Antonio Salsano

Incidence and prognostic impact of bleeding and transfusion after coronary surgery in low-risk patients

Excessive bleeding and blood transfusion are associated with adverse outcome after cardiac surgery, but their mechanistic effects are difficult to disentangle in patients with increased operative risk. This study aimed to evaluate the incidence and prognostic impact of bleeding and transfusion of blood products in low‐risk patients undergoing coronary artery bypass grafting (CABG).

Prosthetic valve endocarditis: Predictors of early outcome of surgical therapy. A multicentric study

OBJECTIVES Prosthetic valve endocarditis (PVE) is an uncommon yet dreadful complication in patients with prosthetic valves that requires a distinct analysis from native valve endocarditis. The present study aims to investigate independent risk factors for early surgical outcomes in patients with PVE. METHODS A retrospective cohort study was conducted in 8 Italian Cardiac Surgery Units from January 2000 to December 2013 by enrolling all PVE patients undergoing surgical treatment. RESULTS A total of 209 consecutive patients were included in the study. During the study period, the global rate of surgical procedures for PVE among all operations for isolated or associated valvular disease was 0.45%. Despite its rarity this percentage increased significantly during the second time frame (2007‐2013) in comparison with the previous one (2000‐2006): 0.58% vs 0.31% (P < 0.001). Intraoperative and in‐hospital mortality rates were 4.3% and 21.5%, respectively. Logistic regression analysis identified the following factors associated with in‐hospital mortality: female gender [odds ratio (OR) = 4.62; P < 0.001], shock status (OR = 3.29; P = 0.02), previous surgical procedures within 3 months from the treatment (OR = 3.57; P = 0.009), multivalvular involvement (OR = 8.04; P = 0.003), abscess (OR = 2.48; P = 0.03) and urgent surgery (OR = 6.63; P < 0.001). CONCLUSIONS Despite its rarity, PVE showed a significant increase over time. Up to now, in‐hospital mortality after surgical treatment still remains high (>20%). Critical clinical presentation and extension of anatomical lesions are strong preoperative predictors for poor early outcome.

Does patient-prosthesis mismatch after aortic valve replacement affect survival and quality of life in elderly patients?

Background To evaluate the impact of patient–prosthesis mismatch (PPM) on survival, functional status, and quality of life (QoL) after aortic valve replacement (AVR) with small prosthesis size in elderly patients. Methods Between January 2005 and December 2013, 152 patients with pure aortic stenosis, aged at least 75 years, underwent AVR, with a 19 or 21 mm prosthetic heart valve. PPM was defined as an indexed effective orifice area less than 0.85 cm2/m2. Median age was 82 years (range 75–93 years). Mean follow-up was 56 months (range 1–82 months) and was 98% complete. Late survival rate, New York Heart Association functional class, and QoL (RAND SF-36) were assessed. Results Overall, PPM was found in 78 patients (53.8%). Among them, 42 patients (29%) had an indexed effective orifice area less than 0.75 cm2/m2 and 17 less than 0.65 cm2/m2 (11.7%). Overall survival at 5 years was 78 ± 4.5% and was not influenced by PPM (P = NS). The mean New York Heart Association class for long-term survivors with PPM improved from 3.0 to 1.7 (P < 0.001). QoL (physical functioning 45.18 ± 11.35, energy/fatigue 49.36 ± 8.64, emotional well being 58.84 ± 15.44, social functioning 61.29 ± 6.15) was similar to that of no-PPM patients (P = NS). Conclusion PPM after AVR does not affect survival, functional status, and QoL in patients aged at least 75 years. Surgical procedures, often time-consuming, contemplated to prevent PPM, may therefore be not justified in this patient subgroup.

