Parwis Massoudy

Combining Classic Surgery With Descending Stent Grafting for Acute DeBakey Type I Dissection

BACKGROUND To possibly prevent late complications after classic type A aortic dissection repair, the radical concept of ascending/arch replacement with simultaneous antegrade descending stent grafting using a hybrid prosthesis was applied and compared with conventional repair leaving the distal false lumen untreated. METHODS Between January 2001 and October 2007, of 71 consecutive patients with acute type A aortic dissection (AAAD), 45 had DeBakey type I dissection and underwent emergency surgery within 24 hours after onset of symptoms. These patients were separated into group 1 (n = 23) undergoing conventional surgery, and group 2 (n = 22) undergoing combined repair with antegrade stent grafting. RESULTS Patients were comparable for baseline characteristics, but more group 2 patients had severely compromised hemodynamics (p = 0.05) and cerebral malperfusion at arrival (p < 0.01). Intraoperative and postoperative characteristics were similar, with an overall hospital mortality of 16% (5 [22%] versus 2 [9%], group 1 versus group 2; p = 0.22). At a mean follow-up time of 48 months for group 1 versus 23 months for group 2 (p < 0.01), late mortality did not differ between groups (p = 0.38) and was mainly related to additional surgical procedures and persisting neurologic sequelae and not to the aortic pathology. Persisting distal false lumen patency was observed in 89% of group 1 versus 10% of group 2 patients (p < 0.01). CONCLUSIONS This hybrid approach to patients with type I acute aortic dissection is technically feasible without increasing the operative risk and offers the chance of persistent occlusion of the persistent graft distal false lumen.

Transcatheter aortic valve implantation in patients with very high risk for conventional aortic valve replacement.

BACKGROUND We sought to determine whether transcatheter aortic valve implantation is a reasonable treatment option in patients with a very or extremely high risk for conventional aortic valve replacement, presenting with a logistic EuroSCORE greater than 30% or a Society of Thoracic Surgeons score greater than 15%. METHODS Between May 2005 and November 2008, 39 of 85 transcatheter aortic valve implantation patients with a very high risk for aortic valve replacement underwent either transfemoral (n = 15) or transapical (n = 24) transcatheter aortic valve implantation with a mean estimated logistic EuroSCORE of 44.2% +/- 12.6% (mean +/- standard deviation) and a Society of Thoracic Surgeons score of 17.9% +/- 6.1%. Transcatheter aortic valve implantation was performed in a hybrid operative theater using the Cribier-Edwards or Edwards SAPIEN prosthesis. RESULTS Valve implantation was successful in 97% of the patients. Operative mortality was 2.6%, and mortality at 30 days was 17.9%. After valve implantation, hemodynamic improvement was assessed by decreased mean pressure gradient (p < 0.001) and increased aortic valve area (p < 0.001), accompanied by improved New York Heart Association functional status (p < 0.01). Actuarial survival was 74.4% at 3 months, 74.4% at 6 months, and 64.1% at 12 months of follow-up. Echocardiography revealed aortic regurgitation in 58% of the patients during hospital stay, 43% at 6 months of follow-up, and 40% at 12 months of follow-up, but no structural valve deterioration could be observed during the complete follow-up period. CONCLUSIONS Transcatheter aortic valve implantation in patients with severe aortic stenosis and a very high risk for aortic valve replacement is feasible and may be a reasonable treatment option in these patients.

