Carlos A. Ingino

Prospective validation of EuroSCORE II in patients undergoing cardiac surgery in Argentinean centres

OBJECTIVES The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) is an updated version of the original EuroSCORE that must be extensively validated. The objective was to prospectively evaluate the efficacy of EuroSCORE II in predicting the immediate results of cardiac surgery in Argentinean centres. METHODS A prospective consecutive series of 503 adults who underwent cardiac surgery between January 2012 and April 2013 was studied. EuroSCORE II discrimination and accuracy were assessed in the overall cohort and in two surgically defined subgroups: isolated coronary artery bypass graft (CABG) surgery and non-CABG surgery. Additionally, a risk-adjusted cumulative sum control chart analysis was performed. RESULTS In-hospital overall mortality rate was 4.17%, while the mortality rate predicted by the EuroSCORE II was 3.18% (P = 0.402). Receiver operating characteristic curve analysis demonstrated a good overall (area 0.856) and non-CABG subgroup (area 0.857) discrimination (P = 0.0001), while discrimination in the CABG subgroup was poorer (area 0.794, P = 0.014). The model showed good calibration in predicting in-hospital mortality, both overall (Hosmer-Lemeshow, P = 0.082) and for each subgroup (non-CABG, P = 0.308, and CABG, P = 0.150). CONCLUSIONS EuroSCORE II reflects a better current surgical performance and offers a new quality standard to evaluate local outcomes. EuroSCORE showed an overall good discriminative capacity and calibration in this local population; nevertheless, the model performed optimally in non-CABG surgery and in highest-risk patients, underestimating in-hospital mortality in lowest-risk cases. The latter finding may be interpreted as an inadequate behaviour of the model, as a poor performance of surgeons or both. Larger prospective studies will elucidate this hypothesis.

Routine operation theatre extubation after cardiac surgery in the elderly

OBJECTIVES The aim was to analyse in-hospital outcomes of patients over 70 years of age undergoing routine immediate operation theatre (OT) extubation after on-pump or off-pump cardiac surgery. METHODS A retrospective analysis was performed of prospectively collected data over a 4-year period (2011-14) from elderly patients undergoing early extubation after cardiac surgery at a single institution. All patients over 70 years were considered eligible for immediate OT or intensive care unit (ICU) early extubation after meeting specific criteria. All types of non-emergency cardiac surgery were included. Cardiac surgical risk stratification was assessed with EuroSCORE II and age, creatinine level and left ventricular ejection fraction (ACEF) score. RESULTS Among the 415 patients operated on during the period, 275 (66.3%) were ≥70 years old. One hundred and forty patients (50.9%) of the elderly group were extubated successfully in the OT. Excluding off-pump coronary surgery, OT extubation was achieved in 51.5% of cases. The rate of risk of reintubation within 24 h of surgery after OT extubation was 2.1%. The in-hospital mortality rate was 4.7%, and the complication rate was 11.6%, independently of extubation timing. Elderly patients extubated in the OT had a significantly lower median EuroSCORE II risk level and ACEF score, more isolated valve surgeries, reduced cardiopulmonary bypass time, less complications and shorter length of stay than ICU-extubated patients. In the multivariate analysis, only the ACEF score remained as an independent variable associated with OT extubation in the elderly (odds ratio 25.0, 95% CI 2.74-228.8, P = 0.004), and had good discriminating power [receiver operating characteristics (ROC) area 0.713]. On the other hand, the EuroSCORE ROC area used to predict OT extubation was 0.694, and the cut-off analysis showed that a risk value under 2.11 was associated with 72.1% OT extubation versus 37.3% when the risk value was over 2.11 (P = 0.0002). CONCLUSIONS OT extubation in the elderly can be safely performed in nearly 50% of patients, without apparently worsening their outcomes. A key point of this success was the use of a short-acting volatile agent to maintain anaesthesia throughout the procedure. Low- or moderate-risk cardiac surgery assessed with a preoperative EuroSCORE II <2.11 will help to better predict successful OT extubation in the elderly.