The impact of minor blood transfusion on the outcome after coronary artery bypass grafting

Purpose To investigate the impact of minor perioperative bleeding requiring transfusion of 1–2 red blood cell (RBC) units on the outcome after coronary artery bypass grafting (CABG). Methods Sixteen cardiac surgical centers contributed to the prospective European CABG registry (E‐CABG). 1014 patients receiving 1–2 RBC units during or after isolated CABG were compared to 2264 patients not receiving RBCs. Results In 827 propensity score matched pairs, transfusion of 1–2 RBC units did not affect the risk of in‐hospital/30‐day death (p = 0.523) or stroke (p = 0.804). However, RBC transfusion was associated with an increased risk of acute kidney injury (p = 0.008), sternal wound infection (p = 0.001), postoperative use of antibiotics (p = 0.001), prolonged use of inotropes (p < 0.0001), use of intra‐aortic balloon pump (p = 0.012), length of intensive care unit stay (p < 0.0001) and length of in‐hospital stay (p < 0.0001). Matched paired analysis excluding pre‐ and postoperative critical hemodynamic conditions showed that RBC transfusion was associated with an increased risk of major complications except in‐hospital/30‐day death. Conclusion Minor perioperative bleeding and subsequent transfusion of 1–2 RBC units did not affect the risk of early death, but increased the risk of other major adverse events. Minimizing perioperative bleeding and prevention of even low‐volume RBC transfusion may improve the outcome after CABG. Highlights1–2 red cell units did not affect the risk of early death after coronary surgery.Transfusion was associated with an increased risk of other major adverse events.‐The results persisted after excluding patients with critical hemodynamic conditions.

Clinical frailty scale and outcome after coronary artery bypass grafting

OBJECTIVES The aim of this study was to assess the impact of frailty on the outcome after coronary artery bypass grafting (CABG) and whether it may improve the predictive ability of European System for Cardiac Operative Risk Evaluation (EuroSCORE II). METHODS The Clinical Frailty Scale (CFS) was assessed preoperatively in patients undergoing isolated CABG from the multicentre E-CABG registry, and patients were stratified into 3 classes: scores 1-2, scores 3-4 and scores 5-7. RESULTS Of the 6156 patients enrolled, 39.2% had CFS scores 1-2, 57.6% scores 3-4, and 3.2% scores 5-7. Logistic regression adjusted for multiple covariates showed that the CFS was an independent predictor of hospital/30-day mortality [CFS scores 3-4, odds ratio (OR) 3.95, 95% confidence interval (CI) 2.19-7.14; CFS scores 5-7, OR 5.90, 95% CI 2.67-13.05] and resulted in an Integrated Improvement Index of 1.3 (P < 0.001) and a Net Reclassification Index of 55.6 (P < 0.001) for prediction of hospital/30-day mortality. Adding the CFS classes to EuroSCORE II resulted in an Integrated Improvement Index of 0.9 (P < 0.001) and Net Reclassification Index of 59.6 (P < 0.001) for prediction of hospital/30-day mortality with a significantly larger area under the receiver operating characteristics curve (0.809 vs 0.781, P = 0.028). The CFS was an independent predictor of mid-term mortality [CFS scores 3-4, hazard ratio (HR) 2.05, 95% CI 1.43-2.85; CFS scores 5-7, HR 3.05, 95% CI 1.83-5.06]. CONCLUSIONS The CFS predicted early- and mid-term mortality in patients undergoing isolated CABG. Further studies are needed to evaluate whether frailty may improve the estimation of the operative risk of patients undergoing adult cardiac surgery. Clinicaltrials.gov number NCT02319083.

Surgery for prosthetic valve endocarditis: a retrospective study of a national registry

