Marzia Cottini

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.

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.

Red blood cell transfusion is a determinant of neurological complications after cardiac surgery

OBJECTIVES The aim of this study was to evaluate the impact of red blood cell (RBC) transfusions on the occurrence of stroke and transient ischaemic attack (TIA) after cardiac surgery. METHODS Data on 14 956 patients undergoing coronary artery bypass grafting (CABG) and valve surgery (with or without concomitant CABG) were retrieved at three European University Hospitals. The prognostic impact of RBC transfusion on postoperative stroke and TIA was investigated by logistic regression and multilevel propensity score analysis. RESULTS Postoperative stroke was observed in 147 (1.0%) patients and combined stroke/TIA in 238 (1.6%). Of the total population, 6439 (43%) patients received RBC transfusion with a median of 2 units (25th-75th percentile, 2-4 units). When adjusted for other significant risk factors, RBC transfusion was an independent predictor of stroke [odds ratio (OR) 1.14; 95% confidence interval (CI) 1.11-1.17 per unit] and stroke/TIA (OR 1.12; 95% CI 1.09-1.15 per unit). Increase in the amount of transfused RBC units was associated with higher rates of stroke (no RBC transfusion: 0.5%, 1-2 RBC units: 1.0%, OR 1.42; >2 RBC units: 2.7%, OR 3.10) and stroke/TIA (no RBC transfusion: 0.8%, 1-2 RBC units: 1.8%, OR 1.49; >2 RBC units: 4.0%, OR 2.72). Multilevel propensity score analysis confirmed these findings and showed a very high risk of stroke (3.9%; OR 3.85; 95% CI 2.30-6.45) and stroke/TIA (5.9%; OR 3.30; 95% CI 2.17-5.02) associated with transfusion of ≥6 units of RBCs. CONCLUSIONS Transfusion of more than 2 units of RBCs after cardiac surgery is associated with a significantly increased risk of postoperative stroke and TIA.

The effect of timing of cardiac catheterization on acute kidney injury after cardiac surgery is influenced by the type of operation

BACKGROUND Acute kidney injury (AKI) is a vexing complication of cardiac surgery. Since exposure to contrast agents is a relevant contributing factor in the development of postoperative AKI, the optimal timing between cardiac catheterization and surgery is decisive. METHODS A total of 2504 consecutive nonemergent patients undergoing isolated coronary artery bypass grafting (CABG), valve surgery (with or without concomitant CABG), and proximal aortic procedures were enrolled. AKI was defined by consensus RIFLE (Risk, Injury, Failure, Loss of function, End-stage renal disease) criteria. The association of postoperative AKI and time between cardiac catheterization and operation was evaluated using multivariable logistic regression modeling and propensity-matched analysis. RESULTS Postoperative AKI occurred in 230 (9%) patients. The median number of days from cardiac catheterization to operation was 5 (25th to 75th percentile: 2 to 10). The incidence of AKI was significantly higher in patients operated on ≤1 day after cardiac catheterization compared to those operated on >1 day after (13% vs. 8%, p=0.004). The time interval between cardiac catheterization and surgery (tested both as a continuous and a categorical variable) was not an independent AKI predictor in the propensity-matched population or the pre-matched one. Contrast exposure≤1 day before surgery was independently associated with postoperative AKI in patients undergoing valve surgery with concomitant CABG only (post-matched: OR 3.68, 95%CI 1.30 to 10.39, p=0.014). CONCLUSIONS Delaying cardiac surgery beyond 24h of exposure to contrast agents seems to be justified only in patients undergoing valve surgery with concomitant CABG.

Outcome of Emergency Coronary Artery Bypass Grafting

OBJECTIVES The aim of this study was to evaluate the immediate and late outcome of emergency coronary artery bypass grafting (CABG) in a multicenter setting. DESIGN Multicenter, retrospective study. SETTING Four university hospitals. PARTICIPANTS 596 patients were included in this study. INTERVENTIONS Included patients underwent isolated, emergency CABG. MEASUREMENTS AND MAIN RESULTS Sixty patients (absolute rate: 10.1%, pooled rate: 8.7%) died during the in-hospital stay period. Increasing emergency CABG classes (p<0.0001), recent myocardial infarction (p=0.019), left ventricular ejection fraction≤30% (p=0.034), on-pump surgery (p=0.012), and participating centers (p<0.0001) were independent predictors of in-hospital mortality. Survival rates at 1, 3, and 5 years were 86.4%, 81.6%, and 76.1%, respectively. Extracorporeal membrane oxygenation was used in 6 patients and 3 of them (50.0%) survived the immediate postoperative period. Patient populations of participating centers differed significantly in most of baseline characteristics. The preoperative use of intra-aortic balloon pump (8% to 51%) and off-pump surgery (2.8% to 56.3%) varied significantly between institutions. In-hospital mortality (2.8%, 5.9%, 7.7% and 19.8%, p<0.0001), as well as midterm survival, significantly differed between institutions (at 3 years, 90.6%, 89.8%, 81.2%, and 67.2%, p<0.0001). CONCLUSIONS The outcome after emergency CABG is satisfactory despite a significant operative risk. However, the results of emergency CABG significantly differed between the participating institutions, likely due to differences in the referral pathways and perioperative treatment strategies. Evaluation of these factors is crucial for implementation of treatment in centers with suboptimal results.