Glucocorticoid Treatment Prevents Progressive Myocardial Dysfunction Resulting From Experimental Coronary Microembolization

Background—The frequency and importance of microembolization in patients with acute coronary syndromes and during coronary interventions have recently been appreciated. Experimental microembolization induces immediate ischemic dysfunction, which recovers within minutes. Subsequently, progressive contractile dysfunction develops over several hours and is not associated with reduced regional myocardial blood flow (perfusion-contraction mismatch) but rather with a local inflammatory reaction. We have now studied the effect of antiinflammatory glucocorticoid treatment on this progressive contractile dysfunction. Methods and Results—Microembolization was induced by injecting microspheres (42-μm diameter) into the left circumflex coronary artery. Anesthetized dogs were followed up for 8 hours and received placebo (n = 7) or methylprednisolone 30 mg/kg IV either 30 minutes before (n = 7) or 30 minutes after (n = 5) microembolization. In addition, chronically instrumented dogs received either placebo (n = 4) or methylprednisolone (n = 4) 30 minutes after microembolization and were followed up for 1 week. In acute placebo dogs, posterior systolic wall thickening was decreased from 20.0±2.1% (mean±SEM) at baseline to 5.8±0.6% at 8 hours after microembolization. Methylprednisolone prevented the progressive myocardial dysfunction. Increased leukocyte infiltration in the embolized myocardium was prevented only when methylprednisolone was given before microembolization. In chronic placebo dogs, progressive dysfunction recovered from 5.0±0.7% at 4 to 6 hours after microembolization back to baseline (19.1±1.6%) within 5 days. Again, methylprednisolone prevented the progressive myocardial dysfunction. Conclusions—Methylprednisolone, even when given after microembolization, prevents progressive contractile dysfunction.

Prognostic value of preoperative cardiac troponin I in patients undergoing emergency coronary artery bypass surgery with non-ST-elevation or ST-elevation acute coronary syndromes.

Background— Cardiac troponin I (cTnI) is a highly sensitive and specific biomarker which has been shown to predict patient outcome pre- and postoperatively following elective coronary artery bypass surgery (CABG). Whether preoperatively elevated cTnI levels similarly predict the outcome in patients undergoing emergency CABG with acute myocardial infarction (AMI) is currently unknown. Methods and Results— A possible correlation between preoperative cTnI and in-hospital mortality and major adverse cardiac events (MACE) was investigated in 57 patients with ST-elevation AMI (STEMI) in group 1 and 197 with Non-ST-elevation AMI (NSTEMI) in group 2, who were operated within 24 hours after onset of symptoms. Primary study end point was all-cause in-hospital mortality. Secondary end points were low cardiac output syndrome (LCOS) and hospital course. CTnI levels on admission were higher in group 1 compared with group 2 (7.1±1.8 versus 1.4±1.8 ng/mL; P<0.001). Overall in-hospital mortality was higher in group 1 compared with group 2 (14.3 versus 4.1%; odds ratio [OR], 3.9, 95% confidence interval [CI], 1.3 to 12.3; P<0.01). LCOS occurred in 16/57 (28.1%), and 18/197 (9.1%) patients, respectively (OR, 3.9, 95% CI, 1.7 to 8.8; P<0.001). Postoperative ventilation time, intensive care, and hospital stay were significantly longer in group 1 versus group 2. Multivariate logistic regression analyses revealed preoperative cTnI as the strongest independent predictor for in-hospital mortality (P<0.001) and MACE (P<0.001) in all AMI patients, regardless whether ST-elevation was included as an additional risk factor or not. Conclusions— Preoperative cTnI measurement before emergency CABG appears as a powerful and independent determinant of in-hospital mortality and MACE in acute STEMI and NSTEMI.

Prognostic Significance of Multiple Previous Percutaneous Coronary Interventions in Patients Undergoing Elective Coronary Artery Bypass Surgery

