Antonino Roscitano

Surgical management of aortic root disease in Marfan syndrome: a systematic review and meta-analysis

Context Surgical treatment of aortic root aneurysm in Marfan syndrome (MFS) patients. Objective To compare results of total root replacement versus valve-sparing aortic root replacement in MFS patients. Data Sources PubMed, Embase and Cochrane library were searched from January 1966 until February 2010 looking for papers reporting on aortic root operations in MFS patients. 530 studies were retrieved. Study Selection Finally, 11 publications were enrolled. Inclusion criteria were observational studies reporting valve-related morbidity and mortality after total root replacement (TTR) and/or valve-sparing root replacement (VSRR) in patients with MFS and study size n≥30, reflecting the centres experience. Data Extraction Data obtained from papers reporting both TRR and VSRR cohorts were analysed separately. In case of multiple publications, the most recent and complete report was selected. If the total number of patient-years was not provided, we calculated it by multiplying the number of hospital survivors with the mean follow-up duration of that study. Results Overall, 1385 patients were analysed (972 patients had TTR and 413 patients had VSRR). Reintervention rate was 0.3%/year (95% CI 0.1 to 0.5) versus 1.3%/year (95% CI 0.3 to 2.2) (p=0.02) and thromboembolic events rate was 0.7%/year (95% CI 0.5 to 0.9) versus 0.3%/year (95% CI 0.1 to 0.6) (p=0.01) after TRR and VSRR, respectively. When composite valve-related events were compared, no difference existed between the two surgical strategies (p=0.41). Among patients undergoing VSRR, reimplantation was associated with a reduced rate of reintervention compared with remodelling (0.7%/year vs 2.4%/year, p=0.02). Conclusions VSRR may represent a valuable option for patients with MFS with aortic aneurysm. However, this technique should be used with caution in patients with valve characteristics at risk for decreased durability.

Preoperative Angiotensin-Converting Enzyme Inhibitors and Acute Kidney Injury After Coronary Artery Bypass Grafting

BACKGROUND Angiotensin-converting enzyme (ACE) inhibitors confer renal protection in different clinical settings. No final conclusions are available on the renal benefits of ACE inhibitors after coronary artery bypass grafting (CABG). Because ACE inhibitors decrease glomerular perfusion pressure, they may exacerbate kidney injury during cardiopulmonary bypass (CPB)-related hypoperfusion. We evaluated the effect of preoperative ACE inhibitors on acute kidney injury (AKI) after CABG. METHODS A propensity score-based analysis of 536 patients undergoing CABG on CPB was performed, among which 281 received ACE inhibitors preoperatively. Patients with preoperative end-stage renal failure requiring dialysis were excluded. Postoperative AKI was defined as 50% or more decrease in the glomerular filtration rate from preoperative or postoperative mechanical renal support. RESULTS After CABG, AKI developed in 49 patients (9.1%), and 23 (4.2%) required dialysis. The incidence of AKI was 6.4% in patients who received preoperative ACE inhibitors and 12.2% in patients who did not (p = 0.02). The incidence of AKI requiring dialysis was 2.4% in the treatment group and 6.3% in controls (p = 0.03). After adjusting for propensity score and covariates, preoperative ACE inhibitors were found to reduce the incidence of postoperative AKI (odds ratio, 0.48; 95% confidence interval, 0.23 to 0.77; p = 0.04). Other independent predictors were age, preoperative glomerular filtration rate, left ventricular ejection fraction of less than 0.35, preoperative use of intraaortic balloon pump, emergency operation, and CPB time. CONCLUSIONS Preoperative ACE inhibitors are associated with a reduced rate of AKI after on-pump CABG surgery.

Does combined mitral valve surgery improve survival when compared to revascularization alone in patients with ischemic mitral regurgitation? A meta-analysis on 2479 patients.

