Ehud Raanani

The impact of hyperlactatemia on postoperative outcome after adult cardiac surgery

PurposeTo evaluate the value of blood lactate value in predicting postoperative mortality (primary outcome), duration of ventilation, and length of stay in an intensive care unit (ICU) and hospital (secondary outcomes).MethodsWe performed a prospective observation study on 1,820 consecutive patients undergoing open heart surgery in a tertiary university medical center. Blood lactate levels were obtained from patients on admission to the cardiac surgical ICU and measured serially.ResultsAll patients were divided into three groups according to their maximum blood lactate levels: group I (normolactatemia, lactate ≤2.2xa0mmol/l), 332 patients; group II (mild hyperlactatemia, lactate 2.2–4.1xa0mmol/l), 1,054 patients; and group III (severe hyperlactatemia, lactate ≥4.4xa0mmol/l), 434 patients. Maximum blood lactate levels ≥4.4xa0mmol/l during the first 10xa0h post admission were associated with prolonged ventilation time, longer ICU stay, and increased mortality (Pxa0<xa00.001).ConclusionsHyperlactatemia is common after cardiac surgery. Maximal lactate threshold ≥4.4xa0mmol/l in the first 10xa0h after operation accurately predicts postoperative mortality.

Takotsubo Syndrome After Cardiac Surgery

We have not found any reports to date of Takotsubo syndrome after cardiac surgery. Recently described Takotsubo syndrome is characterized by acute reversible left ventricular dysfunction with apical ballooning in the absence of coronary artery disease, and with chest pain and electrocardiographic changes mimicking acute anterior myocardial infarction, but with minimal release of myocardial enzymes. We describe Takotsubo syndrome that developed after elective mitral valve replacement and tricuspid annuloplasty in a 62-year-old woman. On supportive therapy with vasopressors, left ventricular function gradually improved with an ejection fraction returning to 50%. Takotsubo cardiomyopathy should be considered as a possible complication of the cardiac surgery.

Factors affecting survival in men versus women following transcatheter aortic valve implantation.

Although transcatheter aortic valve implantation (TAVI) for severe aortic stenosis is becoming an established technique, the impact of gender-related differences remains unclear. Two hundred twenty-four consecutive patients undergoing TAVI were prospectively followed up in a tertiary medical center. The primary end point of the present study was all-cause mortality at 2 years of follow-up. Interaction-term analysis was used to identify gender-specific predictors of mortality after TAVI. Fifty-seven percent of the study patients were women. Age was similar (82 ± 7 years). Compared with men, women had a lower frequency of coronary artery disease (CAD) and a higher baseline left ventricular ejection fraction (LVEF). The cumulative probability of all-cause mortality was significantly lower among women (8.6%) compared with men (26.8%; log-rank p value <0.001). A lower baseline LVEF (<45%) was associated with a significant, more than fourfold (p = 0.0019 and 0.048, respectively), increase in mortality risk among both men and women (p value for gender-by-LVEF interaction = 0.87). In contrast, the risk associated with the presence of previous CAD was shown to be gender related. Thus, in women, CAD was associated with a pronounced >14-fold increase in mortality risk, whereas in men, CAD was not associated with a significant mortality risk (p value for gender-by-LVEF interaction = 0.01). In conclusion, our findings suggest that risk assessment before TAVI should consider gender-specific differences in survival and risk factors.

The significance of pulmonary arterial hypertension pre- and post-transfemoral aortic valve implantation for severe aortic stenosis.

