Cosimo Comito

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.

Preoperative angiotensin-converting enzyme inhibitors protect myocardium from ischemia during coronary artery bypass graft surgery

OBJECTIVES Coronary artery bypass graft surgery may result in perioperative myocardial injury during cardioplegic arrest. Angiotensin-converting enzyme (ACE) inhibitors protect the myocardium from ischemia in several clinical conditions, but no previous study has attempted to evaluate the impact of preoperative ACE inhibitor therapy on myocardial protection in patients undergoing coronary artery bypass graft surgery. METHODS A propensity score-based analysis of 481 patients undergoing isolated on-pump coronary artery bypass graft surgery was carried out, among which 245 patients received preoperative ACE inhibitors and 236 patients did not. Perioperative myocardial injury was assessed by ischemia marker cardiac troponin I (cTnI). RESULTS Preoperative cTnI concentration was similar for patients receiving ACE inhibitors and those who did not [0.1 ng/ml (0.06-0.19) versus 0.1 ng/ml (0.06-0.19); P = 0.3]. Postoperative cTnI peak concentration was lower in patients receiving preoperative ACE inhibitors [1.6 ng/ml (1.05-3.4) versus 2.4 ng/ml (1.13-6.10); P = 0.0006]. After adjusting for propensity score and covariates, preoperative ACE inhibitors were found to decrease postoperative cTnI peak concentration (beta = -0.12; P = 0.004). Other independent predictors of postoperative cTnI peak concentration were female gender, emergency surgery, number of distal anastomoses and aortic cross clamp time. Overall, operative mortality rate was 16/481 (3.3%). Patients receiving preoperative ACE inhibitors had a lower rate of postoperative myocardial infarction (2.0 versus 4.2%; P = 0.25) and low cardiac output syndrome (3.6 versus 6.3%; P = 0.24). CONCLUSION ACE inhibitors prior to surgery confer added myocardial protection during surgical revascularization. Prospective, randomized clinical trials will be necessary to better define the role of ACE inhibitors in improving outcomes when they are prescribed prior to coronary artery bypass graft surgery.Objectives Coronary artery bypass graft surgery may result in perioperative myocardial injury during cardioplegic arrest. Angiotensin-converting enzyme (ACE) inhibitors protect the myocardium from ischemia in several clinical conditions, but no previous study has attempted to evaluate the impact of preoperative ACE inhibitor therapy on myocardial protection in patients undergoing coronary artery bypass graft surgery. Methods A propensity score-based analysis of 481 patients undergoing isolated on-pump coronary artery bypass graft surgery was carried out, among which 245 patients received preoperative ACE inhibitors and 236 patients did not. Perioperative myocardial injury was assessed by ischemia marker cardiac troponin I (cTnI). Results Preoperative cTnI concentration was similar for patients receiving ACE inhibitors and those who did not [0.1 ng/ml (0.06–0.19) versus 0.1 ng/ml (0.06–0.19); P = 0.3]. Postoperative cTnI peak concentration was lower in patients receiving preoperative ACE inhibitors [1.6 ng/ml (1.05–3.4) versus 2.4 ng/ml (1.13–6.10); P = 0.0006]. After adjusting for propensity score and covariates, preoperative ACE inhibitors were found to decrease postoperative cTnI peak concentration (β = −0.12; P = 0.004). Other independent predictors of postoperative cTnI peak concentration were female gender, emergency surgery, number of distal anastomoses and aortic cross clamp time. Overall, operative mortality rate was 16/481 (3.3%). Patients receiving preoperative ACE inhibitors had a lower rate of postoperative myocardial infarction (2.0 versus 4.2%; P = 0.25) and low cardiac output syndrome (3.6 versus 6.3%; P = 0.24). Conclusion ACE inhibitors prior to surgery confer added myocardial protection during surgical revascularization. Prospective, randomized clinical trials will be necessary to better define the role of ACE inhibitors in improving outcomes when they are prescribed prior to coronary artery bypass graft surgery.

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.