Background— A possible relationship between increased perioperative risk during coronary artery bypass grafting (CABG) and previous percutaneous coronary intervention (PCI) is debatable. We sought to determine the impact of previous PCI on patient outcome after elective CABG. Methods and Results— Between January 2000 and January 2005, 2626 consecutive patients undergoing first-time isolated elective CABG as the primary revascularization procedure (group 1) were evaluated for in-hospital mortality and major adverse cardiac events (MACEs) and were compared with 360 patients after single PCI (group 2) and with 289 patients after multiple PCI sessions (group 3) before elective CABG. Unadjusted univariate and risk-adjusted multivariate logistic-regression analysis revealed previous multiple PCIs to be strongly associated with in-hospital mortality (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.52 to 3.21; P<0.001) and MACEs (OR, 2.28; 95% CI, 1.38 to 3.59; P<0.001). To control for selection bias, a computed propensity-score matching based on 13 patient characteristics and preoperative risk factors was performed separately comparing group 1 versus 2 and group 1 versus 3. After propensity matching, conditional logistic-regression analysis confirmed previous multiple PCIs to be strongly associated with in-hospital mortality (OR, 3.01; 95% CI, 1.51 to 5.98; P<0.0017) and MACEs (OR, 2.31; 95% CI, 1.45 to 3.67; P<0.0004). Conclusions— In patients with a history of multiple PCI sessions, perioperative risk for in-hospital mortality and MACEs during subsequent elective CABG is increased.

Coronary artery bypass surgery and acute kidney injury—impact of the off-pump technique

BACKGROUND Acute kidney injury (AKI) is a serious and frequent complication after coronary artery bypass grafting (CABG). Cardiopulmonary bypass (CPB) was identified as a major AKI risk factor after CABG. Our aim was to assess the impact of the off-pump coronary artery bypass (OPCAB) compared to the on-pump coronary artery bypass (ONCAB) technique on the rate and severity of AKI, while taking other risk factors for AKI into account. METHODS An observational study of 201 consecutive adult patients was conducted; 100 were operated by the OPCAB and 101 by the ONCAB technique. All patients in each group were operated by a single, experienced surgeon. Fifteen pre-, intra- and postoperative variables that were repeatedly identified in previous studies as independent AKI risk factors were included in this analysis. AKI was defined as an increase of serum creatinine >/=50% or >/=0.3 mg/dL within 48 h and AKI severity was classified, according to current AKIN definitions. RESULTS Significantly fewer OPCAB patients developed AKI compared to ONCAB (14.0 versus 27.7%; P = 0.03). OPCAB was associated with milder stages of AKI, whereas ONCAB patients had more severe AKI. Congestive heart failure and chronic kidney disease were independent risk factors for AKI. The OPCAB technique for CABG was identified as the only independent factor associated with lower incidence of AKI. CONCLUSIONS Using current AKI definitions and classifications, the OPCAB technique for CABG, which avoids CPB; was associated with a significantly lower rate and less severe AKI compared to ONCAB. The OPCAB technique was identified as the only modifiable and potentially protective factor against postoperative AKI.

Impact of prior percutaneous coronary intervention on the outcome of coronary artery bypass surgery: A multicenter analysis

OBJECTIVES Do prior percutaneous coronary interventions adversely affect the outcome of subsequent coronary artery bypass grafting? We investigated this effect on a multicenter basis. METHODS Eight cardiac surgical centers provided outcome data of 37,140 consecutive patients who underwent isolated first-time coronary bypass grafting between January 2000 and December 2005. Twenty-two patient characteristics and outcome variables were retrieved. Three groups of patients were analysed for in-hospital mortality and in-hospital major adverse cardiac events: patients without a previous percutaneous coronary intervention, with 1 previous intervention, and with 2 or more previous percutaneous coronary interventions before bypass grafting. A total of 29,928 patients with complete information for prior percutaneous coronary intervention underwent final analysis. Unadjusted univariate and risk-adjusted multivariate logistic regression analysis as well as computed propensity score matching were performed, based on 14 major risk factors to correct for and minimize selection bias. RESULTS A total of 10.3% of patients had 1 previous percutaneous coronary intervention, and 3.7% of patients had 2 or more previous interventions. Risk-adjusted multivariate logistic regression analysis revealed a significant association of 2 or more previous percutaneous coronary interventions with in-hospital mortality (odds ratio [OR], 2.0; confidence interval [CI], 1.4-3.0; P = .0005) and major adverse cardiac events (OR, 1.5; CI, 1.2-1.9; P = .0013). After propensity score matching, conditional logistic regression analysis confirmed the results of adjusted analysis. A history of 2 or more previous percutaneous coronary interventions was significantly associated with in-hospital mortality (OR, 1.9; CI, 1.3-2.7; P = .0016) and major adverse cardiac events (OR, 1.5; CI, 1.2-1.9; P = .0019). CONCLUSIONS Multicenter analysis confirms that a history of multiple previous percutaneous coronary interventions increases in-hospital mortality and the incidence of major adverse cardiac events after subsequent coronary artery bypass grafting. Critical discussion of the treatment strategy in these patients is warranted.

