopic evidence of BE and no histological evidence of dysplasia, followed by surveillance endoscopies up to 2 years. Primary outcome measures were complete eradication of dysplasia (CE-D) and complete eradication of all intestinal metaplasia (CE-IM). Ninety-six subjects with Barrett's dysplasia (67% HGD; 65% long-segment BE; mean length 4.5 cm) underwent 321 treatments (mean 3.3 per subject). Mean age was 67 years, 83% were male. Eighty patients (83%) completed treatment with follow-up endoscopy (mean duration 21 months). In patients with LGD, rate of CE-D was 91% (21/23) and rate of CE-IM was 61% (14/23). In HGD, CE-D rate was 81% (46/57) and CE-IM was 65% (37/57). In patients with short-segment BE (SSBE) with any dysplasia, CE-D was achieved in 97% (30/31) and CE-IM in 77% (24/31). There were no esophageal perforations or related deaths. One subject developed a stricture, which did not require dilation. One patient was hospitalized for bleeding in the setting of non-steroidal anti-inflammatory drug use. In the largest prospective cohort to date, data suggest endoscopic spray cryotherapy is a safe and effective modality for eradication of BE with LGD or HGD, particularly with SSBE.

Correlation of Preoperative Renal Insufficiency With Mortality and Morbidity After Aortic Valve Replacement: A Propensity Score Matching Analysis

Preoperative end-stage renal disease carries a high mortality and morbidity risk after aortic valve replacement (AVR), but the effect of renal insufficiency remains to be clarified. Through propensity score analysis, we compared the preoperative demographics, perioperative profiles, and outcomes between patients with and without renal insufficiency. From August 2005 to November 2014, 770 adult patients underwent AVR in a single institution. Patients were classified according to their estimated glomerular infiltration rate (eGFR) as renal insufficiency (eGFR: 30-89 mL/min/1.73 m) or normal (eGFR, ≥90 mL/min/1.73 m). Propensity scoring was performed with a 1:1 ratio, resulting in a matched cohort of 88 patients per group. Demographics, comorbidities, and surgical procedures were well balanced between the 2 groups, except for diabetes mellitus and eGFR. Patients with renal insufficiency had higher in-hospital mortality (19.3% versus 3.4%, P < 0.001), a greater need for postoperative hemodialysis (14.8% versus 3.1%, P = 0.009), and prolonged intubation times (>72 hour; 25% versus 9.1%, P = .008), intensive care unit stays (8.9 ± 9.9 versus 4.9 ± 7.5 days, P = .046), and hospital stays (35.3 ± 31.7 versus 24.1 ± 20.3 days, P = .008), compared with those with normal renal function. Multivariate analysis confirmed that preoperative renal insufficiency was an in-hospital mortality predictor (odds ratio, 2.33; 95% confidence interval, 1.343-4.043; P = .003), as were prolonged cardiopulmonary bypass time, intraaortic balloon pump support, and postoperative hemodialysis. The 1-year survival significantly differed between the 2 groups including (normal 87.5% versus renal insufficiency 67.9%, P < .001) or excluding in-hospital mortality (normal 90.7% versus renal insufficiency 82.1%, P = .05). Patients with preoperative renal insufficiency who underwent AVR had higher in-hospital mortality rates and increased morbidities, especially those associated with hemodynamic instabilities requiring intraaortic balloon pump support or hemodialysis. Earlier surgical intervention for severe aortic valve disease should be considered in patients who show deteriorating renal function during follow-up.

Predicting Acute Kidney Injury Following Mitral Valve Repair

BACKGROUND

Acute kidney injury (AKI) after cardiac surgery is associated with short-term and long-term adverse outcomes. Novel biomarkers have been identified for the early detection of AKI; however, examining these in every patient who undergoes cardiac surgery is prohibitively expensive. Society of Thoracic Surgeons (STS) and Age, Creatinine, and Ejection Fraction (ACEF) scores have been proven to predict mortality in bypass surgery. The aim of this study was to determine whether these scores can be used to predict AKI after mitral valve repair.