Objectives Optimal treatment of significant (≥2+ grade) ischemic mitral regurgitation remains controversial, and the impact of mitral valve surgery (MVS) at the time of coronary artery bypass grafting (CABG) on early and late results has to be still clarified. Methods A systematic literature search for studies comparing CABG combined to MVS (repair or replacement) compared with CABG alone in patients with ischemic mitral regurgitation and meta-analysis for late mortality, postoperative New York Heart Association functional class and late residual mitral regurgitation grade was performed. Risk ratios and the standardized mean difference (SMD) under the fixed or random effects model were reported. Results A total of nine observational nonrandomized studies were identified including 2479 patients with ischemic mitral regurgitation who underwent CABG alone (n = 1515) and CABG combined to MVS (n = 964). Meta-analysis of the pooled study population showed that MVS did not have advantages on late mortality [risk ratio 1.02; 95% confidence interval (CI) 0.90 to 1.14; P = 0.73] compared with CABG alone. Combined MVS was significantly associated with a lower residual mitral regurgitation grade compared with CABG alone (SMD = −0.9; 95% CI −1.250 to −0.559; P < 0.0001). However, postoperative New York Heart Association class was not significantly improved in the combined MVS group (SMD = −0.26; 95% CI −0.766 to −0.24; P = 0.30). Conclusion Most surgeons commonly use additional mitral valve procedure to treat moderate or severe ischemic mitral regurgitation, because it seems logical to assume that the volume overload associated with mitral regurgitation will be detrimental particularly to the patient with compromised left ventricular function. However, until definitive evidence about the superiority of this approach will be available, a tailored surgical strategy should be considered especially in mild ischemic mitral regurgitation.

Miniaturized Cardiopulmonary Bypass and Acute Kidney Injury in Coronary Artery Bypass Graft Surgery

BACKGROUND Acute kidney injury (AKI) is one of the most important complications after on-pump coronary artery bypass graft surgery (CABG). Miniaturized cardiopulmonary bypass (mini-CPB) systems have been developed to allow the ease of on-pump surgery but tempering the disadvantages. Whether mini-CPB reduces the incidence of AKI remains to be determined. METHODS Using a propensity score matched analysis, we investigated the occurrence of AKI among patients undergoing CABG on mini-CPB (n = 104) versus conventional CPB (n = 601). Acute kidney injury was defined according to the recent Acute Kidney Injury Network classification. RESULTS Overall, acute kidney injury developed in 274 of 705 patients (38.8%). A total of 27 of 705 patients (3.8%) required renal replacement therapy. The median postoperative length of intensive care unit stay in survivors with AKI was 5.4 (3.9 to 6.8) days compared with 2.0 (1.0 to 3.0) days for patients without AKI (p = 0.0002). The overall incidence of AKI for patients undergoing mini-CPB was 30 of 104 (28.8%) compared with 244 of 601 (40.5%) for patients undergoing conventional CPB (p = 0.03). In the propensity score matched-pair statistical analysis, mini-CPB was independently associated with a decreased incidence of AKI (adjusted odds ratio [OR] 0.61; 95% confidence interval [CI]: 0.38 to 0.97). Other variables independently associated with AKI were preoperative glomerular filtration rate (OR 0.988 for 1 mL.min(-1).1.73 m(-2) increase; 95% CI: 0.98 to 0.99), postoperative red blood cell transfusion (OR 1.58; 95% CI: 1.12 to 2.23); CPB time (OR 1.005 for 1-minute increase; 95% CI: 1.0 to 1.009), and postoperative low output syndrome (OR 1.72; 95% CI: 1.23 to 2.41). CONCLUSIONS The present study showed that mini-CPB is associated with a lower incidence of AKI when compared with conventional CPB among patients undergoing CABG.

Is minimized extracorporeal circulation effective to reduce the need for red blood cell transfusion in coronary artery bypass grafting? Meta-analysis of randomized controlled trials

DISCUSSION The patient described had parietal pericardial bovine bioprostheses in both the mitral and aortic valve positions for 77 months and during that period developed huge quantities of calcium on the cusps of the bioprosthesis in the aortic valve position and only small quantities of calcium on the cusps of the bioprosthesis in the mitral valve position. Because the closing pressure on the mitral bioprosthesis is usually about a third higher than that on the aortic bioprosthesis (peak left ventricular systolic pressure vs end-diastolic aortic pressure; normally approximately 120 vs 80 mm Hg), it might be expected that the degeneration of a bioprosthesis in the mitral position would be greater (more calcium and more tears) and more rapid than that of a bioprosthesis in the aortic position, but the opposite was the case in the patient described herein. Why might that be the case? Some possibilities include the following:

