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Chandra R, Meier J, Marshall N, Chuckaree I, Harirah O, Khoury MK, Ring WS, Peltz M, Wait MA, Jessen ME, Hackmann AE, Heid CA. Safety-Net Hospital Status Is Associated With Coronary Artery Bypass Grafting Outcomes at an Urban Academic Medical Center. J Surg Res 2024; 294:112-121. [PMID: 37866066 DOI: 10.1016/j.jss.2023.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/25/2023] [Accepted: 08/27/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Socioeconomic disparities impact outcomes after cardiac surgery. At our institution, cardiac surgery cases from the safety-net, county funded hospital (CH), which primarily provides care for underserved patients, are performed at the affiliated university hospital. We aimed to investigate the association of socioeconomic factors and CH referral status with outcomes after coronary artery bypass grafting (CABG). METHODS The institutional Adult Cardiac Surgery database was queried for perioperative and demographic data from patients who underwent isolated CABG between January 2014 and June 2020. The primary outcome was major adverse cardiovascular event (MACE), a composite of postoperative myocardial infarction, stroke, or death. Secondary outcomes included individual complications. Chi-square, Wilcoxon rank-sum, and logistic regression analyses were used to compare differences between CH and non-CH cohorts. RESULTS We included 836 patients with 472 (56.5%) from CH. Compared to the non-CH cohort, CH patients were younger, more likely to be Hispanic, non-English speaking, and be completely uninsured or require state-specific financial assistance. CH patients were more likely to have a history of tobacco and drug use, liver disease, diabetes, prior myocardial infarction, and greater degrees of left main coronary and left anterior descending artery stenosis. CH cases were less likely to be elective. The incidence of MACE was significantly higher in the CH cohort (16.3% versus 8.2%, P = 0.001). There were no significant differences in 30-d mortality, home discharge, prolonged mechanical ventilation, bleeding, sepsis, pneumonia, new dialysis requirement, cardiac arrest, or multiorgan system failure between cohorts. CH patients were more likely to develop renal failure and less likely to develop atrial fibrillation. On multivariable analysis, CH status (odds ratio 2.39, 95% confidence interval 1.25-4.55, P = 0.008) was independently associated with MACE. CONCLUSIONS CH patients undergoing CABG presented with greater comorbidity burden, more frequently required nonelective surgery, and are at significantly higher risk of postoperative MACE.
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Affiliation(s)
- Raghav Chandra
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Memorial Hospital, Dallas, Texas
| | - Jennie Meier
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Memorial Hospital, Dallas, Texas
| | - Nicholas Marshall
- Parkland Memorial Hospital, Dallas, Texas; School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ishwar Chuckaree
- Parkland Memorial Hospital, Dallas, Texas; School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Omar Harirah
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Memorial Hospital, Dallas, Texas
| | - Mitri K Khoury
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Memorial Hospital, Dallas, Texas
| | - W Steves Ring
- Parkland Memorial Hospital, Dallas, Texas; Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthias Peltz
- Parkland Memorial Hospital, Dallas, Texas; Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael A Wait
- Parkland Memorial Hospital, Dallas, Texas; Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael E Jessen
- Parkland Memorial Hospital, Dallas, Texas; Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Amy E Hackmann
- Parkland Memorial Hospital, Dallas, Texas; Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher A Heid
- Parkland Memorial Hospital, Dallas, Texas; Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
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Gaudino M, Flather M, Capodanno D, Milojevic M, Bhatt DL, Biondi Zoccai G, Boden WE, Devereaux PJ, Doenst T, Farkouh M, Freemantle N, Fremes S, Puskas J, Landoni G, Lawton J, Myers PO, Redfors B, Sandner S. European Association of Cardio-Thoracic Surgery (EACTS) expert consensus statement on perioperative myocardial infarction after cardiac surgery. Eur J Cardiothorac Surg 2024; 65:ezad415. [PMID: 38420786 DOI: 10.1093/ejcts/ezad415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/14/2023] [Accepted: 12/12/2023] [Indexed: 03/02/2024] Open
Abstract