MATERIALS AND METHODS

Between January 2010 and December 2013, 196 patients who underwent mitral valve repair were enrolled. The clinical characteristics, outcomes, and scores of prognostic models were collected. The primary outcome was postoperative AKI, defined using the Kidney Disease Improving Global Outcome 2012 clinical practice guidelines for AKI.

RESULTS

A total of 76 patients (38.7%) developed postoperative AKI. The STS renal failure (AUROC: 0.797, P < .001) and ACEF scores (AUROC: 0.758, P < .001) are both satisfactory tools for predicting all AKI. The STS renal failure score exhibited superior accuracy compared with the ACEF score in predicting AKI stage 2 and 3. The overall accuracy of both scores was similar for all AKI and AKI stage 2 and 3 when the cut-off points of the STS renal failure and ACEF scores were 2.2 and 1.1, respectively.

CONCLUSION

In conclusion, the STS renal failure score can be used to accurately predict stage 2 and 3 AKI after mitral valve repair. The ACEF score is a simple tool with satisfactory power in screening patients at risk of all AKI stages. Additional studies can aim to determine the clinical implications of combining preoperative risk stratification and novel biomarkers.

Proinflammatory gene expression in patients undergoing mitral valve surgery and maze ablation for atrial fibrillation

OBJECTIVE

It is difficult to achieve rhythm control in patients with long-standing persistent atrial fibrillation (AF). The radiofrequency maze procedure is an effective means in curing AF with a variable recurrence rate depending on patient characteristics and AF duration. In these patients, the characteristics of the atrial substrate have not been well investigated. Because the inflammatory process has been shown to be important in the pathogenesis of AF, we sought to characterize the proinflammatory gene expression in left atria obtained from patients with AF undergoing mitral valve surgery combined with the maze procedure to distinguish the changes associated with AF and its recurrence after the surgical ablation.

METHODS

Left atrial appendages from 35 patients receiving mitral valve surgery were used for study. Ten patients had sinus rhythm (SR) and 25 patients had persistent AF for more than 1 year and underwent the maze procedure. Among the AF patients, 13 patients remained in SR (AF-SR) and 12 patients had recurrent AF during the 1-year clinical follow-up (AF-AF). The nCounter Human Inflammation Array (NanoString Technologies, Seattle, Wash) was used for evaluating proinflammatory gene expression. Quantitative polymerase chain reaction, Western blot, and immunohistochemistry were applied for studying messenger RNA and protein expression.

RESULTS

Of 144 expressed proinflammatory genes, the inflammation array analysis revealed that 32 genes were differentially expressed between AF (including AF-SR and AF-AF) and SR. Thirteen genes were differentially expressed between AF-SR and AF-AF. The array and quantitative polymerase chain reaction produced parallel results in analyzing the expression of particular genes. Concordant with the gene expression difference between AF and SR patients, rapid pacing increased the expressions of SHC1, RHOA, PDGFA, and TRAF2 in HL-1 myocytes, implicating a causative effect of tachyarrhythmia on these genes. Compared with AF-SR, AF-AF expressed more intense oxidative stress, upregulations of collagen, transforming growth factor beta 1, and intranuclear nuclear factor of activated T-cells. Regression analysis showed that increased left atrial diameter was associated with the expression of RHOA and STAT1.

CONCLUSIONS

Differential expression profiles of proflammatory genes were presented between SR and AF and between maintained SR and recurrent AF after the maze procedure. The identified inflammatory molecules associated with AF and failed surgical ablation may provide clues for developing new potential therapeutic targets to improve AF rhythm control.

