Maciej T. Wybraniec

Complex Assessment of the Incidence and Risk Factors of Delirium in a Large Cohort of Cardiac Surgery Patients: A Single-Center 6-Year Experience

Background. Previous reports provided inconsistent data on the occurrence of postoperative delirium and emphasized its considerable impact on outcome. This study sought to evaluate the incidence and predictors of delirium, together with its relation to cerebral ischemia in a large cohort of cardiac surgery patients in a tertiary high-volume center. Methods and Results. Consecutive patients (n = 8792) were prospectively enrolled from 2003 to 2008. Exclusion criteria were history of psychiatric disorders, use of psychoactive drugs, alcohol abuse, and data incompleteness. Finally, 5781 patients were analyzed in terms of 100 perioperative patient-specific and treatment variables. The incidence of postoperative delirium (DSM IV criteria) was 4.1% and it coexisted with cerebral ischemia in 1.1% of patients. In bivariate analysis, 49 variables were significantly linked to postoperative delirium. Multivariate analysis confirmed that delirium was independently associated with postoperative stroke (logistic odds ratio (logOR) = 2.862, P = 0.004), any blood transfusions (logOR = 4.178, P < 0.0001), age > 65 years (logOR = 2.417, P = 0.002), carotid artery stenosis (logOR = 2.15, P = 0.01), urgent/emergent surgery (logOR = 1.982, P = 0.02), fasting glucose level, intraoperative oxygen partial pressure fluctuations, and hematocrit. Area under ROC curve for the model was 0.8933. Conclusions. Early identification of nonpsychiatric perioperative determinants of delirium facilitates its diagnosis and might help develop preventive strategies to improve long-term outcome after cardiac surgery procedures.

Stress cardiomyopathy: yet another type of neurocardiogenic injury 'Stress cardiomyopathy'

Tako-tsubo syndrome pertains to rare acquired cardiomyopathies, characterized by left ventricular dyskinesia and symptomatology typical for acute myocardial infarction (AMI). Despite its low incidence and relatively benign course, stress cardiomyopathy should be thoroughly differentiated from AMI. The importance of tako-tsubo consists of the fact that its manifestation initially resembles AMI. Despite seemingly low incidence of tako-tsubo, acute coronary syndromes globally constitute a major epidemiological issue and both clinical entities should be accurately differentiated. Many patients present with only mild troponin release, certain extent of regional wall motion abnormalities (RWMA) and absence of hemodynamically significant coronary artery stenosis. In such instances, a careful interview aimed at preceding emotional or physical traumatic event should be undertaken. The subsequent verification of the diagnosis is based upon prompt recovery of contractile function. Although precise diagnostic criteria were formulated, symptomatology of tako-tsubo might be clinically misleading due to the possibility of concomitant coronary vasospasm, atypical pattern of RWMA and presence of non-significant coronary disease. For this reason, its exact rate might be underestimated. Stress cardiomyopathy reflects merely a single aspect of a much wider range of neurocardiogenic injury, which encompasses cardiac dysfunction associated with subarachnoid hemorrhage, intracranial hypertension and cerebral ischemia. Both psychological and physical insult to central nervous system may trigger a disastrous response of sympathetic nervous system, eventually leading to end-organ catecholamine-mediated damage. This review sought to delineate the phenomenon of tako-tsubo cardiomyopathy and deliver evidence for common pathophysiology of the broad spectrum of neurocardiogenic injury.

Delirium Screening in Cardiac Surgery (DESCARD): A Useful Tool for Nonpsychiatrists

BACKGROUND The aim of the study was to set up and validate a predictive scoring system for nonpsychiatrists to facilitate screening of postoperative delirium in cardiac surgery patients. METHODS The project was conducted as a cohort study in 5781 subjects. More than 100 pre- and perioperative somatic variables were collected to build up an algorithm. Delirium was diagnosed using Diagnostic and Statistical Manual of Mental Disorders 4th edition. The patient cohort was divided into a training and validation set to perform cross-validation. Scoring systems (Delirium Screening in Cardiac Surgery [DESCARD] tool) were developed for the set of sole preoperative and all perioperative risk factors. RESULTS Delirium was found in 236 patients (4.1%). The preoperative model comprised age, weight, total protein concentration, arterial hypertension, mode of surgery (elective/urgent/emergent), preoperative fasting glucose, and form of diabetes treatment (diet/oral agents/insulin). Taking into account all the perioperative variables, the scoring system included postoperative cerebral ischemia and the need for red blood cell transfusion, and arterial hypertension and mode of surgery were excluded. Both pre- and perioperative tools had an excellent overall diagnostic accuracy (area under receiver operator characteristics curve = 0.83 and 0.89, respectively) with higher specificity (92% and 93%, respectively) than sensitivity (60% and 69%, respectively). CONCLUSIONS The DESCARD tool might be effective in screening of patients at risk of postoperative delirium and can be easily used by all nonpsychiatrists involved in the care of cardiac surgery patients.