Sodium nitroprusside in patients with compromised left ventricular function undergoing coronary bypass: Reduction of cardiac proinflammatory substances

OBJECTIVE The aim of the present study was to investigate whether the nitric oxide donor sodium nitroprusside can reduce the cardiac inflammatory response during coronary artery bypass grafting in patients with severely compromised left ventricular function. METHODS Patients (n = 30) were assigned to receive placebo or sodium nitroprusside (0.5 microg. kg(-1). min(-1)) for the first 60 minutes of reperfusion. Interleukin 6, interleukin 8, and tumor necrosis factor alpha levels; platelet adhesion molecule CD41 and CD62 levels; and CD11b on leukocytes were determined in the radial artery and coronary sinus before cardiopulmonary bypass and during reperfusion (1, 5, 10, 35, and 75 minutes). RESULTS At 1 minute of reperfusion, coronary venous levels of CD41-positive polymorphonuclear leukocytes were 8% lower than arterial levels in the placebo group and 18% higher in the sodium nitroprusside group (P =.021). At 5 minutes of reperfusion, the respective levels were 29% and 1% for interleukin 6 (P =.015), -5% and 20% for CD41-positive monocytes (P =.032), and -2% and 16% for CD11b-positive monocytes (P =.038). At 10 minutes of reperfusion, these levels were -14% and 21% for CD41-positive monocytes (P =.006). At 35 minutes of reperfusion, these levels were -13% and 7% for CD41-positive monocytes (P =.017), -41% and 23% for CD11b-positive monocytes (P =.001), and 7% and 25% for CD62-positive platelets (P =. 041). At 75 minutes of reperfusion, the levels were 15% and -7% for tumor necrosis factor alpha (P =.025) and -10% and 10% for CD62-positive platelets (P =.041). CONCLUSIONS Transcardiac production of proinflammatory cytokines is reduced in patients undergoing coronary artery bypass grafting treated with the nitric oxide donor sodium nitroprusside. At the same time, less activated leukocytes and platelets are retained in the coronary circulation.

Risk prediction and outcomes in patients with liver cirrhosis undergoing open-heart surgery