Metabolic Syndrome Affects Midterm Outcome After Coronary Artery Bypass Grafting

BACKGROUND Metabolic syndrome (MetS) is frequently associated with coronary artery disease, but data on the impact of MetS on long-term outcome of patients undergoing coronary artery bypass grafting are still lacking. The aim of the present study was to assess the effect of MetS on mortality and morbidity late after coronary artery bypass grafting. METHODS A total of 1,726 consecutive patients who had elective coronary artery bypass grafting were retrospectively reviewed and clinical follow-up was completed (mean follow-up time, 34.4 months; range, 6 to 79 months). The MetS was diagnosed using the modified Adult Treatment Panel III criteria, and to eliminate covariate differences, a propensity score adjustment was used. Major adverse cerebral and cardiovascular events were investigated, and C-reactive protein levels were assessed both preoperatively, postoperatively, and at follow-up. RESULTS A total of 798 of 1,726 patients (46.2%) met the diagnostic criteria for MetS. At follow-up, all-cause mortality (7% versus 4.6%; p=0.04), cardiac arrhythmias (35.3% versus 25.2%; p<0.0001), renal failure (12% versus 8.7%; p=0.03), and major adverse cerebral and cardiovascular events (52.4% versus 39.5%; p<0.0001) showed a significantly higher incidence in MetS patients. Variables correlated with late mortality at propensity-adjusted Cox proportional-hazards regression were age (p=0.0008), preoperative left ventricular ejection fraction (p=0.001), preoperative renal failure (p=0.001), and MetS (p=0.006). Higher C-reactive protein levels were found preoperatively (8.6±2.3 versus 5.14±3.1 mg/L; p<0.0001) and both early (71.2±9 versus 49.6±8.7 mg/L; p<0.0001) and late (7.4±2.7 versus 4.8±2.5 mg/L; p<0.0001) after surgery. CONCLUSIONS The main finding of our study was the association between MetS and mortality both early and late after coronary artery bypass grafting. Thus, MetS should be recognized as an independent preoperative variable that can lead to the identification of high-risk patients and as a risk factor to correct with lifestyle modifications and pharmacologic therapy.

Impact of Prosthesis-Patient Mismatch on the Regression of Secondary Mitral Regurgitation After Isolated Aortic Valve Replacement With a Bioprosthetic Valve in Patients With Severe Aortic Stenosis

Background— Secondary mitral regurgitation (SMR) is generally reduced after isolated aortic valve replacement (AVR), but there is important interindividual variability in the magnitude of this reduction. Prosthesis-patient mismatch (PPM) may hinder normalization of left ventricular geometry and pressure overload following AVR, therefore we aimed to investigate the relationship between PPM and regression of SMR following AVR for aortic valve stenosis. Methods and Results— A total of 419 patients with AS who underwent isolated AVR at 2 institutions and presenting moderate SMR (mitral regurgitant volume 30 to 45 mL/beat) not considered for surgical correction were included in this study. Clinical and echocardiographic follow-up were completed at a median follow-up time of 37 months. PPM was defined as an indexed effective orifice area ⩽0.85 cm2/m2 and was found in 170/419 patients (40.6%). There were no significant differences in baseline and operative characteristics between patients with or without PPM. Patients with PPM had less regression of SMR following AVR compared with those with no PPM (change in mitral regurgitant volume:−11±4 versus −17±5 mL, respectively; P<0.0001). Variables significantly associated with postoperative change in mitral regurgitant volume on univariable analysis were entered in a multivariable linear regression model, which showed indexed effective orifice area (P<0.0001) and left atrial diameter (P=0.006) to be independently associated with mitral regurgitant volume improvement. Patients with PPM also had less postoperative improvement in 6-minute walking test distance (80±78 versus 42±41 m, P<0.0001). Conclusions— PPM is associated with lesser regression of SMR following AVR. This unfavorable effect was associated with worse functional capacity. These findings emphasize the importance of operative strategies aiming to prevent PPM in patients with aortic valve stenosis and concomitant SMR.

Neutrophil gelatinase-associated lipocalin levels after use of mini-cardiopulmonary bypass system

Neutrophil gelatinase-associated lipocalin (NGAL) has been implicated as an early predictive urinary biomarker of ischemic acute kidney injury (AKI). The aim of this study was to compare the effects of miniaturized cardiopulmonary bypass system (MCPB) vs. standard cardiopulmonary bypass system (SCPB) system on kidney tissue in patients undergoing myocardial revascularization using urinary NGAL levels as an early marker for renal injury. Sixty consecutive patients who underwent myocardial revascularization were studied prospectively. An SCPB was used in 30 patients (group A) and MCPB was used in 30 patients (group B). The SCPB group but not the MCPB group showed a significant NGAL concentration increase from preoperative during the 1st postoperative day (169.0+/-163.6 ng/ml in the SCPB group vs. 94.1+/-99.4 ng/ml in the MCPB group, P<0.05, respectively). Two patients in the SCPB group developed AKI and underwent renal replacement therapy; no patient in MCPB developed AKI. The MCPB system is safe in routine clinical use. Kidney function is better protected during MCPB as demonstrated by NGAL levels. NGAL represents an early biomarker of renal failure in patients undergoing cardiac surgery and the valuation of its concentration can aid in medical decision-making.

