Perfusion quality odds (PEQUOD) trial: validation of the multifactorial dynamic perfusion index as a predictor of cardiac surgery-associated acute kidney injury

OBJECTIVES

The multifactorial dynamic perfusion index was recently introduced as a predictor of cardiac surgery-associated acute kidney injury. The multifactorial dynamic perfusion index was developed based on retrospective data retrieved from the patient files. The present study aims to prospectively validate this index in an external series of patients, through an on-line measure of its various components.

METHODS

Inclusion criteria were adult patients undergoing cardiac surgery with cardiopulmonary bypass. Data collection included preoperative factors and cardiopulmonary bypass-related factors. These were collected on-line using a dedicated monitor. Factors composing the multifactorial dynamic perfusion index are the nadir haematocrit, the nadir oxygen delivery, the time of exposure to a low oxygen delivery, the nadir mean arterial pressure, cardiopulmonary bypass duration, the use of red blood cell transfusions and the peak arterial lactates.

RESULTS

Two hundred adult patients were investigated. The multifactorial dynamic perfusion index had a good (c-statistics 0.81) discrimination for cardiac surgery-associated acute kidney injury (any stage) and an excellent (c-statistics 0.93) discrimination for severe patterns (stage 2-3). Calibration was modest for cardiac surgery-associated acute kidney injury (any stage) and good for stage 2-3. The use of vasoconstrictors was an additional factor associated with cardiac surgery-associated acute kidney injury.

CONCLUSIONS

The multifactorial dynamic perfusion index is validated for discrimination of cardiac surgery-associated acute kidney injury risk. It incorporates modifiable risk factors, and may help in reducing the occurrence of cardiac surgery-associated acute kidney injury.

The Importance of Being the Morning Case in Adult Cardiac Surgery: A Propensity-Matched Analysis

OBJECTIVES

The quality of the outcome after cardiac surgery with cardiopulmonary bypass depends on the patient demographics, co-morbidities, complexity of the surgical procedure, and expertise of surgeons and the whole staff. The purpose of the present study is to analyze the timing of surgery (morning vs afternoon) with respect to morbidity and mortality in adult cardiac surgery. Methods: The primary end-point was the incidence of major morbidity defined according to a modified Society of Thoracic Surgeon criterion. We consecutively included all the adult (> 18 years) patients receiving a cardiac surgery operation at our Institution.

RESULTS

From 2017 through 2019 a total of 4,003 cardiac surgery patients were operated. With a propensity-matching technique a final patient population of 1600 patients was selected, with 800 patients in the first-case surgery group and 800 in the second-case surgery group. Patients in the second-case group had a major morbidity rate of 13% vs 8.8% in the first-case group (P = 0.006), and a higher rate of 30-days mortality (4.1% vs 2.3%, P = 0.033). After correction for EuroSCORE and operating surgeon, the second-case group confirmed a higher rate of major morbidity (odds ratio 1.610, 95% confidence interval 1.16-2.23, P = 0.004).

CONCLUSION

Our study suggests that patients operated as second cases are exposed to an increased morbidity and mortality probably due to fatigue, loss of attention and hurriedness in the operating room, and decreased human resources in the intensive care unit.

Sheathless Versus Sheathed Intra-Aortic Balloon Pump Implantation in Patients Undergoing Cardiac Surgery