Passive Leg Raising Correlates with Future Exercise Capacity after Coronary Revascularization

Hemodynamic properties affected by the passive leg raise test (PLRT) reflect cardiac pumping efficiency. In the present study, we aimed to further explore whether PLRT predicts exercise intolerance/capacity following coronary revascularization. Following coronary bypass/percutaneous coronary intervention, 120 inpatients underwent a PLRT and a cardiopulmonary exercise test (CPET) 2–12 days during post-surgery hospitalization and 3–5 weeks after hospital discharge. The PLRT included head-up, leg raise, and supine rest postures. The end point of the first CPET during admission was the supra-ventilatory anaerobic threshold, whereas that during the second CPET in the outpatient stage was maximal performance. Bio-reactance-based non-invasive cardiac output monitoring was employed during PLRT to measure real-time stroke volume and cardiac output. A correlation matrix showed that stroke volume during leg raise (SV_LR) during the first PLRT was positively correlated (R = 0.653) with the anaerobic threshold during the first CPET. When exercise intolerance was defined as an anaerobic threshold < 3 metabolic equivalents, SV_LR / body weight had an area under curve value of 0.822, with sensitivity of 0.954, specificity of 0.593, and cut-off value of 1504·10^-3mL/kg (positive predictive value 0.72; negative predictive value 0.92). Additionally, cardiac output during leg raise (CO_LR) during the first PLRT was related to peak oxygen consumption during the second CPET (R = 0.678). When poor aerobic fitness was defined as peak oxygen consumption < 5 metabolic equivalents, CO_LR / body weight had an area under curve value of 0.814, with sensitivity of 0.781, specificity of 0.773, and a cut-off value of 68.3 mL/min/kg (positive predictive value 0.83; negative predictive value 0.71). Therefore, we conclude that PLRT during hospitalization has a good screening and predictive power for exercise intolerance/capacity in inpatients and early outpatients following coronary revascularization, which has clinical significance.

Timing of Intervention in Blunt Traumatic Aortic Injury Patients: Open Surgical versus Endovascular Repair

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) is a rapidly evolving therapy in treating blunt traumatic aortic injury (TAI). However, currently there is no consensus among literature regarding the repair timing of TAI. Our experiences to manage TAI with comparison between open surgical and endovascular repair in repair timing and short-term outcomes are reported. Risk factors for postoperative mortality and morbidity are stratified.

METHODS

Between January 2003 and February 2014, 63 consecutive patients who have suffered from TAI and underwent conventional open surgical or endovascular aortic repair were retrospectively reviewed in this study. The primary outcomes were in-hospital mortality, postoperative complication, and operation timing. All medical records regarding trauma mechanisms, concomitant injuries, intervention detail, and postoperative outcomes were reviewed and analyzed.

RESULTS

Among the 63 patients (mean age, 37.9 years; 57 male), 23 underwent open repair (OR) and 40 underwent TEVAR for blunt TAI. The TEVAR group had more urgent operation (injury to repair <24 hr; 57.5% vs. 30.4%, P = 0.038) and shorter operative time (136.25 ± 54.48 min vs. 414.78 ± 212.24 min, P = 0.00) than the respective open surgical repair group. Postoperative mortality and morbidity analysis showed that the OR group had higher in-hospital mortality (30.4% vs. 7.5%; P = 0.029), more patients with acute renal failure in need of hemodialysis (17.4% vs. 2.3%; P = 0.038), and more post-operation infection (30.4% vs. 5%; P = 0.005) than the respective TEVAR group. The Multivariate analysis, of the 10 (15.88%) patients that died after the surgery, showed that the risk factors of hospital mortality were grade IV TAI (frank rupture).

CONCLUSIONS

For treating TAI, TEVAR has emerged as a quicker and safer treatment option than OR. The findings of this study support the use of TEVAR over OR for patients who suffered from TAI.

The Prognostic Scoring System Establishment and Validation for Chronic Atrial Fibrillation Patients Receiving Modified Cox-Maze IV and Concomitant Cardiac Surgery

OBJECTIVES

Traditional Cox maze III is the gold standard for treatment of atrial fibrillation (AF). Because of its invasiveness, it has been replaced by a simplified procedure involving radiofrequency ablation of modified Cox maze IV. Although the modified Cox maze IV has the advantages of simplicity and less morbidity, a lower rate of sinus rhythm conversion has been reported. We try to establish a scoring system to predict the outcome of this procedure.