Renalase and Biomarkers of Contrast-Induced Acute Kidney Injury

Background: Contrast-induced acute kidney injury (CI-AKI) remains one of the crucial issues related to the development of invasive cardiology. The massive use of contrast media exposes patients to a great risk of contrast-induced nephropathy and chronic kidney disease development, and increases morbidity and mortality rates. The serum creatinine concentration does not allow for a timely and accurate CI-AKI diagnosis; hence numerous other biomarkers of renal injury have been proposed. Renalase, a novel catecholamine-metabolizing amine oxidase, is synthesized mainly in proximal tubular cells and secreted into urine and blood. It is primarily engaged in the degradation of circulating catecholamines. Notwithstanding its key role in blood pressure regulation, renalase remains a potential CI-AKI biomarker, which was shown to be markedly downregulated in the aftermath of renal injury. In this sense, renalase appears to be the first CI-AKI marker revealing an actual loss of renal function and indicating disease severity. Summary: The purpose of this review is to summarize the contemporary knowledge about the application of novel biomarkers of CI-AKI and to highlight the potential role of renalase as a functional marker of contrast-induced renal injury. Key Messages: Renalase may constitute a missing biochemical link in the mutual interplay between kidney and cardiac pathology known as the cardiorenal syndrome.

Perioperative management of cardiac surgery patients who are at the risk of acute kidney injury

Acute kidney injury is one of the most frequent and clinically important of all postoperative complications in cardiac surgery. It is estimated that almost half of subjects suffer from a deterioration of kidney function after a cardio-pulmonary by-pass. Renal insufficiency impacts upon the outcome in terms of an increase in postoperative morbidity and mortality, and a decrease in quality of life. Recently, a modified and unified classification of cardio-renal syndrome has been devised, which takes into account bilateral association between the heart and the kidneys. Because acute decompensation in heart function leads to acute kidney damage, therefore cardiac surgery-associated acute kidney injury may be recognised as a type 1 cardio-renal syndrome from a pathophysiological point of view. This paper aims to review the current data on the diagnosis of acute kidney injury and preventive strategies that can be implemented in cardiac surgery perioperative care.

Urinary renalase concentration in patients with preserved kidney function undergoing coronary angiography

The purpose of the study was to evaluate urinary renalase concentration before and after coronary angiography/percutaneous coronary interventions (CA/PCI) in patients with coronary artery disease (CAD) and preserved kidney function and verify its potential application as contrast‐induced acute kidney injury (CI‐AKI) diagnostic marker.

Prediction of contrast‐induced acute kidney injury by early post‐procedural analysis of urinary biomarkers and intra‐renal Doppler flow indices in patients undergoing coronary angiography

BACKGROUND The study was designed to evaluate the applicability of combined assessment of urinary biomarkers and intra-renal Doppler flow indices for the prediction of contrast-induced acute kidney injury (CI-AKI) after coronary angiography/percutaneous coronary interventions (CA/PCI). METHODS This prospective observational study covered 95 consecutive patients with coronary artery disease subject to elective or urgent CA/PCI. Doppler intra-renal flow indices were assessed before and 1 h following CA/PCI. Urine samples were collected within 24 h before and 6 h after CA/PCI and assayed for urinary interleukin-18 (IL-18), liver-fatty acid-binding protein (L-FABP), and kidney injury molecule-1 (KIM-1) using ELISA method. CI-AKI was defined as ≥50% relative or ≥0.3 mg/dL absolute increase of serum creatinine concentration at 48 h post-procedurally. RESULTS CI-AKI was confirmed in nine patients (9.5%). CI-AKI onset was associated with significantly higher urinary KIM-1 at 6 h (P = 0.003) and ΔKIM-1 concentrations (P = 0.001), and urinary IL-18 at 6 h (P = 0.014) and ΔIL-18 concentrations (P = 0.012), however, L-FABP and ΔL-FABP levels were comparable in both groups. Receiver operating characteristic curve analysis denoted that post-procedural IL-18 levels at 6 h >89.8 pg/mg (AUC = 0.75, P = 0.007), KIM-1 at 6 h >0.425 ng/mg (AUC = 0.81, P = 0.001), renal resistive index (RRI) at 1 h >0.73 (AUC 0.88; P < 0.0001), and renal pulsatility index (RPI) at 1 h >0.86 (AUC = 0.86; P < 0.0001) predicted CI-AKI onset. Logistic regression analysis of postoperative predictors revealed that IL-18 and RRI were independent predictors of CI-AKI onset (AUC = 0.96; P < 0.0001). CONCLUSIONS Joint assessment of early post-procedural urinary biomarkers and Doppler renovascular parameters aids early diagnosis of CI-AKI in patients undergoing coronary interventions.