Cardiac surgery may lead to myocardial damage and release of cardiac biomarkers through various mechanisms such as cardiac manipulation, systemic inflammation, myocardial hypoxia, cardioplegic arrest and ischaemia caused by coronary or graft occlusion. Defining perioperative myocardial infarction (PMI) after cardiac surgery presents challenges, and the association between the current PMI definitions and postoperative outcomes remains uncertain. To address these challenges, the European Association of Cardio-Thoracic Surgery (EACTS) facilitated collaboration among a multidisciplinary group to evaluate the existing evidence on the mechanisms, diagnosis and prognostic implications of PMI after cardiac surgery. The review found that the postoperative troponin value thresholds associated with an increased risk of mortality are markedly higher than those proposed by all the current definitions of PMI. Additionally, it was found that large postoperative increases in cardiac biomarkers are prognostically relevant even in absence of additional supportive signs of ischaemia. A new algorithm for PMI detection after cardiac surgery was also proposed, and a consensus was reached within the group that establishing a prognostically relevant definition of PMI is critically needed in the cardiovascular field and that PMI should be included in the primary composite outcome of coronary intervention trials.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Biondi Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - William E Boden
- VA New England Healthcare System, Boston University School of Medicine, Boston, MA, USA
| | - P J Devereaux
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Michael Farkouh
- Academic Affairs, Cedars-Sinai Health System, Los Angeles, CA, USA
| | - Nicholas Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Stephen Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - John Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY, USA
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Jennifer Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Patrick O Myers
- Department of Cardiac Surgery, CHUV-Center Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Björn Redfors
- Cardiovascular Research Foundation, New York, NY, USA
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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Semagin AA, Lukin OP, Fokin AA. [Comparative analysis of in-hospital and long-term results of patients with acute dysfunction of coronary bypass grafts depending on treatment tactics]. Khirurgiia (Mosk) 2024:50-57. [PMID: 38258688 DOI: 10.17116/hirurgia202401150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE Comparative analysis of in-hospital and long-term mortality of patients in whom acute dysfunction of coronary bypass grafts was detected in the early postoperative period depending on conservative or surgical tactics. MATERIAL AND METHODS The study is a retrospective analysis of data from 8801 patients who underwent elective coronary artery bypass grafting (CABG) between 2011 and 2022 at the Federal Center for Cardiovascular Surgery (Russia, Chelyabinsk). Among them, 196 patients underwent emergency coronary artery bypass grafting due to suspected perioperative myocardial infarction in the early postoperative period. In 119 patients, dysfunction of coronary bypass grafts was detected, in 77 patients no pathological changes were found. The criteria for inclusion in the study were patients with dysfunction of coronary bypass grafts (n=119). The 1st group included patients who underwent conservative therapy (n=33), the 2nd group (n=86) included those who underwent repeated myocardial revascularization. The primary endpoint was hospital mortality, secondary endpoints were long-term mortality and adverse cardiovascular events (myocardial infarction, stroke, repeat myocardial revascularization). Patients were surveyed via telephone. RESULTS In-hospital mortality in the group of surgical reintervention was 8.1%, in the group of conservative treatment - 9.1% (p=0.867). According to the results of multivariate analysis, predictors of hospital mortality in patients of both groups were extracorporeal membrane oxygenation (p=0.014), time of artificial circulation (p=0.031), duration of artificial ventilation (p=0.001), number of days in intensive care (p<0.001). When analyzing long-term mortality using the Kaplan-Meier method in group 1 and group 2, no statistically significant differences were found; in the group of conservative therapy - 85±9.6 [66.2-103.7] months versus 108.2±4.8 [98.8-117.6] months in the surgery group (log-rank p=0.06). When analyzing long-term mortality from cardiovascular causes and the occurrence of adverse cardiovascular events, statistically significant differences were determined: in the group of conservative therapy - 92.5±9.3 [74.2-110.7] months versus 117.8±3.3 [111.2-124.3] months in the surgical treatment group (log-rank p=0.007) and 78.1±9.2 [60-96.3] months versus 98.9±3.9 [91.3-106.5] months (log-rank p=0.008), respectively. CONCLUSION In-hospital mortality was comparable between groups. Long-term mortality from cardiovascular causes and the number of adverse cardiovascular events were significantly higher in the conservative therapy group. With timely detection of acute dysfunction of coronary bypass grafts, an active surgical approach has an advantage over conservative tactics and can improve the long-term prognosis of patients.