METHODS AND RESULTS

The derivation group consisted of 287 patients with structural heart disease and chronic AF who underwent cardiac surgery and modified Cox-maze IV procedure between August 2005 and March 2013. Demographics, clinical and laboratory variables were retrospectively collected as sinus conversional predictors. Overall sinus conversion rate was 75.8%. The parameters of the Soft Markers Scoring system included AF duration, preoperative left atrial (LA) size, rheumatic pathology and postoperative LA remodeling. We compared 80 patients from another hospital between January 2004 and December 2011 as a validation group to evaluate the power of the scoring system. Soft Markers Score indicated a good discriminative power by using the areas under the receiver operating characteristic curve (AUROC: 0.759 ± 0.032). The score was further divided into three groups: low (0-2), intermediate (3-5), and high (6-10), with predicted sinus conversion rates of 92.4%, 74.2%, and 47.8%, respectively.

CONCLUSIONS

In patients with chronic AF receiving modified Cox-maze IV procedure, the Soft Markers Score demonstrated good discriminative power of predicting sinus recovery in our patients and applied well to the other validation populations.

Blunt aortic injury: risk factors and impact of surgical approaches

PURPOSE

This study reviews our 17-year experience of managing blunt traumatic aortic injury (BTAI).

METHODS

We analyzed information collected retrospectively from a tertiary trauma center.

RESULTS

Between October 1995 and June 2012, 88 patients (74 male and 14 female) with a mean age of 39.9 ± 17.9 years (range 15-79 years) with proven BTAI were enrolled in this study. Their GCS, ISS, and RTS scores were 12.9 ± 3.7, 29.2 ± 9.8, and 6.9 ± 1.4, respectively. Twenty-one (23.8 %) patients were managed non-operatively, 49 (55.7 %) with open surgical repair, and 18 (20.5 %) with endovascular repair. The in-hospital mortality rate was 17.1 % (15/81) and there were no deaths in the endovascular repair group. The mean follow-up period was 39.9 ± 44.2 months. The survivors of blunt aortic injury had lower ISS, RTS, TRISS, and serum creatinine level and lower rate of massive blood transfusion, shock, and intubation than the patients who died, despite higher rates of endovascular repair, hemoglobin, and GCS on presentation. The degree of aortic injury, different therapeutic options, GCS, shock presentation, and intubation on arrival all had significant impacts on outcome.

CONCLUSIONS

Shock, aortic injury severity, coexisting trauma severity, and different surgical approaches impact survival. Endovascular repair achieves a superior mid-term result and is a reasonable option for treating BTAI.

Survival predictors in acute respiratory distress syndrome with extracorporeal membrane oxygenation

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) can be used as a salvage therapy, but the effectiveness is controversial. The aim of this study was to investigate the predictors of mortality and the influence of organ dysfunction scores in severe acute respiratory distress syndrome (ARDS) patients treated with ECMO.

METHODS

The records of adult severe ARDS patients receiving ECMO support from May 2006 to December 2011 at Chang Gung Memorial Hospital were retrospectively analyzed.

RESULTS

The records of 65 patients with severe ARDS who received venovenous ECMO were analyzed. The hospital survival rate was 47.7%. Survivors were younger than nonsurvivors (41.4 ± 15.4 versus 54.1 ± 16.9 years, respectively; p = 0.002) and had shorter duration of mechanical ventilation before ECMO (52.7 ± 51.1 versus 112.1 ± 101.0 hours, respectively; p = 0.01). Before ECMO, Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, and Multiple Organ Dysfunction scores were significantly lower for survivors than for nonsurvivors. Mortality rate increased with rising predictive score. During 7 days of ECMO use, organ dysfunction scores were significantly lower for survivors than nonsurvivors.

CONCLUSIONS

Severe ARDS patients who are younger, have shorter duration of mechanical ventilation, and lower organ dysfunction scores before ECMO initiation have more favorable survival outcome. Early application of ECMO, especially if predictive score is below 2, may improve survival. Organ dysfunction scores before and during ECMO support are correlated with survival.