BACKGROUNDnTranscatheter aortic valve implantation (TAVI) has become the treatment of choice for the symptomatic patients with aortic stenosis (AS) and high surgical risk. Pulmonary hypertension (PHTN) has been shown to be associated with worse early and late outcomes after aortic valve surgery. Data regarding the effect of TAVI on PHTN are limited.nnnMETHODS AND RESULTSnWe evaluated the characteristics and outcome of the patients with various degrees of systolic PHTN referred for TAVI. PHTN was defined as systolic pulmonary arterial pressure (SPAP) ≥50mmHg as assessed by echocardiography. The patients with SPAP decrease after TAVI to below 50mmHg were compared to the patients with persistent PHTN following TAVI. Of the 122 patients included in the present study, 49 (40%) patients had elevated SPAP prior to TAVI. This group of patients presented with smaller aortic valve areas, greater degrees of mitral or tricuspid regurgitation, lower left ventricular ejection fraction, and more prevalent chronic obstructive pulmonary disease (COPD) (all p<0.05). Following TAVI, 57% of the patients with prior PHTN experienced a reduction in SPAP to below 50mmHg. Multivariable analysis identified COPD to be the most powerful predictor for PHTN presence post-TAVI (hazard ratio 3.9, 95% confidence interval 1.5-9.9, p=0.005). Post-TAVI PHTN (SPAP ≥50mmHg) was associated with a 3.4-fold, independent, 2-year mortality risk (p=0.04).nnnCONCLUSIONSnOur data suggest that TAVI is associated with a significant reduction in pulmonary pressure in more than half of the patients with preprocedural PHTN. COPD identifies the patients with persistent PHTN after TAVI. Post-TAVI PHTN is associated with markedly worse outcome.

Adult Respiratory Distress Syndrome Following Cardiac Surgery

Severe lung injury with the development of acute respiratory distress syndrome (ARDS) is a serious complication of cardiac surgery. The aim of this study was to determine the incidence, risk factors, and mortality of ARDS following cardiac surgery.

Comparison of acute kidney injury classifications in patients undergoing transcatheter aortic valve implantation: Predictors and long-term outcomes

Acute kidney injury (AKI) was demonstrated to adversely affect outcome in patients undergoing transcatheter aortic valve implantation (TAVI). We compared predictors for AKI and associated outcomes according to various definitions among patients undergoing TAVI in a tertiary medical center.

Simple repair approach for mitral regurgitation in Barlow disease

OBJECTIVEnMitral valve repair for myxomatous Barlow disease is a challenging procedure requiring complex surgery with less than optimal results. The use of ring-only repair has been previously reported but never analyzed or followed-up. We investigated this simple valve repair approach for patients with Barlow disease and multisegment involvement causing mainly central jet.nnnMETHODSnOf 572 patients who underwent mitral valve repair for mitral regurgitation at our medical center, 24 with Barlow disease (aged 47xa0±xa014xa0years; 46% male) underwent ring-only repair. Patients were characterized by severely enlarged mitral valve annulus, multisegment prolapse involving both leaflets, and demonstrated mainly a central wide regurgitant jet. Surgical technique included only the implantation of a large mitral annuloplasty ring. Early and late outcome results were compared with those of the remaining patients who underwent conventional mitral valve repair for degenerative disease (controls).nnnRESULTSnAll ring-only patients presented with moderate-severe/severe mitral regurgitation (vena contracta, 0.6xa0±xa00.1xa0cm; regurgitation volume, 52xa0±xa017xa0mL), with mainly a central jet and almost preserved ejection fraction (59%xa0±xa06%). Cardiopulmonary bypass and crossclamp times were significantly shorter compared with controls (Pxa0<xa0.0001). At follow-up (ring-only, 38xa0±xa036xa0months and controls, 36xa0±xa029xa0months), there were no late deaths in the ring-only group compared with 19 (4%) in the controls. Late follow-up revealed New York Heart Association functional class I or II in 95% of ring-only patients, compared with 90% of controls. Freedom from recurrent moderate or severe mitral regurgitation was 100% and 89% in the ring-only and control groups, respectively.nnnCONCLUSIONSnMitral annuloplasty for Barlow disease patients with multisegment involvement and mainly central regurgitant jet is both simple and reproducible with excellent late outcomes.

