Gabriele Pelissero

Major bleeding, transfusions, and anemia: the deadly triad of cardiac surgery.

BACKGROUNDnPostoperative bleeding is common after cardiac surgery. Major bleeding (MB) is a determinant of red blood cell (RBC) transfusion, especially in patients with preoperative anemia. Preoperative anemia and RBC transfusions are recognized risk factors for operative mortality. The present study investigates the role of MB as an independent determinant of operative mortality in cardiac surgery.nnnMETHODSnA single-center retrospective study based on the institutional database of cardiac surgery in the period 2000-2012 was conducted. Sixteen thousand one hundred fifty-four (16,154) consecutive adult patients undergoing cardiac surgery were analyzed. The impact of postoperative bleeding and MB on operative (30 days) mortality was analyzed univariately and after correction for preoperative anemia, RBC transfusions, and other confounders.nnnRESULTSnPostoperative bleeding was significantly (p < 0.001) associated with operative mortality, both in univariate and multivariable models. The main complications associated with MB were thromboembolic complications, infections, and surgical reexploration. In a multivariable model, MB remained an independent predictor of operative mortality (odds ratio, 3.45; 95% confidence interval, 2.78 to 4.28). Preoperative anemia and RBC transfusions coexist in the model, acting with a multiplying effect when associated with MB.nnnCONCLUSIONSnMajor bleeding is per se a risk factor for operative mortality. However, its deleterious effects are strongly enhanced by RBC transfusions and, to a lesser extent, preoperative anemia. Major bleeding is a partially modifiable risk factor, and adequate preemptive and treatment strategies should be applied to limit this event.

Impact of preoperative anemia on outcome in adult cardiac surgery: a propensity-matched analysis.

BACKGROUNDnPreoperative anemia is not considered an operative mortality risk factor by the majority of the risk stratification tools used in cardiac surgery. However, retrospective studies have found associations between preoperative anemia and morbidity and mortality in cardiac operations. The present study compares the postoperative outcome of a group of moderate-to-severe anemic patients with a propensity-matched group of nonanemic patients undergoing cardiac operations.nnnMETHODSnThis is a retrospective study based on 17,056 consecutive patients included in our Institutional Database. A total of 13,843 adult patients with preoperative hematocrit value available were selected for this study; 401 patients had a severe anemia (hematocrit<30%). From the remaining patients, a control group of 401 non-severely anemic patients was selected with a propensity-based matching. Postoperative morbidity and mortality were compared between the 2 groups.nnnRESULTSnThe 2 groups were comparable for preoperative comorbidities and operative details. Anemic patients had a significantly (p=0.045) higher rate of stroke (1% vs 0%), major morbidity (27.4% vs 17.5%, p=0.001), and a significantly higher (0.014) operative mortality rate (12.7% vs 7.5%). An additional analysis, inclusive of patients with moderate preoperative anemia, confirmed these results.nnnCONCLUSIONSnModerate-to-severe preoperative anemia is a risk factor for major morbidity and operative mortality in adult cardiac operations. This finding is confirmative of the role of preoperative anemia in determining adverse events in major noncardiac operations. The exclusion of preoperative anemia from the existing risk scores is probably a statistical consequence of the associated comorbid conditions that confound the specific role of anemia as a risk factor.

Accuracy, calibration and clinical performance of the new EuroSCORE II risk stratification system

OBJECTIVESnThe European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been used for many years since its introduction in 1999. Recently, a new EuroSCORE (EuroSCORE II) has been developed to update the previous version. The EuroSCORE II includes some different predictors and/or introduces a new classification of the already existing predictors. This study presents a validation series for the EuroSCORE II compared with the previous additive and the logistic EuroSCORE and with the Age, Creatinine and Ejection Fraction (ACEF) score.nnnMETHODSnA total of 1090 consecutive adult patients operated on at our institution from September 2010 to October 2011 were admitted to this retrospective study. All the patients received a risk stratification based on the EuroSCORE II and the other scores considered. Accuracy, calibration and clinical performance of the various risk models were assessed.nnnRESULTSnThe accuracy of the EuroSCORE II was good (c-statistic 0.81) but not significantly higher than the other scores (range 0.78-0.8). Calibration at the Hosmer-Lemeshow statistic was good for all the scores; the difference between observed (3.75%) and predicted mortality in the overall population was not significant for the EuroSCORE II (3.1%) and the ACEF score (3.4%), whereas the additive EuroSCORE (5.8%) and the logistic EuroSCORE (7.3%) significantly overestimated the risk. In patients at low, mild moderate and high mortality risk, the EuroSCORE II provided a risk prediction not significantly different from the observed mortality rate, whereas in very high-risk patients (observed mortality rate 11%), it significantly underestimated (6.5%) the mortality risk. The accuracy of the EuroSCORE II was acceptable in isolated coronary surgery, and good or excellent in the other operations.nnnCONCLUSIONSnThe EuroSCORE II represents a useful update of the previous EuroSCORE version, with a much better clinical performance and the same good level of accuracy. It is possible that for the risk stratification of very high-risk patients, other factors (rare but associated with a mortality rate >50%) should be included in the future models.