Microsatellite polymorphism in the heme oxygenase-1 gene promoter and the risk of atrial fibrillation in Taiwanese

Background

Atrial fibrillation (AF) is associated with increased oxidative stress. Emerging evidence suggests that heme oxygenase-1 (HO-1) is a potent antioxidant system against various oxidative stress-related diseases. The human HO-1 promoter has a GT-repeat length polymorphism that can determine the level of gene transcription.

Objective

The aim of this study is to assess the role of the GT-repeat polymorphism in the promoter region of the HO-1 gene in Chinese-Taiwanese patients with AF.

Methods and Results

This study enrolled 200 AF patients and 240 controls, comparable for age and gender. In each subject, the length of GT-repeat polymorphism in the HO-1 promoter region was examined by polymerase chain reactions. The frequencies of long GT-repeat alleles (≧32) were significantly higher in AF patients than in controls. Multivariate analysis showed that the presence of long allele was significantly and independently associated with AF (odds ratio: 1.91, 95% CI 1.07–3.72; P = 0.028). Right atrial tissues from patients with chronic AF were investigated with immunoconfocal microscopy. Patients homozygous for shorter GT-repeat alleles exhibited greater HO-1 expression in their atria than those homozygous for longer alleles, which was reflected by less oxidative stress, myofibril degradation, and fibrosis in the atria of patients with shorter GT-repeat. In vitro, transient transfection assay in HL-1 atrial myocytes showed that the responsiveness of HO-1 transcriptional activity to tachypacing was inversely correlated with the length of the GT-repeats.

Conclusion

Our results suggest that the HO-1 microsatellite polymorphism may contribute to the genetic background of AF in Chinese-Taiwanese patients.

Acute kidney injury in adults receiving extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) has been utilized for critically ill patients such as patients with postcardiotomy cardiogenic shock or life-threatening respiratory failure. Acute kidney injury (AKI) that develops during ECMO is associated with a very poor outcome, possibly because of accumulated extravascular water causing interstitial overload, impaired oxygen transport through tissues, and increased extravascular lung water volume with impaired O(2) transport. Increased water is associated with subsequent organ dysfunction, particularly of the heart, lungs, and brain. Based on single-center studies, the incidence of AKI is 70-85% in ECMO patients. Therefore, renal replacement therapy is required in approximately 50% of these patients. This review summarizes three modalities that can be used to introduce renal replacement therapy to patients on ECMO, the pathophysiology of AKI in ECMO, and the impact of AKI on mortality. This review also identifies specific research-focused questions that need to be addressed to predict AKI early and to improve outcomes in this at-risk adult population.

Clinical, microbiologic, and outcome analysis of mycotic aortic aneurysm: the role of endovascular repair

BACKGROUND

Mycotic aortic aneurysm (MAA) is an infrequent but devastating form of vascular disease.

METHODS

We conducted a retrospective cohort study at a major medical center to identify independent risk factors for MAA and to provide opinions about treating it. The study population consisted of 43 patients who had had 44 MAAs over a period of 15 y.

RESULTS

All of the patients had positive blood cultures, radiologic findings typical of MAA, and clinical signs of infection (leukocytosis, fever, and elevated C-reactive protein). The mean age of the patients was 63.8±10.6 y and the mean period of their follow up was 35.7±39.3 mo. Twenty-nine patients with MAAs underwent traditional open surgery, 11 others received endovascular stent grafts, and four MAAs were managed conservatively. The most frequent causative pathogens were Salmonella (36/44 patients [81.8%]), in whom organisms of Salmonella serogroup C (consisting mainly of S. choleraesuis) were identified in 14 patients, organisms of Salmonella serogroup D were identified in 13 patients, and species without serogroup information were identified in nine patients. The overall mortality in the study population was 43.2% (with an aneurysm-related mortality of 18.2%, surgically related mortality of 13.6%, and in-hospital mortality of 22.7%).

CONCLUSIONS

Shock is a risk factor for operative mortality. Misdiagnosis and treatment of MAA as low back pain, co-existing connective-tissue disease such as systemic lupus erythematosus and rheumatoid arthritis, and Salmonella serogroup C-associated bacteremia are risk factors for aneurysm-related death. Endovascular repair should be considered as an alternative option to the open repair of MAA.