The intra-aortic balloon pump (IABP) is the most widely available mechanical support device, but its use has been disputed in recent decades. Although several efforts have been made to reduce the associated complication rate, contemporary data on this matter is lacking. The present study aims to evaluate the differences in vascular complications between the sheathless and the sheathed IABP implantation technique in cardiac surgery patients. A retrospective multi-center cohort, consisting of patients treated in 8 cardiac surgical centers, was evaluated. Patients who underwent cardiac surgery with peri-operative IABP support were included. Primary outcome was a composite end point of vascular complications. Propensity score matching (PSM) was performed, and a multivariable regression model was applied to evaluate predictors of vascular complications. The unmatched cohort consisted of 2,615 patients (sheathless n = 1,414, 54%, sheathed n = 1,201, 46%). A total of 878 patients were matched (n = 439 for both groups). The composite vascular complication end point occurred in 3% of patients in the sheathless group, compared with 8% in the sheathed group (p <0.001). Vascular complications were significantly associated with mortality (odds ratio [OR] 3.86, 95% confidence interval [CI] 2.01 to 7.40, p <0.001). Peripheral arterial disease was associated with vascular complications (OR 3.10, 95% CI 1.46 to 6.55, p = 0.003), whereas the sheathless implantation technique was found to be protective (OR 0.36, 95% CI 0.18 to 0.73, p = 0.005). In conclusion, the present retrospective multi-center analysis demonstrated the sheathless implantation technique to be associated with a significant reduction in vascular complication rate. Future studies should focus on even less invasive implantation techniques using smaller-sized catheters, sheathless implantation, and imaging guiding.

Effect of Aortic Valve Type on Patients Who Undergo Type A Aortic Dissection Repair

Aortic valve replacement (AVR) is common in the setting of type A aortic dissection (TAAD) repair. Here, we evaluated the association between prosthesis choice and patient outcomes in an international patient cohort. We reviewed data from the International Registry of Acute Aortic Dissection (IRAD) interventional cohort to examine the relationship between valve choice and short- and mid-term patient outcomes. Between January 1996 and March 2016, 1290 surgically treated patients with TAAD were entered into the IRAD interventional cohort. Of those, 364 patients undergoing TAAD repair underwent aortic valve replacement (AVR; mean age, 57 years). The mechanical valve cohort consisted of 189 patients, of which 151 (79.9%) had a root replacement. The nonmechanical valve cohort consisted of 5 patients who received homografts and 160 patients who received a biologic AVR, with a total of 118 (71.5%) patients who underwent root replacements. The mean follow-up time was 2.92 ± 1.75 years overall (2.46 ± 1.69 years for the mechanical valve cohort and 3.48 ± 1.8 years for the nonmechanical valve cohort). After propensity matching, Kaplan-Meier estimates of 4-year survival rates after surgery were 64.8% in the mechanical valve group compared with 74.7% in the nonmechanical valve group (p = 0.921). A stratified Cox model for 4-year mortality showed no difference in hazard between valve types after adjusting for the propensity score (p = 0.854). A biologic valve is a reasonable option in patients with TAAD who require AVR. Although this option avoids the potential risks of anticoagulation, long-term follow up is necessary to assess the effect of reoperations or transcatheter interventions for structural valve degeneration.

Patients With Type A Acute Aortic Dissection Presenting With an Abnormal Electrocardiogram

BACKGROUND

The electrocardiogram (ECG) is often used in the diagnosis of patients presenting with chest pain to emergency departments. Because chest pain is a common manifestation of type A acute aortic dissection (TAAAD), ECGs are obtained in much of this population. We evaluated the effect of particular ECG patterns on the diagnosis and treatment of TAAAD.

METHODS

TAAAD patients (N = 2,765) enrolled in the International Registry of Acute Aortic Dissection were stratified based on normal (n = 1,094 [39.6%]) and abnormal (n = 1,671 [60.4%]) findings on presenting ECGs and further subdivided according to specific ECG findings. Time data are presented in hours as medians (quartile 1 to quartile 3).

RESULTS

Patients with ECGs with abnormal findings presented to the hospital sooner after symptom onset than those with ECGs with normal findings (1.4 [0.8 to 3.3] vs 2.0 [1.0 to 3.3]; p = 0.005). Specifically, this was seen in patients with infarction with new Q waves or ST elevation (1.3 [0.6 to 2.7] vs 1.5 [0.8 to 3.3]; p = 0.049). Interestingly, the time between symptom onset and diagnosis was longer with infarction with old Q waves (6.7 [3.2 to 18.4] vs 5.0 [2.9 to 11.8]; p = 0.034) and nonspecific ST-T changes (5.8 [3.0 to 13.8] vs 4.5 [2.8 to 10.5]; p = 0.002). Surgical mortality was higher in patients with abnormal ECG findings (20.6% vs 11.9%, p < 0.001), especially in those with ischemia by ECG (25.7% vs 16.8%, p < 0.001) and infarction with new Q waves or ST elevation (30.1% vs 17.1%, p < 0.001).