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Affiliation(s)
- A A Semagin
- Federal Center for Cardiovascular Surgery, Ministry of Health of Russia, Chelyabinsk, Russia
| | - O P Lukin
- Federal Center for Cardiovascular Surgery, Ministry of Health of Russia, Chelyabinsk, Russia
- Federal State Budgetary Educational Institution of Higher Professional Education «South Ural State Medical University» of the Ministry of Health of Russia, Chelyabinsk, Russia
| | - A A Fokin
- Federal State Budgetary Educational Institution of Higher Professional Education «South Ural State Medical University» of the Ministry of Health of Russia, Chelyabinsk, Russia
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Gaudino M, Dangas GD, Angiolillo DJ, Brodt J, Chikwe J, DeAnda A, Hameed I, Rodgers ML, Sandner S, Sun LY, Yong CM. Considerations on the Management of Acute Postoperative Ischemia After Cardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2023; 148:442-454. [PMID: 37345559 DOI: 10.1161/cir.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Acute postoperative myocardial ischemia (PMI) after cardiac surgery is an infrequent event that can evolve rapidly and become a potentially life-threatening complication. Multiple factors are associated with acute PMI after cardiac surgery and may vary by the type of surgical procedure performed. Although the criteria defining nonprocedural myocardial ischemia are well established, there are no universally accepted criteria for the diagnosis of acute PMI. In addition, current evidence on the management of acute PMI after cardiac surgery is sparse and generally of low methodological quality. Once acute PMI is suspected, prompt diagnosis and treatment are imperative, and options range from conservative strategies to percutaneous coronary intervention and redo coronary artery bypass grafting. In this document, a multidisciplinary group including experts in cardiac surgery, cardiology, anesthesiology, and postoperative care summarizes the existing evidence on diagnosis and treatment of acute PMI and provides clinical guidance.
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Robinson NB, Sef D, Gaudino M, Taggart DP. Postcardiac surgery myocardial ischemia: Why, when, and how to intervene. J Thorac Cardiovasc Surg 2023; 165:687-695. [PMID: 34556355 DOI: 10.1016/j.jtcvs.2021.05.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/21/2021] [Accepted: 05/30/2021] [Indexed: 01/18/2023]
Affiliation(s)
- N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Davorin Sef
- Department of Cardiac Surgery, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - David P Taggart
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.
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Commentary: Postcardiac surgery myocardial ischemia: Be on the lookout and sort it out! J Thorac Cardiovasc Surg 2023; 165:696-697. [PMID: 34247866 DOI: 10.1016/j.jtcvs.2021.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 06/21/2021] [Accepted: 06/21/2021] [Indexed: 01/18/2023]
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Successful Treatment of Whole Coronary Artery Spasm after Off-Pump Coronary Artery Bypass Grafting. Case Rep Cardiol 2022; 2022:9003921. [PMID: 36119440 PMCID: PMC9481397 DOI: 10.1155/2022/9003921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/24/2022] [Indexed: 11/24/2022] Open
Abstract
Coronary artery spasm after coronary artery bypass grafting is a rare but life-threatening condition. Herein, we report the case of a 77-year-old man who received off-pump coronary artery bypass grafting. An hour after surgery, there was a sudden hemodynamic compromise due to coronary artery spasm, prompting emergent coronary angiography with extracorporeal membrane oxygenation support. Because the angiography results showed diffuse severe spasm of the entire native coronary artery, the patient was treated with an intracoronary injection of vasodilators. The patient recovered in 7 days with mechanical support, catecholamines, and vasodilators, and he was discharged on postoperative day 30. Although coronary artery spasm after off-pump coronary artery bypass surgery is a rare condition, it must be suspected when sudden circulatory collapse occurs.
