Giovanni Mariscalco

Atrial fibrillation after isolated coronary surgery affects late survival.

Background— Atrial fibrillation (AF) after coronary artery bypass graft surgery is a difficult problem and a continuing source of morbidity and mortality. However, the prognostic implications of postoperative AF are still in dispute. Our aim was to ascertain the impact of AF after coronary artery bypass graft on postoperative survival and to assess its prognostic role in cause-specific mortality. Methods and Results— We conducted a prospective observational study of 1832 patients undergoing isolated coronary artery bypass graft between January 2000 and December 2005 at 2 cardiac surgery centers in northern Italy. Patients affected by postoperative AF were identified and followed up until death or study end (April 30, 2007). A total of 570 patients (31%) developed AF after coronary surgery. Patients affected by postoperative AF experienced a longer hospital stay (7 days [25th to 75th percentile, 7 to 10 days] versus 7 days [25th to 75th percentile, 6 to 8 days]; P<0.001). Hospital mortality also was higher in AF patients (3.3% versus 0.5%; P<0.001). On discharge, 1806 patients were alive; 143 were lost to follow-up. The remaining 1663 were followed up for a median of 51 months (25th to 75th percentile, 41 to 63 months); 126 of them died after a median of 14 months (25th to 75th percentile, 5 to 32 months). Long-term mortality rates were significantly higher for patients with postoperative AF (2.99 per 100 person-years; 95% confidence interval, 2.33 to 3.84; 61 deaths) compared with those without the arrhythmia (1.34 per 100 person-years; 95% confidence interval, 1.05 to 1.71; 65 deaths), with an adjusted hazard ratio of 2.13 (P<0.001) and 2.56 (P=0.001) when also accounting for the prescription of warfarin at discharge. With Cox regression, patients with AF were shown to be at higher risk of dying from embolism (adjusted hazard ratio, 4.33; 95% confidence interval, 1.78 to 10.52) but not from other causes. Conclusions— Postoperative AF affects early and late mortality after isolated coronary artery bypass graft surgery. Patients affected by AF are at higher risk of fatal embolic events. Careful postoperative surveillance with a specific antiarrhythmic and antithrombotic prophylaxis, aimed at reducing AF and its complications, is recommended.

Acute Kidney Injury: A Relevant Complication After Cardiac Surgery

Acute kidney injury (AKI) occurs in as many as 40% of patients after cardiac surgery and requires dialysis in 1% of cases. Acute kidney injury is associated with an increased risk of mortality and morbidity, predisposes patients to a longer hospitalization, requires additional treatments, and increases the hospital costs. Acute kidney injury is characterized by a progressive worsening course, being the consequence of an interplay of different pathophysiologic mechanisms, with patient-related factors and cardiopulmonary bypass as major causes. Recently, several novel biomarkers have emerged, showing reasonable sensitivity and specificity for AKI prediction and protection. The development and implementation of potentially protective therapies for AKI remains essential, especially for the relevant impact of AKI on early and late survival.

Preoperative Statin Therapy Is Not Associated With a Decrease in the Incidence of Delirium After Cardiac Operations

BACKGROUND Delirium after cardiac operations is associated with significant morbidity and death. Statins have been recently suggested to exert protective cerebral effects. This study investigated whether preoperative statins were associated with decreased incidence of postoperative delirium in patients undergoing coronary artery bypass grafting. METHODS The study enrolled 4,659 consecutive patients (21% women; age, 67.8±9.2 years) undergoing coronary artery bypass grafting. A propensity score-based optimal-matching algorithm was used to match 1,577 patients receiving preoperative statins with a control group (1:1). Patients were screened for delirium in the intensive care unit according to the Confusion Assessment Method for the intensive care unit. RESULTS Delirium affected 89 patients (3%), and preoperative statin administration was not multivariably associated with a decreased incidence of delirium (odds ratio, 1.52; 95% confidence interval, 0.97 to 2.37; p=0.18) and was also unrelated to a delirium decrease in patient subgroups undergoing isolated coronary artery bypass grafting (odds ratio, 1.31; 95% confidence interval, 0.68 to 2.52; p=0.51) or combined valvular procedures (odds ratio, 1.72; 95% confidence interval, 0.96 to 3.07, p=0.08). Similar results were observed for age groups and cardiopulmonary bypass durations. Patients affected by postoperative delirium experienced a longer hospital stay (25th to 75th percentile) of 11 (7 to 18 days) vs 7 days (7 to 8 days, p<0.001) and 12% hospital mortality vs 1% (p<0.001). CONCLUSIONS Preoperative statins were not associated with a decreased incidence of delirium in patients undergoing coronary revascularization.

Atrial fibrillation after pulmonary lobectomy for lung cancer affects long-term survival in a prospective single-center study.