Red blood cell distribution width predicts mortality after coronary artery bypass grafting

Risk stratification in cardiac surgery is a relevant issue. Many mortality risk models are currently available [1,2], and they are used to assess riskof operativemortality, and toprovide internal and/or external benchmark comparisons. However these risk models, such as the European System for Cardiac Operative Risk Evaluation (EuroSCORE) [2], have shown several limitations, including poor performance in the elderly and overestimated mortality, especially among isolated coronary artery bypass grafting (CABG) patients. Therefore there is a need to identify new risk factors in this setting which are expected to be simple enough for clinical use, available for all patients and cost-effective. Complete blood cell count parameters, such as haemoglobin, have been shown to predict outcomes in patients with cardiovascular disease [3,4] but none of themhas been incorporated into surgical risk scores. In particular, the preoperative haemoglobin has been investigated as a risk factor of early death but discordant results were reported. Red blood cell distribution width (RDW), routinely reported in automated complete blood counts, is a numerical measure of the variability in size of circulating erythrocytes, and has been emerging as a strong predictor of adverse events for several categories of patients [5]. However, the role of RDW in predicting mortality of CABG patients has not been investigated yet. To assess predictive power of RDW on both early and late mortalities following CABG, prospectively collected data from the surgical database of two European institutions (Sapienza University of Rome, Italy and Papworth Hospital NHS, United Kingdom) have been retrospectively analysed by authors whom have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. The primary end points of the study were early (within 30 day) death and all-cause late death after hospital discharge. All-cause death is the most robust and unbiased index because no adjudication is required, thus avoiding inaccurate or biased documentation and clinical assessments. Furthermore, to deeply investigate the relationship between RDWandmortality, cause of deaths were recorded and a sub-analysis of cardiac-related late mortality was performed (any sudden, cardiac, or unknown death was considered a cardiac-related death; stroke as well was considered as cardiac death). Participants were classified into 4 groups using the RDW quartile values. Differences in baseline clinical characteristics among groups were examined by 1-way analysis of variance for continuous variables and χ test for categorical variables. Kaplan–Meier analysis of survival was performed and estimates were compared with logrank test. Potential confounding factors were derived among variables included into EuroSCORE [1,2], on the basis of a literature review and a clinical plausibility. We used 4 stepwise logistic and Cox proportional hazards models to assess the associationsbetween thebaselineRDWquartiles and risks of early and late mortalities. Estimates were calculated as crude association between outcomes and RDW quartiles (Model 1), adjusting for demographic risk factors showing significant correlation at univariate analysis (Model 2), adding haemoglobin levels (Model 3), and adding other biochemical factors (Model 4). All statistical analyses were performed using SPSS v. 20.0 (SPSS, Chicago, IL).

β-Blockers Improve Survival of Patients With Chronic Obstructive Pulmonary Disease After Coronary Artery Bypass Grafting

BACKGROUND β-Blockers are known to improve survival of patients with cardiovascular disease, but their administration in patients with chronic obstructive pulmonary disease (COPD) remains controversial. The aim of the present study was to assess the effect of β-blocker administration in patients with COPD undergoing coronary artery bypass grafting. METHODS A total of 388 consecutive patients with COPD who underwent isolated coronary artery bypass grafting were studied, and clinical follow-up was completed. Diagnosis of COPD was based on preoperative forced expiration volume; exacerbation episodes were defined as a pulsed-dose prescription of prednisolone or a hospital admission for an exacerbation. Two propensity-matched cohorts of 104 patients each either receiving or not receiving β-blockers were identified. RESULTS At baseline, there was no significant difference among groups. After a median follow-up of 36 months, there were 8 deaths in 104 patients (7.7%) receiving β-blockers versus 19 deaths in 104 patients (18.3%) who did not receive β-blockers (p = 0.03). Kaplan-Meyer analysis showed a survival of 91.8% ± 2.8% for patients taking β-blockers versus 80.6% ± 4.0% for control subjects (χ(2), 29.4; p = 0.003; hazard ratio, 0.38). In addition, β-blocker administration did not increase rates of COPD exacerbation, which was experienced by 46 of 104 patients (44.2%) receiving β-blockers versus 45 of 104 patients (43.3%) not receiving β-blockers (p = 0.99). CONCLUSIONS This study showed that in patients with COPD undergoing coronary artery bypass grafting the administration of β-blockers is safe and significantly improves survival at mid-term follow-up. Further randomized studies are needed to confirm these findings.