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Beerkens FJ, Claessen BE, Mahan M, Gaudino MFL, Tam DY, Henriques JPS, Mehran R, Dangas GD. Contemporary coronary artery bypass graft surgery and subsequent percutaneous revascularization. Nat Rev Cardiol 2022; 19:195-208. [PMID: 34611327 DOI: 10.1038/s41569-021-00612-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2021] [Indexed: 11/09/2022]
Abstract
Patients who have undergone coronary artery bypass graft (CABG) surgery are susceptible to bypass graft failure and progression of native coronary artery disease. Although the saphenous vein graft (SVG) was traditionally the most-used conduit, arterial grafts (including the left and right internal thoracic arteries and the radial artery) have improved patency rates. However, the need for secondary revascularization remains common, and percutaneous coronary intervention (PCI) has become the most common modality of secondary revascularization after CABG surgery. Procedural characteristics and clinical outcomes differ considerably from those associated with PCI in patients without previous CABG surgery, owing to altered coronary anatomy and differences in conduit pathophysiology. In particular, SVG PCI carries an increased risk of complications, and operators are shifting their focus towards embolic protection strategies and complex native-vessel interventions, increasingly using SVGs as conduits to facilitate native-vessel PCI rather than pursuing SVG PCI. In this Review, we discuss the differences in conduit pathophysiology, changes in CABG surgery techniques, and the latest evidence in terms of PCI in patients with previous CABG surgery, with a particular emphasis on safety and long-term efficacy. We explore the subject of contemporary CABG surgery and subsequent percutaneous revascularization in this complex patient population.
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Affiliation(s)
- Frans J Beerkens
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bimmer E Claessen
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Cardiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Marielle Mahan
- Department of Ophthalmology, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto, Toronto, ON, Canada
| | - José P S Henriques
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George D Dangas
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Amr MA, Fayad E. Predictors of perioperative myocardial infarction in patients undergoing off-pump coronary artery bypass grafting. THE CARDIOTHORACIC SURGEON 2022. [DOI: 10.1186/s43057-021-00066-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Perioperative myocardial infarction (PMI) increases morbidity and mortality after off-pump coronary artery bypass grafting (CABG). The objective of the current study was to characterize patients with PMI after off-pump CABG and identify its predictors.
Results
We included 1181 patients who had off-pump CABG from 2010 to 2020; 59 patients (5%) had PMI. We compared patients with PMI to those without PMI. Patients with PMI were older (57 (25th–75th percentiles: 51–63) vs. 54 (48–60) years; P = 0.01) and had higher NYHA class (28 (47.46%) vs. 326 (29.06%): P = 0.01). The distal anastomosis time was longer in patients with PMI (28 (23–35) vs. 24 (16–30) min; P ˂ 0.001). Patients with PMI had higher postoperative low cardiac output (10 (18.18%) vs. 1 (0.1%): P ˂ 0.001), prolonged ventilation (12 (8–39) vs. 8 (6–10) h, P ˂ 0.001), ICU (71 (46–138) vs. 24 (23–42) h; P ˂ 0.001), and hospital stay (9 (6–15) vs. 7 (6–8) days; P ˂ 0.001). Mortality was significantly higher in patients with PMI (20 (33.9%) vs. 6 (0.53%); P ˂ 0.001). Older age (OR: 1.05 (95% CI: 1.01–1.1); P = 0.02), increased number of distal anastomoses (OR: 1.74 (95% CI: 1.20–2.50); P = 0.003), preoperative congestive heart failure (OR: 10.27 (95% CI: 2.58–40.95); P = 0.001), and thrombolysis within 24 h of surgery (OR: 15.34 (1.93–121.9); P = 0.01) were associated with increased PMI, while PMI was lower in male patients (OR: 0.42 (95% CI: 0.19–0.93); P = 0.03) and with higher body surface area (BSA) (OR: 0.08 (95% CI: 0.07–0.86); P = 0.04).
Conclusions
Post-off-pump CABG PMI was associated with increased morbidity and mortality. Risk factors for PMI were older age, lower BSA, females, increased distal anastomoses, preoperative heart failure, and thrombolysis.