Fulminant variant of Loeffler disease mimicking arrhythmogenic right ventricular cardiomyopathy in the course of enterobiasis

A 37-year-old male farmer initially presented with recurrent palpitations and fatigue following recent influenza-like infection. Laboratory tests showed mild eosinophilia (828/µL), C-reactive protein elevation and troponin release, and Enterobius vermicularis infestation, which triggered treatment with pyrantel. Rest electrocardiogram revealed left-axis deviation, right bundle branch block, and epsilon-like wave in leads V1–V3 ( Panel A ). Several …

Lower soluble Klotho and higher fibroblast growth factor 23 serum levels are associated with episodes of atrial fibrillation

Aims The proarrhythmic effect of fibroblast growth factor 23 (FGF23) was observed in patients with end stage kidney disease (ESKD). However, there is no data on the role of FGF23 and soluble Klotho (sKlotho) in the pathogenesis of atrial fibrillation (AF) beyond ESKD. The aim of the study was to assess the peripheral vein and left atrial (LA) serum levels of FGF23 and sKlotho along with calcium‐phosphates parameters in patients with AF undergoing percutaneous radiofrequency pulmonary vein isolation (PVI). Methods and results Sixty‐nine consecutive patients (mean age: 55.8 ± 9.7 years, F/M: 26/43, CHA2DS2‐Vasc: 1.7 ± 1.1) with paroxysmal/persistent AF undergoing PVI were included into the study. Blood samples were taken during PVI – baseline from the peripheral vein, then from the LA immediately after a septal puncture. Results There were significant differences in the concentrations of peripheral and LA serum sKlotho, intact FGF23 (iFGF23), calcium and phosphates; peripheral FGF23, calcium and phosphates levels were significantly higher, and sKlotho levels were significantly lower than the LA concentrations. Serum sKlotho levels correlated with the CHADS2‐VASc score (r = 0.254, p = 0.034) and glucose level (r = 0.300, p = 0.005). Serum sKlotho gradient (LA – peripheral vein) correlated with the baseline AF burden in the Holter monitoring (r = −0.389, p = 0.003). PVI efficacy was confirmed in 52 (75%) patients. There was a significant difference in the iFGF23 gradient between patients with AF and without AF (80.3 vs. −47.6 pg/ml, p = 0.009) in the six‐month follow‐up. A receiver operating characteristic (ROC) analysis revealed that an iFGF23 gradient >28.7 pg/ml (AUC = 0.742, p = 0.002) was a predictor for AF recurrence. Conclusions There is a gradient between the LA and peripheral vein in the markers of calcium‐phosphate metabolism in patients undergoing PVI. Lower sKlotho and higher iFGF23 serum levels are associated with episodes of AF. Serum iFGF23 gradient is a potent predictor for the recurrence of AF. HighlightsFGF23 and soluble Klotho play a role in the pathogenesis of atrial fibrillation.Gradient in the concentrations of peripheral and atrial serum sKlotho and FGF23.Serum sKlotho gradient correlated with the AF burden in the Holter monitoring.iFGF23 gradient >28.7 pg/ml was a predictor for atrial fibrillation recurrence.Lower sKlotho and higher iFGF23 serum levels are associated with episodes of AF.

Atorvastatin facilitates protection against contrast-induced nephropathy in patients undergoing coronary angiography via humoral mediators rather than altered renal hemodynamics

Corresponding author: Maciej T. Wybraniec MD, PhD, First Department of Cardiology, School of Medicine, Medical University of Silesia, 47 Ziołowa St, 40-635 Katowice, Poland, phone: +48 32 359 88 90, e-mail: maciejwybraniec@gmail.com Received: 8.02.2018, accepted: 18.03.2018. Atorvastatin facilitates protection against contrastinduced nephropathy in patients undergoing coronary angiography via humoral mediators rather than altered renal hemodynamics