Davor Barić

Cardiac surgery-associated acute kidney injury: risk factors analysis and comparison of prediction models

OBJECTIVESnCardiac surgery-associated acute kidney injury (AKI) is a well-known factor influencing patients long-term morbidity and mortality. Several prediction models of AKI requiring dialysis (AKI-D) have been developed. Only a few direct comparisons of these models have been done. Recently, a new, more uniform and objective definition of AKI has been proposed [Kidney Disease: Improve Global Outcomes (KDIGO)-AKI]. The performance of these prediction models has not yet been tested.nnnMETHODSnPreoperative demographic and clinical characteristics of 1056 consecutive adult patients undergoing cardiac surgery were collected retrospectively for the period 2012-2014. Multivariable logistic regression analysis was used to determine the independent predictors of AKI-D and the KDIGO-AKI stages. Risk scores of five prediction models were calculated using corresponding subgroups of patients. The discrimination of these models was calculated by the c-statistics (area under curve, AUC) and the calibration was evaluated for the model with the highest AUC by calibration plots.nnnRESULTSnThe incidence of AKI-D was 3.5% and for KDIGO-AKI 23% (17.3% for Stage 1, 2.1% for Stage 2 and 3.6% for Stage 3). Older age, atrial fibrillation, NYHA class III or IV heart failure, previous cardiac surgery, higher preoperative serum creatinine and endocarditis were independently associated with the development of AKI-D. For KDIGO-AKI, higher body mass index, older age, female gender, chronic obstructive pulmonary disease, previous cardiac surgery, atrial fibrillation, NYHA class III or IV heart failure, higher preoperative serum creatinine and the use of cardiopulmonary bypass were independent predictors. The model by Thakar et al. showed the best performance in the prediction of AKI-D (AUC 0.837; 95% CI = 0.810-0.862) and also in the prediction of KDIGO-AKI stage 1 and higher (AUC = 0.731; 95% CI = 0.639-0.761), KDIGO-AKI stage 2 and higher (AUC = 0.811; 95% CI = 0.783-0.838) and for KDIGO-AKI stage 3 (AUC = 0.842; 95% CI = 0.816-0.867).nnnCONCLUSIONSnThe performance of known prediction models for AKI-D was found reasonably well in the prediction of KDIGO-AKI, with the model by Thakar having the highest predictive value in the discrimination of patients with risk for all KDIGO-AKI stages.

Endoscopic Radial Artery Harvesting Reduces Postoperative Pain and Neurologic Complications

BACKGROUNDnEndoscopic radial artery harvest provides better cosmetic result without compromising the quality of the graft. We sought to compare postoperative harvesting site neurologic and vascular outcome.nnnMETHODSnFrom 10/2002 until 10/2004, 50 patients were randomized to have their radial artery harvested for coronary bypass either endoscopically (group A, n = 25) or conventionally (group B, n = 25). Radial arteries were preoperatively evaluated by Doppler echocardiography. Neurologic and functional status was assessed by a self reporting questionnaire with a semiquantitative (1-5) scale. Vascular status of the forearm was assessed by control echocardiography.nnnRESULTSnAt an average follow-up of 37 +/- 7 months, patients undergoing endoscopic radial artery harvesting had less overall neurologic complications (11 versus 17 patients, P = .023) and they were less severe (0.8 +/- 1.1 versus 2.2 +/- 1.2; P < .001). Ulnar flow increase was similar among the groups: 13.1 +/- 5.43 cm/s in group A versus 15.9 +/- 4.9 cm/s in group B (P = .147) as well as ulnar artery diameter increase 0.29 +/- 0.16 mm in group A versus 0.29 +/- 0.26 cm in group B (P = .914).nnnCONCLUSIONnEndoscopic radial artery is safe and does not compromise graft quality or forearm and hand circulation postoperatively. Along with providing a better cosmetic result, endoscopic artery harvesting reduces postoperative harvesting site pain and neurologic complications.

Asymptomatic Calcifying Fibrous Pseudotumor Compressing Heart Cavities

Calcifying fibrous pseudotumor is a rare benign lesion composed mostly of dense hyalinized colagen with multiple dystrophic or psammomatous calcifications and variable lymphoplasmacytic infiltrate. Children and young adults are most commonly affected by this tumor of uncertain pathogenesis. This is a case of an asymptomatic young woman with calcifying fibrous pseudotumor of the pericardium compressing heart cavities. Partial resection and marsupialization of the mass was performed.

Successful treatment of annular rupture during transcatheter aortic valve implantation

SummaryAnnular rupture presents axa0rare but potentially fatal complication of transcatheter aortic valve implantation (TAVI). Although it can be subtle and subclinical in presentation, most severe forms present with hemodynamic instability and represent true emergencies requiring axa0more invasive treatment, even conventional surgery. We present axa0case of successful treatment of annular rupture by left ventricular outflow tract patch and surgical aortic valve replacement.

