Euclide Tonelli

The impact of arterial cannulation strategy on operative outcomes in aortic surgery: Evidence from a comprehensive meta-analysis of comparative studies on 4476 patients

OBJECTIVES There is a growing perception that peripheral cannulation through the femoral artery, by reversing the flow in the thoracoabdominal aorta, may increase the risk of retrograde brain embolization in aortic surgery. Central cannulation sites, including the right axillary artery, have been reported to improve operative outcomes by allowing antegrade blood flow. However, peripheral cannulation still remains largely used because a consensus for the routine use of central cannulation approaches has not been reached. METHODS A meta-analysis of comparative studies reporting operative outcomes using central cannulation versus peripheral cannulation was performed. Pooled weighted incidence rates for end points of interest were obtained using an inverse variance model. RESULTS A total of 4476 patients were included in the final analysis. Central cannulation was used in 2797 patients, and peripheral cannulation was used in 1679 patients. Central cannulation showed a protective effect on in-hospital mortality (risk ratio, 0.59; 95% confidence interval, 0.48-0.7; P < .001) and permanent neurologic deficit (risk ratio, 0.71; 95% confidence interval, 0.55-0.90; P = .005) when compared with peripheral cannulation. A trend toward an increased benefit in terms of reduced in-hospital mortality was observed when only the right axillary artery was used as the central cannulation approach (risk ratio, 0.35; 95% confidence interval, 0.22-0.55; P < .001; I(2) = 0%). CONCLUSIONS Central cannulation was superior to peripheral cannulation in reducing in-hospital mortality and the incidence of permanent neurologic deficit. This superiority was particularly evident when the axillary artery was used for central cannulation.

Moderate chronic kidney disease and left ventricular hypertrophy after aortic valve replacement for aortic valve stenosis

OBJECTIVE Left ventricular hypertrophy regression is assumed to be one of the most important goals after aortic valve replacement for aortic stenosis. A moderate decrease in the glomerular filtration rate is associated with a significantly increased risk of left ventricular hypertrophy in hypertensive patients. The effect of moderate kidney disease on left ventricular hypertrophic remodeling in other conditions of chronic left ventricular pressure overload, such as aortic stenosis, remains unknown. Therefore we tested the hypothesis that moderate chronic kidney disease affects left ventricular mass regression in patients undergoing isolated aortic valve replacement for aortic stenosis. METHODS In 157 patients with aortic stenosis, left ventricular mass regression was assessed at 18 months after aortic valve replacement. Among them, 73 (46%) had a moderate chronic kidney disease (glomerular filtration rate between 60 and 30 mL/min per 1.73 m(2)). Patients with severely impaired kidney function (glomerular filtration rate of <30 mL/min per 1.73 m(2)) were excluded. RESULTS After surgical intervention, left ventricular mass was significantly lower from baseline value in both groups, but patients with moderate chronic kidney disease continued to show an increased left ventricular mass (61 +/- 18 vs 50 +/- 16 g/m(2.7), P = .0001). The baseline glomerular filtration rate was significantly related to left ventricular mass at 18 months after surgical intervention (beta = -0.17, r(2) = 0.45, P = .01) and left ventricular mass absolute (beta = 0.18, r(2) = 0.19, P = .03) and relative (beta = 0.20, r(2) = 0.21, P = .02) regression. These associations persisted after adjusting for confounding factors, including hypertension and patient-prosthesis mismatch. After a mean time of 34 +/- 12 months from surgical intervention, congestive heart failure symptoms developed mainly in subjects with moderate chronic kidney disease (adjusted hazard ratio, 1.9; 95% confidence interval, 1.2-3.9; P = .035). CONCLUSIONS Patients with aortic stenosis with concomitant moderate chronic kidney disease present a less evident left ventricular mass regression after aortic valve replacement. Moreover, this condition is related to an increased occurrence of congestive heart failure after surgical intervention.

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.

Cardiac troponin I concentrations during on-pump coronary artery surgery.

Perioperative myocardial infarction remains a frequent complication after coronary artery bypass grafting, and is associated with a poor prognosis. This retrospective study compared cardiac troponin I concentrations after on-pump bypass grafting in 2 groups of patients: 100 operated on using a single-clamp technique to perform anastomoses, and 80 operated on using a double-clamp technique. Postoperative cardiac troponin I levels were not significantly different between groups. It was concluded that the double-clamp technique did not reduce the incidence of myocardial infarction after elective on-pump coronary artery bypass grafting, and use of a single clamp is safe with no adverse effect on postoperative outcome.