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.

n-3 Polyunsaturated Fatty Acids After Coronary Artery Bypass Grafting

BACKGROUND Despite the robust evidence of the potential benefits of n-3 polyunsaturated fatty acid (PUFA) supplementation in patients with established coronary artery disease, the impact of this therapy on patients after coronary artery bypass grafting remains completely unknown. METHODS Among 2,100 patients undergoing isolated coronary artery bypass grafting in one tertiary care institution, 930 (44%) were put under n-3 PUFA therapy chronically at discharge. The impact of n-3 PUFAs was assessed by means of propensity-score adjusted analysis. The primary end point was all-cause mortality. Secondary end points were repeat revascularization and the composite of death, Q-wave myocardial infarction, and cerebrovascular events. RESULTS In a crude analysis, patients discharged on n-3 PUFAs had a lower risk for late mortality (unadjusted hazard ratio [HR], 0.51; 95% confidence interval [CI], 0.36 to 0.73; p = 0.0002), which was conformed at multivariable adjusted Cox regression analysis (HR, 0.55; 95% CI, 0.26 to 0.90; p = 0.02). Adjusted risk of repeat revascularization was significantly lower in patients receiving n-3 PUFAs than in those who did not (HR, 0.52; 95% CI, 0.28 to 0.97; p = 0.04). The adjusted risk for the composite of death, Q-wave myocardial infarction, or cerebrovascular events was lower in patients who received n-3 PUFAs compared with patients who did not (HR, 0.56; 95% CI, 0.36 to 0.81; p = 0.001). Subgroup analyses showed that mortality benefit associated with n-3 PUFAs was particularly relevant in patients with poor left ventricular function (HR, 0.36; 95% CI, 0.17 to 0.76; p = 0.007), but it was only marginal in patients with good ventricular function (HR, 0.89; 95% CI, 0.65 to 1.01; p = 0.05). CONCLUSIONS This study showed that n-3 PUFAs after coronary artery bypass grafting were associated with a lower risk for repeat revascularization and overall mortality in patients with poor ventricular function.

Slow coronary flow and stress myocardial perfusion imaging. Different patterns in acute patients.

Objective We investigated myocardial perfusion in acute patients with slow coronary flow (SCF) at angiography. Whether impaired myocardial perfusion occurs in acute patients with SCF is unknown. Methods We enrolled 28 consecutive patients with SCF in the epicardial coronary arteries with no evidence of significant stenosis. SCF affected a single coronary artery in 14 patients (group A) and all three coronary vessels in 14 others (group B). Coronary angiography was repeated after dipyridamole infusion and single photon emission computed tomography was performed using dipyridamole as the stress agent. The Thrombolysis in Myocardial Infarction frame count was measured in SCF vessels at baseline and after dipyridamole infusion. Results Mean Thrombolysis in Myocardial Infarction frame count significantly decreased after dipyridamole in both groups. At baseline, mean values of the single photon emission computed tomography score were 31.5 ± 1.6 and 25.1 ± 2.1 in groups A and B, respectively. After dipyridamole, they increased from 31.5 ± 1.6 to 37.8 ± 1.4 (P < 0.001) in group A, whereas a further decrease to 15.0 ± 1.2 (P < 0.005) was observed in group B. Conclusions An opposite behavior of myocardial perfusion was observed after dipyridamole infusion: a normal response in patients with SCF affecting one single coronary artery versus an ischemic-like response in those with CSF affecting all three coronary arteries.

Impact of prosthesis–patient mismatch on tricuspid valve regurgitation and pulmonary hypertension following mitral valve replacement