Aortic valve endocarditis in a transplanted heart after urethral instrumentation.

Endocarditis represents a rare but life-threatening condition after heart transplantation. Recent American Heart Association guidelines recognize cardiac transplantxa0patients with valvulopathy as high risk for endocarditis, but acknowledge that there were not sufficient data to make a recommendation for prophylaxis. Also, genitourinary procedures were no longer consideredxa0a risk factor for endocarditis in the most recent guidelines. Wexa0present a patient who acquired aortic valve endocarditis of the intact valve, after multiple urethral instrumentation 2 years after heart transplantation, who was successfully treated by aortic valve replacement and prolonged antibiotic therapy.

Isolated Tricuspid Valve Libman-Sacks Endocarditis in Systemic Lupus Erythematosus with Secondary Antiphospholipid Syndrome

Libman-Sacks endocarditis, one of the most prevalent cardiac presentations of systemic lupus erythematosus, typically affects the aortic or mitral valve; tricuspid valve involvement is highly unusual. Secondary antiphospholipid syndrome increases the frequency and severity of cardiac valvular disease in systemic lupus erythematosus. We present the case of a 47-year-old woman with lupus and antiphospholipid syndrome whose massive tricuspid regurgitation was caused by Libman-Sacks endocarditis isolated to the tricuspid valve. In addition, we discuss this rare case in the context of the relevant medical literature.

Omentum flap as a salvage procedure in deep sternal wound infection

and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Therapeutics and Clinical Risk Management 2017:13 1495–1497 Therapeutics and Clinical Risk Management Dovepress

Ventricular tachycardia: ominous sign of devastating prosthetic aortic valve dehiscence

Prosthetic valve endocarditis (PVE) is the most feared complication after valve implantation. It usually results in substantial morbidity and mortality in the postoperative period. An adverse effect on the annulus can cause conduction disturbances in the atrioventricular (AV) node, resulting in a high-degree AV block. This study describes a case of PVE that predominantly presented with sustained monomorphic ventricular tachycardia, which indicated a severe clinical course of PVE caused by a significant displacement of the aortic valve prosthesis. In our opinion, a very pronounced flap valve motion of the dehisced valve probably caused, in the critical moment, coronary artery blood flow limitation by means of coronary microembolization, which produced temporary ischemia and provoked sustained ventricular tachycardia. Furthermore, disturbances of rhythm such as ventricular tachycardia in the setting of endocarditis indicate a high-risk condition and should mandate fast and thorough noninvasive diagnostic procedures to obtain correct diagnosis even in the case of mild, slowly progressing disease.

Off-pump myocardial revascularization attenuates endothelin-1 expression in systemic, pulmonary, and coronary circulation