BackgroundAtrial fibrillation (AF) after thoracic surgery is a continuing source of morbidity and mortality. The effect of postoperative AF on long-term survival however has not been studied. Our aim was to evaluate the impact of AF on early outcome and on survival > 5 years after pulmonary lobectomy for lung cancer.MethodsFrom 1996 to June 2009, 454 consecutive patients undergoing lobectomy for lung cancer were enrolled and followed-up until death or study end (October 2010). Patients with postoperative AF were identified; AF was investigated with reference to its predictors and to short- and long-term survival (> 5 years).ResultsHospital mortality accounted for 7 patients (1.5%), while postoperative AF occurred in 45 (9.9%). Independent AF predictors were: preoperative paroxysmal AF (odds ratio [OR] 5.91; 95%CI 2.07 to 16.88), postoperative blood transfusion (OR 3.61; 95%CI 1.67 to 7.82) and postoperative fibro-bronchoscopy (OR 3.39; 95%CI 1.48 to 7.79). Patients with AF experienced higher hospital mortality (6.7% vs. 1.0%, p = 0.024), longer hospitalization (15.3 ± 10.1 vs. 12.2 ± 5.2 days, p = 0.001) and higher intensive care unit admission rate (13.3% vs. 3.9%, p = 0.015). The median follow-up was 36 months (maximum: 179 months). Among the 445 discharged subjects with complete follow-up, postoperative AF was not an independent predictor of mortality; however, among the 151 5-year survivors, postoperative AF independently predicted poorer long-term survival (HR 3.75; 95%CI 1.44 to 9.08).ConclusionAF after pulmonary lobectomy for lung cancer, in addition to causing higher hospital morbidity and mortality, predicts poorer long-term outcome in 5-year survivors.

Preoperative n-3 Polyunsatured Fatty Acids Are Associated With a Decrease in the Incidence of Early Atrial Fibrillation Following Cardiac Surgery

Background: Atrial fibrillation (AF) after cardiac surgery is associated with increased mortality, morbidity, and expenditure. Controversial data exist on possible preventive effects of n-3 polyunsatured fatty acids (PUFAs) against postoperative AF. We investigated whether preoperative PUFA therapy is effective in reducing AF after cardiac surgery during the surgical hospitalization and/or the cardiac rehabilitation period. Methods: Over a 4-year period, 530 patients (363 men, 68.5%) with a mean age of 66.4 ± 10.9 years, undergoing cardiac surgery were monitored for ‘‘early AF’’ and ‘‘late AF’’ defined as AF documented in the surgical department or during the rehabilitation program, respectively. Results: The overall incidence of early AF in the whole study sample was 44.7%, whereas late AF occurred in 14.7% patients. Patients with AF had a longer length of hospital and rehabilitation stay (10.4 ± 9.8 vs 9.5 ± 9.2 days, P = .025 and 24.2 ± 15.3 vs 21.1 ± 8.3 days, P = .008, respectively). Early AF occurred in 31.0% of the patients with preoperative PUFAs compared with 47.3% of those without them (P = .006). Conversely, late AF was not influenced by preoperative PUFA regimen (11.9% vs 15.2%, P = .43). Preoperative PUFAs were independently associated with a 46% reduction in risk of early AF development (OR 0.54, 95% CI 0.31-0.92), after propensity score analysis. Conclusion: Preoperative PUFA therapy is associated with a decreased incidence of early AF after cardiac surgery but not late AF. Patients undergoing cardiac surgery may benefit from a preventive PUFA approach.

Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients: A 5-year multi-institutional experience

BACKGROUND Acute fulminant myocarditis (AFM) may represent a life-threatening event, characterized by rapidly progressive cardiac compromise that ultimately leads to refractory cardiogenic shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in this circumstance, but few clinical series are available about early and long-term results. Data from a multicenter study group are reported which analyzed subjects affected by AFM and treated with VA-ECMO during a 5-year period. METHOD From hospital databases, 57 patients with diagnoses of AFM treated with VA-ECMO in the past 5 years were found and analyzed. Mean age was 37.6 ± 11.8 years; 37 patients were women. At VA-ECMO implantation, cardiogenic shock was present in 38 patients, cardiac arrest in 12, and severe hemodynamic instability in 7. A peripheral approach was used with 47 patients, whereas 10 patients had a central implantation or other access. RESULTS Mean VA-ECMO support was 9.9 ± 19 days (range, 2 to 24 days). Cardiac recovery with ECMO weaning was achieved in 43 patients (75.5%), major complications were observed in 40 patients (70.1%), and survival to hospital discharge occurred in 41 patients (71.9%). After hospital discharge (median follow-up, 15 months) there were 2 late deaths. The 5-year actual survival was 65.2% ± 7.9%, with recurrent self-recovering myocarditis observed in 2 patients (at 6 and 12 months from the first AFM event), and 1 heart transplantation. CONCLUSIONS Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of AFM, although major complications may characterize the hospital course. Long-term outcome appears favorable with rare episodes of recurrent myocarditis or cardiac-related events.