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Putro B, Hidayat J, Soenarto R. The use of blood and crystalloid cardioplegia in adult open-heart surgery on postsurgical outcomes: A systematic review of atrial fibrillation incidence, myocardial infarction, inotropic use, length of stay in ICU, and postoperative mortality. BALI JOURNAL OF ANESTHESIOLOGY 2022. [DOI: 10.4103/bjoa.bjoa_148_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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Putra E, Putro B, Purwoko P, Supraptomo R, Sunjoyo A. The use of blood versus crystalloid cardioplegia in adult open heart surgery: A systematic review. BALI JOURNAL OF ANESTHESIOLOGY 2022. [DOI: 10.4103/bjoa.bjoa_62_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Chandiramani AS, Jenkin I, Botezatu B, Harky A. Protamine-Induced Coronary Graft Thrombosis: A Review. J Cardiothorac Vasc Anesth 2021; 36:2679-2684. [PMID: 34774407 DOI: 10.1053/j.jvca.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/07/2021] [Accepted: 10/06/2021] [Indexed: 11/11/2022]
Abstract
Perioperative myocardial infarction is a serious complication affecting a significant portion of patients undergoing coronary artery bypass graft surgery. This may arise due to coronary graft thrombosis, a rare but potentially fatal phenomenon associated with both congenital and acquired risk factors. Multiple case reports implicate the role of protamine in the development of such thromboses. The role of protamine in facilitating the regulation of hemostasis by reversing the anticoagulant effects of heparin in patients undergoing cardiopulmonary bypass is well-recognized. However, discussion of its potential contribution to coronary graft thrombosis and mechanisms by which this may occur is lacking. Furthermore, its narrow therapeutic index and side effect profile are such that its appropriateness as a universal reversal agent to heparin requires reconsideration. This article reviews the current body of evidence regarding the use of protamine in cardiac surgery and the limited case reports pertaining to its potential role in the pathophysiology of coronary graft thrombosis.
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Affiliation(s)
- Ashwini Suresh Chandiramani
- College of Medical, Veterinary and Life Sciences, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Ifan Jenkin
- Department of General Surgery, The Whittington Hospital, London, United Kingdom
| | - Bianca Botezatu
- Department of Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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Semagin AA, Lukin OP, Shaldybin PD, Fokin AA. [Peculiariities of diagnostic parameters in patients with acute myocardial lesion after coronary artery bypass grafting]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:114-120. [PMID: 34166351 DOI: 10.33529/angio2021214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Annually, up to 850 000 coronary aortic bypass graft operations are performed worldwide. Despite modern technical equipment ensuring a high level of safety of the procedure, currently important remains a problem related to intraoperative myocardial damage in using artificial circulation. Early detection and clinical assessment of myocardial ischaemia often present a difficult task. This article deals with clinical, instrumental and laboratory methods of diagnosis, aimed at verification of an intraoperative cardiac lesion associated with graft dysfunction in coronary artery bypass grafting. Isolated electrocardiographic and echocardiographic signs of myocardial ischaemia between the comparison groups did not differ significantly. Analysing the markers of myocardial lesions, statistically significant differences were obtained only after 48 hours which, from the point of view of saving viable myocardium, is an utterly long-term interval. Studying the findings of intraoperative flowmetry showed statistically significant dependence between velocity characteristics, pulse index of shunts and their patency on angiographic examination. Thus, only combination of diagnostic parameters makes it possible to detect myocardial damage related to shunt dysfunction. This enables early determination of indications for performing bypass angiography and selection of the required therapeutic policy. Timely coronary artery angiography makes it possible to reveal defects of shunts and to timely perform surgical correction, preventing myocardial infarction.