Surgical Treatment of Valvular Infective Endocarditis Complicated by An Abscess: A Single Centerâs Experience

Objectives: To examine the surgical treatment and mortality rate of valvular infective endocarditis complicated by an abscess in patients at a major tertiary care center. Background: Infective endocarditis (IE) involving a heart valve is fatal if left untreated. The appearance of a comorbid abscess impacts the choice of treatment and surgical technique and, in some instances, may present unique technical challenges. Methods: Departmental data from all patients who underwent surgery for IE at a single major tertiary care center from July 2007 to January 2016 were retrospectively screened for the presence of an intracardiac abscess. Patients with at least one confirmed abscess were examined further with respect to the surgical procedures completed and 30-day mortality rate. Results: Over the almost nine years of data collection, we identified 14 patients (9 males, 5 females) with at least one confirmed cardiac abscess. Patients ranged in age from 28 to 77 years old (mean 57.8 ± 14 years). Various surgical procedures were performed, including aortic or/and mitral valve replacement, mitral or/and tricuspid valve repair, and a freestyle prosthetic valve implant in the pulmonary position. In two patients, surgery was extended to include the ascending aorta; while two patients underwent coronary artery bypass grafting. A patch technique was adopted whenever necessary. Overall, 12 patients survived, while one died from septic shock and another from pneumonia. Conclusions: An abscess is a serious complication of valvular infective endocarditis that can appreciably increase the complexity of surgical intervention. In our experience, however, this seemed not to directly affect the 30-day mortality-rate, with both deaths ascribed to disseminated infection.

Isolated Celiac Trunk Dissection after Cardiac Surgery

The most catastrophic postoperative gastrointestinal complication in cardiac surgery is mesenteric ischemia, which is frequently fatal. This may result from atheroembolization, heparin-induced thrombocytopenia or hypoperfusion. We reported the case of 72 year old man undergone to coronary artery bypass and aortic valve replacement, presented isolated celiac trunk dissection after surgery. CT scan described a dissection flap of the first part of celiac trunk possible due to ulcerative plaque without note of anterograde or retrograde development. Considering patients hemodynamic, respiratory and general trend, we decided to choose conservative management. The sequent postoperative period was uneventfully, the patient was hemodynamically stable and he was discharged at the 20th postoperative day. The atheroembolization was a life-threatening problem of all vascular districts: a correct CPB pressure and postoperative BP monitoring could help to reduce the incidence of its complications.

Large Posterior Ascending Aortic Pseudoaneurysm 10 Years after Cardiac Surgery

Ascending Aortic Pseudoaneurysm (AscAP) is a late and rare complication after cardiac surgery. This may occur 0.02-0.2% of after cardiac surgery procedures and the hospital mortality rate could be 6.9-15.4%. Multidetector computed tomography can provide accurate diagnoses as to the exact location and size of AscAP for surgical planning and follow-up. According to the scientific literature, the gold standard treatment is surgery but many case reports describe conservative therapy. Authors presented a case of giant posterior aortic pseudoaneurysm originating from the left side of the previous aortotomy. To cite this article [Cottini, M., Terrieri, F., Piffaretti, G., & Beghi, C. (2016). Large Posterior Ascending Aortic Pseudoaneurysm 10 Years After Cardiac Surgery. The Journal of Middle East and North Africa Sciences, 2(8), 10-12]. (p-ISSN 24129763) (e-ISSN 2412-8937). www.jomenas.org. 3

Atypical Complications of Huntington Chorea Disease

Neurodegenerative diseases are defined as hereditary or acquired conditions which are characterized by progressive nervous system dysfunction. They include diseases such as Alzheimer’s Disease and other dementias, Huntington’s Disease, and so on. We report a case of 59-years-old man with Huntington Chorea admitted to our department for dyspnoea in massive pulmonary embolism due to a migration of a part of thrombus from deep venous thrombosis situs. He had recent history of pneumonia and severe hypomobility, and the thrombophilic screening showed a deficiency of C protein and S protein. While the diagnostic workup had been done, we discovered severe coronary disease, patent foramen ovale and paradoxical embolism.

Endovascular Repair of Ascending Aortic Pseudoaneurysm With Custom-Designed Endograft

Open repair of ascending aortic pseudoaneurysm (AscAP) carries high risks and mortality rate. Previous papers reported the off-label use of standard thoracic or abdominal endograft in very selected cases. We present the case of a 57-year-old man with an AscAP successfully managed with a new custom-designed endograft.