European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG registry): Study Protocol for a Prospective Clinical Registry and Proposal of Classification of Postoperative Complications

BackgroundClinical evidence in coronary surgery is usually derived from retrospective, single institutional series. This may introduce significant biases in the analysis of critical issues in the treatment of these patients. In order to avoid such methodological limitations, we planned a European multicenter, prospective study on coronary artery bypass grafting, the E-CABG registry.DesignThe E-CABG registry is a multicenter study and its data are prospectively collected from 13 centers of cardiac surgery in university and community hospitals located in six European countries (England, Italy, Finland, France, Germany, Sweden). Data on major and minor immediate postoperative adverse events will be collected. Data on late all-cause mortality, stroke, myocardial infarction and repeat revascularization will be collected during a 10-year follow-up period. These investigators provided a score from 0 to 10 for any major postoperative adverse events and their rounded medians were used to stratify the severity of these complications in four grades. The sum of these scores for each complication/intervention occurring after coronary artery bypass grafting will be used as an additive score for further stratification of the prognostic importance of these events.DiscussionThe E-CABG registry is expected to provide valuable data for identification of risk factors and treatment strategies associated with suboptimal outcome. These information may improve the safety and durability of coronary artery bypass grafting. The proposed classification of postoperative complications may become a valuable research tool to stratify the impact of such complications on the outcome of these patients and evaluate the burden of resources needed for their treatment.Clinical Trials numberNCT02319083

Impact of prophylactic intra-aortic balloon counter-pulsation on postoperative outcome in high-risk cardiac surgery patients: a multicentre, propensity-score analysis §

OBJECTIVE The aim of this multicentre study was to determine whether the prophylactic use of intra-aortic balloon pump (IABP) translates into better early and long-term results in high-risk patients undergoing cardiac surgery. METHODS From January 2000 to March 2009, 6121 high-risk patients (EuroSCORE >8), at six different institutions, underwent cardiac surgery. Propensity-score computer matching was performed, based on 10 variables representing patients characteristics and preoperative risk factors to correct for and minimise selection bias (Hosmer-Lemeshow goodness of fit, p=0.3; c=0.94). A total of 956 patients were successfully matched and consisted of 478 pairs either undergoing preoperative IABP (group A) or not receiving IABP preoperatively (group B). RESULTS Multivariate logistic regression (odds ratio) revealed that group B had a 64% higher risk of in-hospital mortality (p=0.001), 57% higher risk of 30-day mortality (p=0.003), 45% higher risk of perioperative myocardial infarction (p=0.01), 57% higher risk of postoperative low-output syndrome (p=0.003), 45% higher risk of intensive care unit (ICU) length of stay (p=0.001) and 44% higher risk of hospital length of stay (p=0.001). Patients in group A showed, at follow-up, significant improvements in left ventricular (LV) ejection fraction (p<0.001), wall-motion score index (p<0.001) and LV dimensions (p<0.001). Five- and 8-year survivals did not differ between groups (5-year survival: 91.7 ± 3.1% vs 95 ± 2.1% in groups A and B, respectively, log-rank p=0.34; 8-year survival: 84.3 ± 5.5% vs 85.9 ± 6.1% in groups A and B, respectively, log-rank p=0.2). CONCLUSIONS Prophylactic IABP support, in this multicentre experience, was showed to enhance perioperative management and outcome of high-risk cardiac surgery patients.

Papillary Fibroelastoma: Insight to a Primary Cardiac Valve Tumor

Abstract  Papillary fibroelastomas are rare benign cardiac tumors. Although they have minimal hemodynamic effects, their propensity for embolization can result in serious morbidity. The pathophysiology and management of these tumors is the subject of this review. (J Card Surg 2010;25:198‐205)

Bedside Tool for Predicting the Risk of Postoperative Atrial Fibrillation After Cardiac Surgery: The POAF Score

Background Atrial fibrillation (AF) remains the most common complication after cardiac surgery. The present study aim was to derive an effective bedside tool to predict postoperative AF and its related complications. Methods and Results Data of 17 262 patients undergoing adult cardiac surgery were retrieved at 3 European university hospitals. A risk score for postoperative AF (POAF score) was derived and validated. In the overall series, 4561 patients (26.4%) developed postoperative AF. In the derivation cohort age, chronic obstructive pulmonary disease, emergency operation, preoperative intra‐aortic balloon pump, left ventricular ejection fraction <30%, estimated glomerular filtration rate <15 mL/min per m2 or dialysis, and any heart valve surgery were independent AF predictors. POAF score was calculated by summing weighting points for each independent AF predictor. According to the prediction model, the incidences of postoperative AF in the derivation cohort were 0, 11.1%; 1, 20.1%; 2, 28.7%; and ≥3, 40.9% (P<0.001), and in the validation cohort they were 0, 13.2%; 1, 19.5%; 2, 29.9%; and ≥3, 42.5% (P<0.001). Patients with a POAF score ≥3, compared with those without arrhythmia, revealed an increased risk of hospital mortality (5.5% versus 3.2%, P=0.001), death after the first postoperative day (5.1% versus 2.6%, P<0.001), cerebrovascular accident (7.8% versus 4.2%, P<0.001), acute kidney injury (15.1% versus 7.1%, P<0.001), renal replacement therapy (3.8% versus 1.4%, P<0.001), and length of hospital stay (mean 13.2 versus 10.2 days, P<0.001). Conclusions The POAF score is a simple, accurate bedside tool to predict postoperative AF and its related or accompanying complications.