CONCLUSIONS

TAAAD patients presenting with abnormal ECG results are sicker, have more in-hospital complications, and are more likely to die. The frequency of nonspecific ST-T abnormalities and its association with delay in diagnosis and treatment presents an opportunity for practice improvement.

Emergent treatment of aortic rupture in acute type B dissection

Massive left hemothorax is a rare and dramatic complication of acute type B aortic dissection. The primary endpoint is to treat the aortic rupture, stop the bleeding and stabilize the hemodynamic status, with the aim to prevent mortality and major cardiac, cerebral, visceral and renal complications. Thoracic endovascular repair (TEVAR) is the most frequent management, although its planning, in these emergent patients, may be very difficult and sub-optimal imaging may result at post-operative examination (CT and MRI). In case of TEVAR is not the definitive treatment of the aortic disease, a second stage surgical management can be performed in elective status, in a patient with a total clinical recover. In acute and dramatic circumstances, like ruptured type B dissection, TEVAR is a valid and suitable bridge procedure to open surgery, reducing the overall risk for mortality and major complications.

Bentall operation in 375 patients: long-term results and predictors of death

BACKGROUND AND AIM OF THE STUDY

The Bentall operation is a 40-year-old standardized procedure for treating aortic valve diseases and aneurysms involving the aortic root. The study aim was to analyze the results and predictors of long-term outcome after the Bentall procedure for aortic root diseases.

METHODS

Between January 1990 and December 2007, a total of 375 patients (296 males, 79 females) underwent the Bentall operation at the authors' institution. Bicuspid aortic valve (BAV) was present in 91 patients, and Marfan syndrome in 13. Thirty-six patients were treated as emergencies, and 30 for acute dissection. A concomitant surgical procedure was performed in 78 patients. The operative procedure included both classic Bentall and button techniques. Follow up data were obtained from hospital and office records and from telephone contacts. Kaplan-Meier survival analysis and Cox regression analysis were performed to investigate the predictors of long-term outcome.

RESULTS

The overall in-hospital mortality was 4.5%, and after elective operations was 2.3%. A 20-year long-term follow up included 32 late deaths, of which 14 were cardiac-related. Freedom from late all-cause mortality at 5, 10, and 15 years was 97.1%, 81.9%, and 53.9%, respectively. At univariate analysis, long-term mortality was associated with age, diabetes, BAV, NYHA class III/IV, emergency treatment, cardiopulmonary bypass time, and coronary artery bypass grafting. Independent predictors of long-term mortality were age (OR 1.16; CI: 1.08-1.23), emergency surgery (OR 28; CI: 4-192) and BAV (OR 3; CI: 1.3-6.9).

CONCLUSION

The Bentall procedure is a safe and durable operation, with a very good early and long-term results and a low rate of reoperation. In the present series, age, BAV and emergency surgery were important independent predictors of mortality.

Aortic cross-clamp time, new prostheses, and outcome in aortic valve replacement

BACKGROUND AND AIM OF THE STUDY

A number of sutureless bioprosthetic aortic valves have been recently introduced in clinical practice, their main advantage being a reduction in the aortic cross-clamp time (AXCT). The study aim was to investigate if AXCT was a determinant of cardiovascular morbidity in patients undergoing surgical aortic valve replacement (AVR) to treat aortic valve stenosis, and to identify any subset of patients who might benefit from a reduction in AXCT.

METHODS

A retrospective analysis was conducted of 979 consecutive patients with aortic valve stenosis who underwent surgical AVR. The AXCT was analyzed as an independent predictor of severe cardiovascular morbidity, defined as the presence of a low cardiac output, stroke, acute kidney injury, or operative mortality. Subgroups of patients who benefited more from a reduction in AXCT were investigated.