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Affiliation(s)
- A A Semagin
- Cardiosurgical Department #2, Federal Centre of Cardiovascular Surgery, Chelyabinsk, Russia; Department of Surgery of the Institute of Additional Professional Education, South Ural State Medical University under the RF Ministry of Public Health, Chelyabinsk, Russia
| | - O P Lukin
- Cardiosurgical Department #2, Federal Centre of Cardiovascular Surgery, Chelyabinsk, Russia; Department of Surgery of the Institute of Additional Professional Education, South Ural State Medical University under the RF Ministry of Public Health, Chelyabinsk, Russia
| | - P D Shaldybin
- Department of Surgery of the Institute of Additional Professional Education, South Ural State Medical University under the RF Ministry of Public Health, Chelyabinsk, Russia
| | - A A Fokin
- Department of Surgery of the Institute of Additional Professional Education, South Ural State Medical University under the RF Ministry of Public Health, Chelyabinsk, Russia
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14
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Iguina MM, Smithson S, Danckers M. Incessant Refractory Polymorphic Ventricular Tachycardia After Coronary Artery Bypass Graft. Cureus 2021; 13:e12752. [PMID: 33643727 PMCID: PMC7886165 DOI: 10.7759/cureus.12752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/17/2021] [Indexed: 11/08/2022] Open
Abstract
Polymorphic ventricular tachycardia (PVT) post coronary artery bypass (CABG) surgery is associated with acute myocardial ischemia, hemodynamic instability, and metabolic derangements. When acute ischemia is suspected, a comprehensive investigation for reversible causes is justified to improve patient outcomes. We present a curious case of incessant, refractory PVT in a patient with an unknown etiology requiring percutaneous coronary intervention (PCI) post CABG. The patient was a 73-year-old female with multiple comorbidities who presented to the hospital with anginal chest pain for one day. Initial electrocardiogram (EKG) showed sinus tachycardia with ST-segment depressions in the inferior-lateral leads. Initial cardiac troponin I was elevated at 28.280 ng/mL. Dual antiplatelet therapy and heparin were started. Urgent coronary angiography revealed significant triple-vessel disease, and she subsequently underwent three-vessel CABG. Her postoperative course was complicated by PVT refractory to all antiarrhythmic therapy and ventricular fibrillatory (VF) arrest with the recovery of spontaneous circulation after defibrillation and amiodarone bolus. Despite normal electrolytes and discontinuation of all QT-prolonging agents, PVT persisted. Urgent coronary angiography revealed a patent venous graft to a previously underappreciated severely stenotic distal segment of the left anterior descending artery (LAD). She underwent PCI of the culprit lesion with the termination of PVT. Although acute graft failure is regularly the culprit for acute myocardial infarction perioperatively, emergent coronary angiography post coronary bypass surgery revealed patent grafts and a previously underestimated severe coronary lesion contributing to ongoing ischemia. Post CABG percutaneous coronary intervention (PCI) yielded a complete resolution of her arrhythmia.
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Affiliation(s)
- Michele M Iguina
- Internal Medicine, Aventura Hospital and Medical Center, Aventura, USA
| | - Shaun Smithson
- Cardiology, Aventura Hospital and Medical Center, Aventura, USA
| | - Mauricio Danckers
- Critical Care Medicine, Aventura Hospital and Medical Center, Aventura, USA
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15
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Sef D, Predrijevac M, Raja SG, Turina MI. Is it better to treat bypass graft or native coronary artery following early graft failure? J Card Surg 2020; 36:9-11. [PMID: 33085109 DOI: 10.1111/jocs.15144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/09/2020] [Accepted: 10/11/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Davorin Sef
- Department of Cardiac Surgery, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Mladen Predrijevac
- Department of Cardiac Surgery, Magdalena Clinic for Cardiovascular Diseases, Krapinske Toplice, Croatia
| | - Shahzad G Raja
- Department of Cardiac Surgery, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, London, UK
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16
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Abstract