OBJECTIVES We described clinical-epidemiological features of prosthetic valve endocarditis (PVE) and assessed the determinants of early surgical outcomes in multicentre design. METHODS Data regarding 2823 patients undergoing surgery for endocarditis at 19 Italian Centers between 1979 and 2015 were collected in a database. Of them, 582 had PVE: in this group, the determinants of early mortality and complications were assessed, also taking into account the different chronological eras encompassed by the study. RESULTS Overall hospital (30-day) mortality was 19.2% (112 patients). Postoperative complications of any type occurred in 256 patients (44%). Across 3 eras (1980-2000, 2001-08 and 2009-14), early mortality did not significantly change (20.4%, 17.1%, 20.5%, respectively, P  = 0.60), whereas complication rate increased (18.5%, 38.2%, 52.8%, P  < 0.001), consistent with increasing mean patient age (56 ± 14, 64 ± 15, 65 ± 14 years, respectively, P  < 0.001) and median logistic EuroSCORE (14%, 21%, 23%, P  = 0.025). Older age, female sex, preoperative serum creatinine >-2 mg/dl, chronic pulmonary disease, low ejection fraction, non-streptococcal aetiology, active endocarditis, preoperative intubation, preoperative shock and triple valve surgery were significantly associated with mortality. In multivariable analysis, age (OR = 1.02; P  = 0.03), renal insufficiency (OR = 2.1; P  = 0.05), triple valve surgery (OR = 6.9; P  = 0.004) and shock (OR = 4.5; P  < 0.001) were independently associated with mortality, while streptococcal aetiology, healed endocarditis and ejection fraction with survival. Adjusting for study era, preoperative shock (OR = 3; P  < 0.001), Enterococcus (OR = 2.3; P  = 0.01) and female sex (OR = 1.5; P  = 0.03) independently predicted complications, whereas ejection fraction was protective. CONCLUSIONS PVE surgery remains a high-risk one. The strongest predictors of early outcome of PVE surgery are related to patients haemodynamic status and microbiological factors.

Expectation and quality of life after aortic valve replacement over 85 years of age match those of the contemporary general population

Background In the transcatheter aortic valve implantation (TAVI) years, very elderly patients with aortic stenosis (AS) are referred to surgery with reluctance despite excellent hospital outcomes. A poorly assessed outcome of discharged survivors might further overlook the actual efficacy of the surgical strategy in this cohort. We thus evaluated life-expectancy and functional results in discharged survivors over 85 years operated on for AS. Methods Between January 2001 and December 2013, 57 consecutive patients aged ≥85 years underwent aortic valve replacement (AVR) with or without concomitant procedures at our institution. Late survival rate (SR), New York Heart Associaion (NYHA) functional class and quality of life (RAND SF-36) were assessed. SR and quality of life (QoL) were than compared to the contemporary general population matched for age and gender, as calculated by the Italian National Institute of Statistics. Results Overall in-hospital mortality was 8.8% (5 pts). In patients without concomitant coronary artery bypass grafting (CABG), in-hospital mortality was 2.9%. Survival at 5 and 9 years was 57.7 ± 8.4% and 17.9 ± 11.4%, respectively. No predictors of late mortality including concomitant CABG were identified at Cox analysis. The mean NYHA class for long-term survivors improved from 3.1 to 1.6 (p<0.001). Survivors reported better QoL-scores compared to the age- and gender-matched contemporary general population in 4 RAND SF-36 domains. Life-expectancy resulted comparable to that predicted for the age and gender-matched general population. Conclusions Isolated AVR in patients aged ≥85 years can be performed with acceptable risk. Survivors improve in NYHA class and, when compared to age- and gender-matched individuals, show a similar life expectancy and a no lower QoL.

A Nearly Missed Catastrophic Aortic Injury After Reduction of a Thoracic Spine Fracture Managed by Prompt Endovascular Treatment

Fig 3. Tcedures are rare. Delayed diagnosis and the clinical complexity may result in a catastrophic outcome. Moreover, in such circumstances a conventional surgical approach might be impeded by the need to keep the patient in a supine position to avoid spinal injuries. A 48-year-old man was transferred to our hospital for emergency treatment of an aortic intramural hematoma after an open reduction of a traumatic thoracic spine fracture. Routine computed tomography of the chest performed after the orthopedic procedure had revealed the lower screw impinging on the descending thoracic aorta (Fig 1A), thus producing an intramural hematoma that extended to the concavity of the aortic arch and ascending aorta (Fig 1B, arrow). In the hybrid room under direct fluoroscopic guidance, a single Gore Tag 31/31/100 mm thoracic endoprosthesis (Gore, Flagstaff, AZ) was introduced through the right femoral artery and deployed into the proximal descending thoracic aorta (Fig 2A; arrow indicates impinging screw). Within the same procedure, the screw was removed (Fig 2B, insert), and the aorta was rechecked (Fig 2B). Follow-up computed tomography of the chest (Fig 3) and the clinical outcome showed an uneventful recovery.