RESULTS

The AXCT was an independent predictor of severe cardiovascular morbidity, with an increased risk of 1.4% per 1 min increase. Patients with a left ventricular ejection fraction < or = 40%, and also diabetic patients, showed the most relevant clinical benefits induced by a reduction in AXCT.

CONCLUSION

In selected patient populations at high risk of systolic dysfunction, the use of sutureless aortic valve bioprostheses may be considered. However, the routine use of such bioprostheses should be pondered within a cost-benefit analysis.

[New frontiers in aortic surgery]

In cardiac surgery, aortic diseases represent an important chapter, and include treatments from the aortic valve to the descending aorta. The infra-diaphragmatic abdominal aorta, generally and historically, is the domain of vascular surgery. Despite the excellent and consolidated results obtained in the treatment of thoracic aortic disease, surgical mortality and morbidity are still relevant, also due to the presence of older patients with more extensive and complex aortic disease. In the last decades, the better knowledge of the aortic issues and the availability of new grafts have resulted in an important evolution of the management, both at the aortic valve and vessel level, with use of transcatheter grafts (transcatheter aortic valve implantation and thoracic endovascular aortic repair). The evidence of the right indications and the long-term results will determine the real usefulness and effectiveness of these "new" procedures and their role as safe and definitive aortic therapies.

Comparison of morbidity and mortality in diabetics versus nondiabetics having isolated coronary bypass versus coronary bypass plus valve operations versus isolated valve operations

The impact of diabetes mellitus (DM) on the outcome of patients requiring cardiac surgery has been investigated in previous decades. However, the profile of cardiac surgical practice is changing in addition to changes in patients' risk profile, making the results inconclusive. In this study we sought to investigate the impact of DM on operative mortality and morbidity in patients undergoing cardiac surgery and adjust for patient and disease characteristics. In total 10,709 patients (9,229 nondiabetics and 1,480 diabetics) were admitted to the study; 5,557 patients (1,012 diabetics) underwent an isolated coronary operation, 1,775 patients (278 diabetics) underwent coronary plus valve operations, and 3,337 patients (209 diabetics) underwent valve operations. To control for differences in patient and disease characteristics, a propensity score (for DM) was performed. DM increased crude morbidity and this difference was maintained after risk adjustment for propensity score; conversely, the crude operative mortality risk was higher in diabetics but not significantly after adjustment for propensity score. Thereafter, DM remained independently associated to operative mortality risk in the valve population only (odds ratio 2.53, 95% confidence interval 1.45 to 4.4, p = 0.001). In conclusion, DM has a significant impact on operative mortality of patients undergoing heart valve surgery. Although diabetic patients undergoing coronary operations are not at increased risk of operative mortality, morbidity is significantly affected in the overall population.

[Surgical treatment of early complications after ST-elevation myocardial infarction]

Cardiac rupture is a fatal complication of myocardial infarction that may involve especially the left ventricular free wall, the ventricular septum and the papillary muscle, but also the right ventricular free wall and more rarely the atrium. This complication is responsible for 10-15% of in-hospital deaths after ST-elevation myocardial infarction. Advanced age, female sex, first infarction and hypertension (in the acute phase of infarction) are the most important risk factors for cardiac rupture. It occurs typically between 4 and 7 days after the infarction but it may also develop within the first 24-48h, particularly in patients undergoing fibrinolytic therapy and in cardiac patients with the following characteristics: 1) recent coronary artery occlusion, 2) transmural necrosis, 3) poor collateral circulation, and 4) minimal or absent myocardial fibrosis. Cardiac rupture should be suspected when sudden or rapidly progressive hemodynamic deterioration occurs. After prompt diagnosis and stabilization, the patient can be operated. The high mortality rate between 5 and 14 days post-infarction justifies the urgency of surgical repair, which includes infartectomy and the employment of a Dacron patch and biological glues. Also percutaneous strategies have recently been used in patients with high surgical risk. The most frequently performed surgical techniques for the treatment of cardiac rupture are described below. By now early diagnosis and surgical treatment are crucial for successful outcome.