Background. Cardiac surgery carries a well-known risk of perioperative myocardial infarction (MI), which is associated with high morbidity and both in-hospital and late mortality. The rapid haemodynamics deterioration and presence of myocardial ischemia early after cardiac surgical operations is a complex life-threatening condition where rapid diagnosis and management is of fundamental importance. Objective. To analyse the factors associated with mortality of patients with postcardiotomy MI and to study the role of emergency coronary angiography in management and outcome. Methods. We retrospectively enrolled adult patients diagnosed to have postcardiotomy MI and underwent emergency coronary angiography at our tertiary care hospital between January 2016 and August 2019. Results. Sixty-one patients from consecutive 1869 adult patients who underwent cardiac surgeries were enrolled in our study. The studied patients had a mean age of 49 ± 16.2 years with a mean BMI of 29.5 ± 6.6 and 65.6% of them were males. As compared to the survivors group, the nonsurvivors of perioperative MI had significant preoperative CKD, postoperative AKI, longer CPB time, frequent histories of previous PCI, previous cardiotomies, pre and postoperative ECMO use, higher median troponin I levels, higher peak and 24 hours median lactate levels. Regression analysis revealed that reoperation for revascularization (OR: 23; 95% CI: 8.27–217.06; P=0.034) and hyperlactataemia (OR: 3.21; 95% CI: 1.14–9.04; P=0.027) were independent factors associated with hospital mortality after perioperative MI. Hospital mortality occurred in 25.7% vs 86.7% (P<0.001), AKI occurred in 37.1% vs 93.3% (P<0.001), haemodialysis was used in 28.6% vs 80% (P=0.002), and mediastinal exploration for bleeding was performed in 31.4% vs 80% (P=0.006) in the PCI and reoperation groups, respectively, while there were no significant differences regarding gastrointestinal bleeding, cerebral strokes, or intracerebral bleeding. The median peak troponin level was 795 (IQR 630–1200) vs 4190 (IQR 3700–6300) (P<0.001) in the PCI and reoperation groups, respectively. Absence of significant angiographic findings occurred in 18% of patients. Conclusions. Perioperative MI is associated with significant morbidities and hospital mortality. Reoperation for revascularization and progressive hyperlactataemia are independent predictors of hospital mortality. Emergency coronary angiography is helpful in diagnosis and management of perioperative MI.
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Affiliation(s)
- Mohamed Laimoud
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
- Critical Care Medicine Department, Cairo University, Cairo, Egypt
| | - Rehan Qureshi
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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17
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Outcome of Postcardiac Surgery Acute Myocardial Infarction and Role of Emergency Percutaneous Coronary Interventions. Cardiol Res Pract 2020. [DOI: 10.1155/2020/2014675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background. Cardiac surgery carries a well-known risk of perioperative myocardial infarction (MI), which is associated with high morbidity and both in-hospital and late mortality. The rapid haemodynamics deterioration and presence of myocardial ischemia early after cardiac surgical operations is a complex life-threatening condition where rapid diagnosis and management is of fundamental importance. Objective. To analyse the factors associated with mortality of patients with postcardiotomy MI and to study the role of emergency coronary angiography in management and outcome. Methods. We retrospectively enrolled adult patients diagnosed to have postcardiotomy MI and underwent emergency coronary angiography at our tertiary care hospital between January 2016 and August 2019. Results. Sixty-one patients from consecutive 1869 adult patients who underwent cardiac surgeries were enrolled in our study. The studied patients had a mean age of 49 ± 16.2 years with a mean BMI of 29.5 ± 6.6 and 65.6% of them were males. As compared to the survivors group, the nonsurvivors of perioperative MI had significant preoperative CKD, postoperative AKI, longer CPB time, frequent histories of previous PCI, previous cardiotomies, pre and postoperative ECMO use, higher median troponin I levels, higher peak and 24 hours median lactate levels. Regression analysis revealed that reoperation for revascularization (OR: 23; 95% CI: 8.27–217.06; P=0.034) and hyperlactataemia (OR: 3.21; 95% CI: 1.14–9.04; P=0.027) were independent factors associated with hospital mortality after perioperative MI. Hospital mortality occurred in 25.7% vs 86.7% (P<0.001), AKI occurred in 37.1% vs 93.3% (P<0.001), haemodialysis was used in 28.6% vs 80% (P=0.002), and mediastinal exploration for bleeding was performed in 31.4% vs 80% (P=0.006) in the PCI and reoperation groups, respectively, while there were no significant differences regarding gastrointestinal bleeding, cerebral strokes, or intracerebral bleeding. The median peak troponin level was 795 (IQR 630–1200) vs 4190 (IQR 3700–6300) (P<0.001) in the PCI and reoperation groups, respectively. Absence of significant angiographic findings occurred in 18% of patients. Conclusions. Perioperative MI is associated with significant morbidities and hospital mortality. Reoperation for revascularization and progressive hyperlactataemia are independent predictors of hospital mortality. Emergency coronary angiography is helpful in diagnosis and management of perioperative MI.
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