Residual SYNTAX score following coronary artery bypass grafting

Objectives To quantify residual coronary artery disease measured using the SYNTAX score (SS) and its relation to outcomes after coronary artery bypass grafting (CABG). Methods We conducted a retrospective analysis on a consecutive series of 1608 patients [mean age 68 years, standard deviation (SD): 7, F:M, 242:1366] undergoing first-time isolated CABG from 2004 to 2015. The baseline SS was retrospectively determined from preoperative angiograms, and the residual SS (rSS) was measured during assessment of the actual operative report for each patient after CABG. Patients were then stratified according to tercile cut points of low (rSS low 0-11, N  = 537), intermediate (rSS mid  >11-18.5, N  = 539) and high residual SS (rSS high  >18.5, N  = 532). The Cox regression model was used to investigate the impact of rSS on major adverse cardiac and cerebrovascular events (MACCE) at 1 year. Results The mean preoperative SS was 26.6 (SD: 9.4) (range 10.1-53), and the residual SS after CABG was 15.3 (SD: 8.4) (range 0-34) ( P  <   0.001 versus preoperative). At 1 year, cumulative incidence of MACCE in the low rSS was 1.5% ( N  = 8/537), 4.5% ( N  = 24/539) in the intermediate and 8.8% ( N  = 47/532) in the high rSS group. Kaplan-Meier analysis showed a statistically significant difference of MACCE-free survival between the three groups (log-rank test, P  <   0.001). The estimated MACCE-free survival rate at 1 year was 98.1% [standard error (SE): 1.6] for the rSS low , 95.5% (SE: 1.9) for the rSS mid , and 90.5% (SE: 1.3) for the rSS high group, respectively. After multivariable adjustment, the rSS high group was independently associated with a higher incidence of MACCE at 1 year (hazard ratio 1.92, 95% confidence interval 1.21-3.23) compared to the rSS low group. Conclusions These unanticipated findings suggest that a residual SS may be a useful tool for risk stratification of patients undergoing isolated first-time CABG. Our study may set the stage for further investigations addressing this important clinical question.

Disfunção aguda devido a uma trombose da prótese da válvula mitral mecânica

An 64-year-old man received a 31-mm CarboMedics mechanical prosthesis for severe mitral regurgitation. After four days the patient presented fatigue and dyspnoea with rest; transthoracic and transesophageal Doppler echocardiographic study confirmed a failing mobility of prosthetic valve leaflet from thrombosis and an emergency operation was done. The postoperative course was uneventful. This is an unusual case of acute dysfunction from thrombosis of a mechanical mitral valve prosthesis in a patient on oral anticoagulant therapy and calciheparin.

A network meta-analysis of randomized trials and observational studies on left ventricular assist devices in adult patients with end-stage heart failure

OBJECTIVES The use of left ventricular assist devices (LVADs) is an approved treatment option for end-stage heart failure. Several devices have been developed over the years, including 2 newer ones (HeartMate 3 and HeartWare), but an overall comparative analysis has never been performed. We conducted a network meta-analysis of randomized trials on LVAD for adults with end-stage heart failure. METHODS Pertinent studies were searched in several databases. Selected outcomes were extracted, including death, stroke and bleeding. Incident relative risks were computed with network meta-analysis with 95% confidence intervals (CIs) and P-scores (with highest values indicating the best therapy). RESULTS Four randomized clinical trials and 4 observational studies were identified, totalling 2248 patients. Using HeartMate XVE/VE as the benchmark, all LVADs provided a significant better outcome for survival rate in comparison with medical therapy, without significant differences among newer LVADs. The relative risk for death was 0.79 (95% 0.60-1.04; P-score 0.89) for HeartMate II, 0.85 (95% CI 0.62-1.17; P-score 0.64) for HeartWare, 0.88 (95% CI 0.59-1.31; P-score 0.60) for HeartMate 3 and 1.48 (95% CI 1.21-1.80; P-score 0.01) for medical management. While appraising other outcomes, new generation devices (HeartMate 3 and HeartWare) proved better than older generation devices for bleeding, device thrombosis, hepatic dysfunction, renal dysfunction, respiratory dysfunction, right ventricular failure and sepsis with significant differences among them. CONCLUSIONS In the management of end-stage heart failure, LVADs provided significant improvement in terms of survival rate compared to medical therapy, but no significant differences exist among LVADs. Despite the reduction of adverse events over time, further technological refinements will be crucial to improve this technology to better address decision-making and to improve clinical outcomes.