SummaryObjectiveThe objective of this study was to evaluate the influence of cardiopulmonary bypass (CPB) on endothelin-1 (ET-1) expression in various circulation compartments in patients undergoing myocardial revascularization.MethodsA total of 30 patients were randomized to undergo myocardial revascularization with (CABG, nu2009=u200915) or without (OPCAB, nu2009=u200915) CPB. Samples were taken preoperatively, after establishing CPB and after CPB (CABG group), prior to and after revascularization (OPCAB group), and 6 and 24xa0h postoperatively. Values of ET-1 were compared between groups at all time points and correlated with postoperative cardioselective enzyme values and clinical parameters.ResultsIn OPCAB group, ET-1 levels did not significantly vary between time points. In CABG group, ET-1 levels were significantly elevated vs. baseline in arterial: ART-T2 vs. ART-T0 (1.83u2009±u20091.81 vs. 0.76u2009±u20091.07xa0fmol/mL, pu2009=u20090.05), pulmonary: SG-T2 vs. SG-T0 (2.70u2009±u20092.75 vs. 0.39u2009±u20090.28xa0fmol/mL, pu2009<u20090.001) and SG-T3 vs. SG-T0 (1.56u2009±u20090.28 vs. 0.39u2009±u20090.28xa0fmol/mL, pu2009<u20090.001), and coronary circulation CS-T2 vs. CS-T1 (1.12u2009±u20090.49 vs. 0.27u2009±u20090.09xa0fmol/mL, pu2009=u20090.01). ET-1 levels were significantly higher in CABG group in all vascular compartments: ART-T2 (1.83u2009±u20091.81 vs. 0.17u2009±u20090.16xa0fmol/mL, pu2009=u20090.02), ART-T4 (0.99u2009±u20090.56 vs. 0.24u2009±u20090.12xa0fmol/mL, pu2009=u20090.01), SG-T1 (0.59u2009±u20090.15 vs. 0.25u2009±u20090.13xa0fmol/mL, pu2009=u20090.01), SG-T2 (2.70u2009±u20092.75 vs. 0.30u2009±u20090.24xa0fmol/mL, pu2009=u20090.004), SG-T3 (1.56u2009±u20090.28 vs. 0.35u2009±u20090.31xa0fmol/mL, pu2009<u20090.001), SG-T4 (1.34u2009±u20090.11 vs. 0.34u2009±u20090.16xa0fmol/mL, pu2009<u20090.001), and CS-T2 (1.12u2009±u20090.49 vs. 0.12u2009±u20090.12xa0fmol/mL, pu2009=u20090.004). Coronary sinus ET-1 level after CPB (CS-T2) in CABG group correlated positively with troponin-I level 24xa0h postoperatively (r2u2009=u20090.802, pu2009=u20090.02)ConclusionOff-pump myocardial revascularization attenuates ET-1 expression in all investigated vascular compartments. Elevated coronary ET-1 levels after CPB in CABG group correlate with troponin-I levels 24xa0h postoperatively.ZusammenfassungZielwar es, den Einfluss eines kardiopulmonalen Bypasses auf die Endothelin-1 (ET-1) Expression in verschiedenen Kreislauf Kompartments von Patienten mit myokardialer Revaskularisation zu erheben.MethodenBei dreißig Patienten wurden eine myokardiale Revaskularisation randomisiert mit (CABG nu2009=u200915) oder ohne (OP-CAB, nu2009=u200915) Herzkreislauf Maschine (HKM) durchgeführt. Proben wurden präoperativ, nach Anschluss an die Maschine und nach dem Ende des Herzkreislauf Bypasses (CABG Gruppe), vor und nach Revaskularisation (OP-CAB Gruppe) sowie 6 und 24xa0h postoperativ abgenommen. Die bei beiden Gruppen erhobenen ET-1 Werte aller Blutabnahme-Zeitpunkte wurden verglichen und mit postoperativen kardioselektiven Enzymwerten sowie klinischen Parametern korreliert.ErgebnisseIn der OP-CAB Gruppe ergab sich im gesamten Verlauf kein statistisch signifikanter Unterschied der ET-1 Konzentrationen. In der CABG Gruppe waren die ET-1 Werte signifikant im Vergleich zu den Ausgangswerte erhöht: arteriell – ART-T2 vs. ART-T0 (1,83u2009±u20091,81 vs. 0,76u2009±u20091,07xa0fmol/mL, pu2009=u20090,05), pulmonal arteriell – SG-T2 vs. SG-T0 (2,70u2009±u20092,75 vs. 0,39u2009±u20090,28xa0fmol/mL, pu2009<u20090,001), SG-T3 vs. SG-T0 (1,56u2009±u20090,28 vs. 0,39u2009±u20090,28xa0fmol/mL, pu2009<u20090,001) und Koronar Kreislauf CST2 vs. CS-T1 (1,12u2009±u20090,49 vs. 0,27u2009±u20090,09xa0fmol/mL, pu2009=u20090,01). Die ET-1 Konzentrationen waren in der CABG –Gruppe in allen Gefäß-Kompartments signifikant höher: ART-T2 (1,83u2009±u20091,81 vs. 0,17u2009±u20090,16xa0fmol/mL, pu2009=u20090,02); ARTT4 (0,99u2009±u20090,56 vs. 0,24u2009±u20090,12xa0fmol/mL, pu2009=u20090,01); SG-T1 (0,59u2009±u20090,15 vs. 0,25u2009±u20090,13xa0fmol/mL, pu2009=u20090,01); SG-T2 (2,70u2009±u20092,75 vs. 0,30u2009±u20090,24xa0fmol/mL, pu2009=u20090,004); SG-T3 (1,56u2009±u20090,28 vs. 0,35u2009±u20090,31xa0fmol/mL, pu2009<u20090,001); SG-T4 (1,34u2009±u20090,11 vs. 0,34u2009±u20090,16xa0fmol/mL, pu2009<u20090,001); CS-T2 (1,12u2009±u20090,49 vs. 0,12u2009±u20090,12xa0fmol/mL, pu2009=u20090,004).Die ET-1 Konzentrationen im Koronarsinus waren nach dem Herz-Kreislauf Bypass in der CABG Gruppe positiv mit den 24 Stunden- postoperativen Troponin-I Werten korreliert (r2u2009=u20090,802, pu2009=u20090,02).SchlussfolgerungEine myokardiale Revaskularisation off-pump schwächt die ET-1 Expression in allen untersuchten Gefäßgebieten ab. Die nach der Herz Lungen Maschine erhöhten ET-1 Werte der CABG Gruppe korrelieren mit den 24xa0h postoperativ gemessenen Troponin-I Werten.