OBJECTIVE There are few data assessing factors, which identify patients with liver cirrhosis (LC) facing high risk for open-heart surgery. We sought to compare the Model for End-Stage Liver Disease (MELD) score, the Child-Turcotte-Pugh (CTP) classification and the European system for cardiac operative risk evaluation (EuroSCORE) for risk prediction in cirrhotic patients. METHODS Fifty-seven consecutive patients with non-cardiac LC, who underwent open-heart surgery with the use of cardiopulmonary bypass between 1998 and 2008, were studied at our institution. Potential preoperative predictors of outcome, as well as preoperative MELD score, CTP classification and EuroSCORE were calculated. The primary study end points were all-cause in-hospital and long-term mortality. RESULTS MELD score and CTP classification both differed significantly between survivors and non-survivors for in-hospital (P<0.0001) and long-term mortality (P<0.0001). Univariate predictors of in-hospital mortality were emergency surgery (odds ratio (OR), 4.9; 95% confidence interval (CI), 1.2-20.6; P=0.03), ascites (OR, 7.2; 95% CI, 2.0-25.5; P=0.002), total serum protein (OR, 0.4; 95% CI, 0.2-0.8; P=0.01), CTP class (OR, 5.5; 95% CI, 1.4-21.5; P=0.04) and MELD score (OR, 1.4; 95% CI, 1.1-1.6; P=0.001). Multivariable exact logistic regression analyses revealed MELD score (OR, 1.3; 95% CI, 1.005-1.6; P=0.04) as the only independent factor associated with in-hospital mortality. Receiver operating characteristic curve (ROC) analysis showed MELD score to be highly predictive with an optimal cut-off value of 13.5 (sensitivity: 82.0%, specificity: 78.5%) for postoperative in-hospital mortality (area under curve (AUC): 85.1 ± 0.05%) and superior compared to the CTP classification (AUC: 75.7±0.08%) and EuroSCORE (AUC: 65.9 ± 0.08%). CONCLUSIONS The mortality of patients with liver cirrhosis undergoing open-heart surgery progressively increases with the severity of liver dysfunction. Therefore, the MELD score most reliably identifies those cirrhotic patients who are at high risk for open-heart surgery.

Sodium nitroprusside during coronary artery bypass grafting: evidence for an antiinflammatory action

BACKGROUND It was the aim of the present study to investigate whether a nitric oxide donor can reduce systemic inflammation and the cardiac inflammatory response during coronary artery bypass grafting with cardiopulmonary bypass. METHODS Patients undergoing elective coronary artery bypass grafting (n = 22) were randomly assigned to treatment with either sodium nitroprusside (0.5 microg x kg(-1) x min(-1)) or placebo (controls), both for the first 20 minutes of reperfusion. Interleukin-6 and interleukin-8 levels, the adhesion molecules CD41 and CD62 on platelets and CD41 on monocytes and PMN (as markers for coaggregate formation), CD11b on monocytes and PMN, as well as platelet and leukocyte counts were determined in radial artery and coronary sinus blood before cardiopulmonary bypass and during reperfusion (1, 5, 10, 25, and 35 minutes). RESULTS A reduction of systemic interleukin-6 levels (15.4+/-3.5 pg/mL, 36.7+/-5.9 pg/mL, and 46.8+/-8.0 pg/mL versus 33.4+/-7.7 pg/mL, 76.7+/-13.2 pg/mL, and 106.0+/-26.5 pg/mL, respectively, at 1, 25, and 35 minutes of reperfusion) and interleukin-8 (29.6+/-4.5 pg/mL versus 54.0+/-9.4, pg/mL, resp., at 35 minutes of reperfusion) resulted from treatment with sodium nitroprusside. No intracardiac production of interleukin-8 in sodium nitroprusside-treated patients (-1.1+/-0.4 pg/mL and -2.8+/-2.2 pg/mL, resp., for the coronary sinus-radial artery difference at 5 and 25 minutes of reperfusion) was observed, whereas cardiac production of interleukin-8 was present in controls (2.5+/-1.5 pg/mL and 5.5+/-2.8 pg/mL, resp.). Retention of platelet/leukocyte coaggregates occurred during coronary passage in controls (coronary sinus-radial artery difference for CD41-positive monocytes at 1 and 10 minutes of reperfusion, -16.3%+/-8.5% and -8.8%+/-2.6%, resp.). This was reduced in sodium nitroprusside-treated patients (with 5.8%+/-5.2% and 0.0%+/-3.2%). Retention of platelets in controls (ratio of coronary sinus to radial artery platelet count at 5 and 10 minutes of reperfusion, 88%+/-6% and 91%+/-5%) was compared to washout in treated patients (108%+/-6% and 113%+/-7%). CONCLUSIONS In patients undergoing routine coronary artery bypass grafting, administration of sodium nitroprusside during early reperfusion alleviates systemic inflammation and the cardiac inflammatory response.