Nongated vs electrocardiography-gated CT imaging of blunt aortic root rupture in a trauma patient.

An 18-year-old male, involved in a car accident, underwent a non-gated contrast enhanced CT with apparently no evidence of significant abnormalities of the thoracic aorta. The later onset of aortic valve regurgitation prompted a prospectively ECG-triggered high-pitch spiral acquisition using a dual-source CT system which showed a tear with a huge pseudoaneurysm of the aortic root. The patient underwent successful urgent conservative surgical repair. CT is the primary screening modality for aortic injuries. Cardiac motion artifacts may hamper sensitivity at the root/ascending aorta level when a non ECG-gated technique is used, thus masking a potentially life-threatening condition. ECG-gated-CT should be mandatorily performed in patients with a high suspicion for an aortic root trauma thus allowing timely repair and avoiding a catastrophic event.

Impact of preoperative thrombocytopenia on the outcome after coronary artery bypass grafting

Abstract The impact of thrombocytopenia on postoperative bleeding and other major adverse events after cardiac surgery is unclear. This issue was investigated in a series of patients who underwent isolated coronary artery bypass grafting (CABG) from the prospective, multicenter E-CABG registry. Preoperative thrombocytopenia was defined as preoperative platelet count <150 × 109/L and it was considered moderate-severe when preoperative platelet count was <100 × 109/L. Multilevel mixed-effects regression analysis was performed to adjust the effect of thrombocytopenia on outcomes for baseline and operative covariates as well as for interinstitutional differences in patient-blood management. Among 7189 patients included in this analysis, 599 (8.3%) had preoperative thrombocytopenia. Patient with preoperative thrombocytopenia had an increased chest drainage output at 12 h (mean, 519 vs. 456 mL, adjusted coeff. 39, 95%CI 18–60) and rates of severe-massive bleeding (Universal Definition of Perioperative Bleeding (UDPB) severity grades 3–4: 12.7% vs. 8.1%, adjusted OR 1.47, 95%CI 1.11–1.93; E-CABG bleeding severity grades 2–3: 10.4% vs. 6.1%, adjusted OR 1.78, 95%CI 1.30–2.43). Thrombocytopenia was associated with an increased risk of hospital/30-day death (3.2% vs. 1.9%, adjusted OR 2.02, 95%CI 1.20–3.42), 1-year death (5.7% vs. 3.4%, adjusted HR 1.68, 95%CI 1.16–2.44), deep sternal wound infection (3.5% vs. 2.4%, adjusted OR 1.65, 95%CI 1.02–2.66), acute kidney injury (28.1% vs. 22.2%, OR 1.45, 1.18–1.78), and prolonged stay in the intensive care unit (mean, 3.6 vs 2.8 days, adjusted coeff. 0.74, 95%CI 0.40–1.09). Similar results were observed in a subset of patients with moderate-severe thrombocytopenia (51 patients, 0.7%). In particular, these patients had a markedly higher rate of acute kidney injury (40%, adjusted OR, 1.94, 95%CI 1.05–3.57), resternotomy for bleeding (7.8%, adjusted OR 3.49, 95%CI 1.20–10.21), and severe-massive bleeding (UDPB severity grades 3–4: 23.5%, adjusted OR 3.08, 95%CI 1.52–6.22; E-CABG bleeding severity grades 2–3: 23.5%, adjusted OR 4.43, 95%CI 2.15–9.15) compared to patients with normal preoperative platelet count. Mild preoperative thrombocytopenia is associated with increased risk of severe-massive bleeding, mortality, and other major adverse events after CABG. Such risks are markedly increased in patients with moderate-severe preoperative thrombocytopenia.