BACKGROUND Mitral PPM can be equated to residual mitral stenosis, which may halt the expected postoperative improvement of PH and concomitant functional tricuspid regurgitation (fTR). Aim of the present study is to evaluate the impact of mitral prosthesis-patient mismatch (PPM) on late tricuspid valve regurgitation and pulmonary hypertension (PH). METHODS A total of 210 patients undergoing isolated mitral valve replacement (MVR) were investigated. Mitral valve effective orifice area was determined by the continuity equation and indexed for body surface area (EOAi) and PPM was defined as EOAi ≤ 1.2 cm(2)/m(2). Pulmonary hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP) > 40 mmHg. Clinical and echocardiographic follow-up (median 27 months) was 100% completed. A total of 88/210 (42%) patients developed mitral PPM. RESULTS There were no significative differences in baseline and operative characteristics between patients with and without PPM. At follow-up, the prevalence of fTR ≥ 2+ (57%vs.22%; p = 0.0001), and PH (62%vs.24%;p < 0.0001) were significantly higher in patients with PPM. On multivariable regression analysis, EOAi (p < 0.0001) and preoperative left ventricular (LV) end-diastolic diameter (p < 0.0001) were found to be independently associated with fTR decrease after MVR. In addition, EOAi (p < 0.0001) and LV ejection fraction (p < 0.0001) were independently associated with PH decrease after MVR. No significant differences in mortality rates were found between patients having or not PPM. CONCLUSIONS This study shows that mitral PPM is associated with the persistence of fTR and PH following MVR. These findings support the realization of tricuspid valve annuloplasty when PPM is anticipated at the time of operation.

Intensive hyperglycemia control reduces postoperative infections after open heart surgery

Background: Diabetes mellitus increases the risk of infections in patients undergoing cardiac surgery. We hypothesized that intensive perioperative hyperglycemia control by intravenous insulin infusion reduces postoperative infections in all patients undergoing open heart surgical procedures. Methods: Sixty diabetics patients who underwent CABG operation (Group 1) were compared with fifty-five patients who underwent other cardiac surgery (Group 2) between January 2004 and March 2005. A continuous infusion of insulin was used in all these patients. Results: There were no 30-day mortalities in either group. There was no difference in the incidence of infections between the two groups: in Group 1, 3 (5%) patients were diagnosed to have postoperative infection (superficial sternal wound infections in 1 (1.66%) and lung infection in 2 (3.33%) patients); postoperative infection occurred in only 2 patients (3.63%) in Group 2, 1 superficial sternal wound infections (1.81%) and 1 lung infection (1.81%). Conclusions: Our analysis indicates that continuous intravenous insulin infusion improves outcome and reduces postoperative infections in patients undergoing CABG as well as those undergoing other cardiac surgery procedures.

Perioperative administration of enoximone and renal function after cardiac surgery: A propensity-matched analysis

BACKGROUND Perioperative administration of enoximone has been shown to improve hemodynamics, organ function, and inflammatory response. Aim of the present study is to evaluate the impact of enoximone on postoperative renal function after on-pump cardiac surgery. METHODS A total of 3727 patients undergoing cardiac surgery at one Institution between May 2004 and November 2010 were reviewed. A propensity score was built and a 1:1 perfect matching was performed, providing two fairly comparable cohorts of 712 patients each, receiving or not enoximone after surgery. Renal function was evaluated by lower glomerular filtration rate (GFR) value reached postoperatively. RESULTS Overall 30-day mortality rate was 4.3% (62/1424). Cumulative incidence of postoperative renal failure (RF) was 157/1424(11%), of which 99/1424(7%) needed renal replacement therapy. Mean lower postoperative GFR in patients who received or not enoximone was 63 ± 30.1 and 53.5 ± 26.1 ml/min/1.73 m(2) (p<0.0001), respectively. At multivariable analysis age (OR2.75, p=0.0004), diabetes (OR1.82, p=0.006), preoperative GFR (OR3.81, p<0.0001), preoperative cardiogenic shock (OR1.65, p=0.004), previous cardiac surgery (OR2.12, p=0.0002), type of intervention (OR1.96, p=0.005), and enoximone (OR0.38, p=0.001) were found to be independently associated with postoperative RF. Logistic regression analysis showed that the administration of enoximone (OR0.41, p=0.0001), and of no inotropes (OR0.27, p<0.0001) were protective vs. the occurrence of postoperative RF. CONCLUSION Patients perioperatively receiving enoximone showed a statistically significant better renal function after cardiac surgery.