Incidence of prosthesis-patient mismatch in patients receiving mitral Biocor® porcine prosthetic valves

BACKGROUND The aim was to assess the incidence of prosthesis-patient mismatch (PPM) after mitral valve replacement (MVR) in patients receiving Biocor® porcine or mechanical valves, and to evaluate the effect of PPM on long-term survival. METHODS All patients undergoing MVR between 2009 and 2013 received either mechanical or bioprosthetic valves (Biocor® porcine). PPM was defined as severe when the indexed effective ori-fice area was < 0.9 cm2/m2, moderate between 0.9 cm2/m2 and 1.2 cm2/m2 or absent > 1.2 cm2/m2. The primary endpoint was all-cause long-term mortality. RESULTS Among a total of 136 MVR, PPM was severe in 27%, moderate in 44% and absent in 29% of patients. Implanted valves were 57% mechanical and 43% bioprosthetic. Only 3% of patients with mechanical valves had severe PPM vs. 59% with bioprostheses (p < 0.0001). Sixty-month survival with severe mismatch was 0.559 (SE 0.149) and with no mismatch 0.895 (SE 0.058) (p = 0.043). Survival of patients suffering from severe mismatch, or moderate mismatch with pulmonary hypertension (PH) was 0.749 (SE 0.101); while for patients with no mismatch or with moderate mismatch without PH, survival was 0.951 (SE 0.028) (p = 0.016). CONCLUSIONS About one-fourth of patients had severe PPM and almost all of them had received a bioprosthesis. Sixty-month survival was significantly lower in patients with severe mismatch, or moderate mismatch with PH. Specifically, when a bioprothesis is chosen and while further evidence on the impact of PPM on clinical outcomes appears, surgeons are recommended to follow a preoperative strategy to implant a mitral prosthesis of adequate size in order to prevent PPM.

Agrandamiento del anillo aórtico pequeño con la técnica de Nicks en la cirugía de la estenosis valvular aórtica

La siguiente presentacion es una aproximacion a los Modos Ventilatorios durante la Ventilacion Mecanica Invasiva. Repasaremos sucesivamente las variables de control y de fase de los modos mas utilizados en las Unidades de Cuidados Intensivos. Haremos un repaso de la programacion basica, revision de las alarmas mas importantes, y por ultimo daremos un vistazo al monitoreo de variables mecanicas en cada uno de los modos.

In-hospital Outcomes of Surgical Aortic Valve Replacement: the Benchmark for Transcatheter Valve Implant

Background: The aim of this study was to analyze the current in-hospital outcomes of aortic valve replacement (AVR) surgery in order to serve as a benchmark for comparing the local results of transcatheter aortic valve implantation (TAVI). Methods: We retrospectively analyzed the in-hospital outcomes of 422 patients undergoing isolated AVR between 2012 and 2017 in our institutions associated with the University of Buenos Aires. Results: Overall in-hospital mortality was 3.6%, and 3.8% at 30 days, while the in-hospital and 30-day mortality rate of 71 patients older than 80 years was 4.2%. In the entire series, in-hospital mortality in the low-risk group (EuroSCORE II <4%) was 2.2%, and in the moderate risk group (EuroSCORE II between 4% and 7%) it was 5.0%. Conclusions: This updated information on the local outcomes of AVR surgery stratified by risk could serve as a standard for comparing TAVI results.

Transient acute kidney injury after cardiac surgery does not independently affect postoperative outcomes

The objective of this study was to assess the incidence of in‐hospital acute kidney injury (AKI) after cardiac surgery by comparing preoperative baseline renal function with renal function during the postoperative period and at discharge, and to relate these indices with in‐hospital postoperative outcomes.

Geometric patterns of time-delay plots from different cardiac rhythms and arrhythmias using short-term EKG signals

To date, no systematic work has been intended to describe spatio‐temporal patterns of cardiac rhythms using only short series of RR intervals, to facilitate visual or computerized‐aided identification of EKG motifs for use in clinical practice. The aim of this study was to detect and classify eye‐catching geometric patterns of Poincaré time‐delay plots from different types of cardiac rhythms and arrhythmias using short‐term EKG signals.

Tratamiento endovascular de los aneurismas toracoabdominales tipo IV

Resumen es: Los pacientes con aneurismas toracoabdominales tipo IV se caracterizan anatomicamente por la presencia de una dilatacion aortica visceral que determina l...