Local Application of Leptin Antagonist Attenuates Angiotensin II–Induced Ascending Aortic Aneurysm and Cardiac Remodeling

Background Ascending thoracic aortic aneurysm (ATAA) is driven by angiotensin II (AngII) and contributes to the development of left ventricular (LV) remodeling through aortoventricular coupling. We previously showed that locally available leptin augments AngII‐induced abdominal aortic aneurysms in apolipoprotein E–deficient mice. We hypothesized that locally synthesized leptin mediates AngII‐induced ATAA. Methods and Results Following demonstration of leptin synthesis in samples of human ATAA associated with different etiologies, we modeled in situ leptin expression in apolipoprotein E–deficient mice by applying exogenous leptin on the surface of the ascending aorta. This treatment resulted in local aortic stiffening and dilation, LV hypertrophy, and thickening of aortic/mitral valve leaflets. Similar results were obtained in an AngII‐infusion ATAA mouse model. To test the dependence of AngII‐induced aortic and LV remodeling on leptin activity, a leptin antagonist was applied to the ascending aorta in AngII‐infused mice. Locally applied single low‐dose leptin antagonist moderated AngII‐induced ascending aortic dilation and protected mice from ATAA rupture. Furthermore, LV hypertrophy was attenuated and thickening of aortic valve leaflets was moderated. Last, analysis of human aortic valve stenosis leaflets revealed de novo leptin synthesis, whereas exogenous leptin stimulated proliferation and promoted mineralization of human valve interstitial cells in culture. Conclusions AngII‐induced ATAA is mediated by locally synthesized leptin. Aortoventricular hemodynamic coupling drives LV hypertrophy and promotes early aortic valve lesions, possibly mediated by valvular in situ leptin synthesis. Clinical implementation of local leptin antagonist therapy may attenuate AngII‐induced ATAA and moderate related LV hypertrophy and pre–aortic valve stenosis lesions. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00449306.

Addition of albumin to Traditional Risk Score Improved Prediction of Mortality in Individuals Undergoing Transcatheter Aortic Valve Replacement

The ability of the Society of Thoracic Surgeons (STS) and European System for Cardiac Operative Risk Evaluation (EuroSCORE)‐2 scores to predict outcomes after transcatheter aortic valve replacement (TAVR) is insufficient. Frailty and serum albumin as a frailty marker were shown to correlate with prognosis after TAVR. We sought to evaluate the additive value of serum albumin to STS and EuroSCORE‐2 scores to predict mortality in individuals undergoing TAVR.

Coxiella burnetii Endocarditis and Aortic Vascular Graft Infection: An Underrecognized Disease

BACKGROUNDnQ fever is considered endemic worldwide, and endocarditis, or aortic vascular infection, or both caused by Coxiella burnetii can be a fatal disease. The importance of surgical intervention has not yet been defined. We performed a descriptive retrospective study to assess indications for surgical treatment, timing of treatment, and outcome.nnnMETHODSnWe studied all patients from the cardiac surgery department of a large tertiary hospital who underwent valve surgical procedure due to endocarditis or aortic surgical procedure due to graft infection.nnnRESULTSnThroughout a 10-year period, we performed a total of 171 procedures due to valve endocarditis and/or vascular infection. In 16 patients (9.36%) Coxiella burnetii infection was diagnosed. Ten patients had previous cardiac surgical procedures, 3 had previous aortic surgical procedures, 2 had preexisting valvular disease, and 1 patient had no previous valve disorder. All patients received prolonged oral-specific antibiotic therapy under serologic guidance. In 9 patients antibiotic treatment (doxycycline and hydroxychloroquine) was started before the surgical procedure (12.4 ± 37.5 days), and in 7 patients after the surgical procedure (5.1 ± 13.5 days). We observed one in-hospital death (6.25%) and no long-term mortality. The mean follow-up period was 50.5 ± 34.7 months (range, 2 to 104 months).nnnCONCLUSIONSnIn this series surgical treatment yielded good results for both Q fever endocarditis and vascular graft infection. No association was found between timing of the surgical procedure and patients outcomes.