Surgical therapy for ischemic heart failure: Single-center experience with surgical anterior ventricular restoration

OBJECTIVES

Our objectives were (1) to report operative and long-term mortality in patients submitted to anterior surgical ventricular restoration, (2) to report changes in clinical and cardiac status induced by surgical ventricular restoration, and (3) to report predictors of death in a large cohort of patients operated on at San Donato Hospital, Milan, Italy.

METHODS

A total of 1161 consecutive patients (83% men, 62 +/- 10 years) had anterior surgical ventricular restoration with or without coronary artery bypass grafting and with or without mitral repair/replacement. A complete echocardiographic study was performed in 488 of 1161 patients operated on between January 1998 and October 2005 (study group). The indication for surgery was heart failure in 60% of patients, angina, and/or a combination of the two.

RESULTS

Thirty-day cardiac mortality was 4.7% (55/1161) in the overall group and 4.9% (24/488) in the study group. Determinants of hospital mortality were mitral valve regurgitation and need for a mitral valve repair/replacement. Mitral regurgitation (>2+) associated with a New York Heart Association class greater than II and with diastolic dysfunction (early-to-late diastolic filling pressure >2) further increases mortality risk. Global systolic function improved postoperatively: ejection fraction improved from 33% +/- 9% to 40% +/- 10% (P < .001); end-diastolic and end-systolic volumes decreased from 211 +/- 73 to 142 +/- 50 and 145 +/- 64 to 88 +/- 40 mL, respectively (P < .001) early after surgery. New York Heart Association functional class improved from 2.7 +/- 0.9 to 1.6 +/- 0.7 (P < .001) late after surgery. Long-term survival in the overall population was 63% at 120 months.

CONCLUSIONS

Surgical ventricular restoration for ischemic heart failure reduces ventricular volumes, improves cardiac function and functional status, carries an acceptable operative mortality, and results in good long-term survival. Predictors of operative mortality are mitral regurgitation of 2+ or more, New York Heart Association class greater than II, and diastolic dysfunction (early-to-late diastolic filling pressure >2).

Combined Atrial Septal Defect Surgical Closure and Irrigated Radiofrequency Ablation in Adult Patients

BACKGROUND

Atrial arrhythmias are relatively common among patients over 40 years old with atrial septal defect (ASD) and are a precipitating cause of heart failure. Surgical closure of the ASD in these patients is feasible and is associated with a low mortality rate and a beneficial effect on the clinical status; however the occurrence of atrial arrhythmia does not decrease after surgery. We present the results of our preliminary experience with surgical ASD closure combined with intraoperative irrigated radiofrequency (IRF) ablation in adult patients.

METHODS

During a 26-month period between September 2002 and December 2004, 15 patients more than 40 years old with ASD and atrial arrhythmia underwent elective surgical closure of the defect and intraoperative IRF ablation. All patients had supraventricular arrhythmias: 8 had permanent atrial fibrillation, whereas 7 had previous episodes of atrial flutter or intra-atrial reentry tachycardia. The biatrial approach (Cox-Maze III procedure) was used in 7 patients and a right-sided Maze procedure (ablation lines on the right atrium only) was carried out in the remaining 8 patients.

RESULTS

All patients survived the procedure. Fourteen patients left the operating room in sinus rhythm and 1 had a pacemaker implanted. There were no complications resulting from the IRF ablation. All 15 patients survived over the average follow-up period of 24 months. Thirteen patients were still in sinus rhythm, 1 had pacemaker rhythm, and only 1 (1 of 15; 6.5%) suffered a recurrence of atrial fibrillation 3 months after the procedure.

CONCLUSIONS

We suggest adding intraoperative IRF ablation during surgical closure of an ASD in all adult ASD patients with arrhythmias. The IRF ablation is easy to perform, safe, and effective.