Percutaneous closure of multiple defects of the atrial septum: Procedural results and long‐term follow‐up

Background: The percutaneous closure of single atrial septal defect (ASD) is a valid alternative to surgery. Objectives: To assess the feasibility of percutaneous treatment of multiple ASDs. Methods: Between 1998 and 2007, 165 out of 1280 consecutive patients undergoing ASD percutaneous closure at our institution showed multiple defects that were classified in four categories: double atrial septal defects (d‐ASD), multifenestrated atrial septal defects (f‐ASD), multifenestrated defects with no signs of right heart overload (f‐PFO), and complex cases (c‐ASD). The following end points were taken into consideration: (1) immediate procedural success; (2) long term safety and efficacy. In this study, up to 81% of multiple ASDs were suitable for percutaneous closure. Results: Multiple device implantations were required in 47% of cases, especially in patients with d‐ASD and c‐ASD. Complication rate, residual shunt, and long term outcome were comparable among the four different categories. In particular, at long term follow‐up (6 ± 2 years) no patient required further surgical or percutaneous treatment and complete closure was confirmed in 99% of cases. Conclusions: Percutaneous closure of multiple ASDs is feasible and associated with a good outcome. A thorough identification and analysis of morphological aspects are mandatory in order to select the appropriate device and the optimal strategy.

Preoperative antithrombin supplementation in cardiac surgery: a randomized controlled trial.

OBJECTIVESnPurified antithrombin supplementation in cardiac surgery has been suggested for the treatment of heparin resistance and the prevention of thromboembolic complications. This study is a randomized controlled trial of preoperative purified antithrombin supplementation, with the primary end point of avoiding low (<58%) postoperative antithrombin activity levels and secondary end points including avoidance of heparin resistance, clinical outcome, and safety end points.nnnMETHODSnTwo hundred patients were randomly allocated to the antithrombin group and the control group. Patients in the antithrombin group received a dose of purified antithrombin to reach an antithrombin activity value of 120%, whereas patients in the control group did not receive antithrombin.nnnRESULTSnThe antithrombin activity values were significantly higher in the antithrombin group at all postoperative determinations until discharge. Antithrombin activity levels <58% at admission to the intensive care unit were found in 26.6% of patients in the control group versus none in the antithrombin group (Pxa0=xa0.001). Heparin resistance rate was significantly (Pxa0=xa0.001) higher in the control group (38.2%) versus the antithrombin group (17%). Patients in the antithrombin group had a significant but clinically irrelevant (8 mL/hour) higher postoperative bleeding, with no differences in transfusion rates. No differences were found for clinical outcomes, and no safety issues were identified.nnnCONCLUSIONSnPreoperative antithrombin supplementation prevents heparin resistance and avoids excessive postoperative decrease of antithrombin activity.

Update on psychological functioning in adults with congenital heart disease: a systematic review

The population of adults with congenital heart disease is increasing due to advancements in cardiology and cardiac surgery. Many patients face medical complications and psychosocial difficulties; however, it is not yet clear whether there is a direct relationship between medical status and the psychological functioning of these patients. This systematic review of the relevant literature is an attempt to: provide a comparison between the population of adults with congenital heart disease, the healthy reference population and similar cardiac populations when it comes to psychological functioning; explore the relationship between medical status/cardiac condition and psychological functioning; and identify the predictors of psychological distress in this population.

Knowledge, Attitudes, and Smoking Behaviours among Physicians Specializing in Public Health: A Multicentre Study

Background. Healthcare professionals have an important role to play both as advisers—influencing smoking cessation—and as role models. However, many of them continue to smoke. The aims of this study were to examine smoking prevalence, knowledge, attitudes, and behaviours among four cohorts physicians specializing in public health, according to the Global Health Profession Students Survey (GHPSS) approach. Materials and Methods. A multicentre cross-sectional study was carried out in 24 Italian schools of public health. The survey was conducted between January and April 2012 and it was carried out a census of students in the selected schools for each years of course (from first to fourth year of attendance), therefore among four cohorts of physicians specializing in Public Health (for a total of n. 459 medical doctors). The GHPSS questionnaires were self-administered via a special website which is created ad hoc for the survey. Logistic regression model was used to identify possible associations with tobacco smoking status. Hosmer-Lemeshow test was performed. The level of significance was P ≤ 0.05. Results. A total of 388 answered the questionnaire on the website (85%), of which 81 (20.9%) declared to be smokers, 309 (79.6%) considered health professionals as behavioural models for patients, and 375 (96.6%) affirmed that health professionals have a role in giving advice or information about smoking cessation. Although 388 (89.7%) heard about smoking related issues during undergraduate courses, only 17% received specific smoking cessation training during specialization. Conclusions. The present study highlights the importance of focusing attention on smoking cessation training, given the high prevalence of smokers among physicians specializing in public health, their key role both as advisers and behavioural models, and the limited tobacco training offered in public health schools.

Effects of priming volume reduction on allogeneic red blood cell transfusions and renal outcome after heart surgery

Introduction: Excessive hemodilution during cardiopulmonary bypass (CPB) is associated with an increased rate of red blood cell (RBC) transfusion and acute kidney injury (AKI). Minimization of the oxygenator priming volume is a measure to contain hemodilution. In this study, we evaluated the new oxygenator, Sorin Inspire 6™, with respect to its ability to limit hemodilution, RBC transfusion rate and postoperative AKI rate. Methods: A retrospective study on a consecutive series of 1,724 adult patients receiving heart surgery with CPB. Patients treated with the Inspire 6™ were assigned to the low priming volume oxygenator (LPVO) group (N=383) and patients treated with conventional oxygenators to the conventional group (N=1,341). Dynamic priming volume, time course of the hematocrit, RBC transfusions and AKI rate were compared between the groups. Results: Priming volume was significantly (p=0.001) lower in the LPVO group (624±113 mL) vs. the conventional group (775±150 mL), with higher values of hematocrit during and after CPB. After correction for other confounders, patients in the LPVO group had a significantly lower RBC transfusion rate (odds ratio 0.68, 95% confidence interval 0.52-0.90, p=0.006) and AKI rate (odds ratio 0.55, 95% confidence interval 0.32-0.93, p=0.032). Conclusion: The Inspire 6™ oxygenator allows a significant containment of hemodilution during CPB, reducing the risk of RBC transfusions and postoperative AKI.

Influenza vaccination coverage among medical residents: an Italian multicenter survey

Although influenza vaccination is recognized to be safe and effective, recent studies have confirmed that immunization coverage among health care workers remain generally low, especially among medical residents (MRs). Aim of the present multicenter study was to investigate attitudes and determinants associated with acceptance of influenza vaccination among Italian MRs. A survey was performed in 2012 on MRs attending post-graduate schools of 18 Italian Universities. Each participant was interviewed via an anonymous, self-administered, web-based questionnaire including questions on attitudes regarding influenza vaccination. A total of 2506 MRs were recruited in the survey and 299 (11.9%) of these stated they had accepted influenza vaccination in 2011–2012 season. Vaccinated MRs were older (P = 0.006), working in clinical settings (P = 0.048), and vaccinated in the 2 previous seasons (P < 0.001 in both seasons). Moreover, MRs who had recommended influenza vaccination to their patients were significantly more compliant with influenza vaccination uptake in 2011–2012 season (P < 0.001). “To avoid spreading influenza among patients” was recognized as the main reason for accepting vaccination by less than 15% of vaccinated MRs. Italian MRs seem to have a very low compliance with influenza vaccination and they seem to accept influenza vaccination as a habit that is unrelated to professional and ethical responsibility. Otherwise, residents who refuse vaccination in the previous seasons usually maintain their behaviors. Promoting correct attitudes and good practice in order to improve the influenza immunization rates of MRs could represent a decisive goal for increasing immunization coverage among health care workers of the future.

Development of an Entirely Subcutaneous Implantable Cardioverter-Defibrillator

The recent advent of an entirely subcutaneous implantable defibrillator (ICD) has provided a relevant contribution to the debate concerning the use of ICD therapy in patients at high risk for death. Although conventional transvenous ICDs have proven very effective during the past 23 years, they still appear to be limited by nontrivial acute and long-term complications. This study delineates some of the historical and current issues characterizing the advent of the subcutaneous ICD system in daily clinical practice. Subcutaneous ICDs have proven effective in more than 1100 patients worldwide and appear to be competitive with transvenous ICD in all clinical conditions not requiring antibradycardia, antitachycardia, or cardiac resynchronization pacing.