Petar Vukovic

Steroids and statins: an old and a new anti-inflammatory strategy compared

Objectives: This study compared the anti-inflammatory effects of methylprednisolone (MP) and atorvastatin and analysed their influences on clinical variables in patients undergoing coronary revascularization. Methods: Ninety patients with compromised left ventricular ejection fraction (≤30%) undergoing elective coronary surgery were equally randomized to one of three groups: statin group, treatment with atorvastatin (20 mg/day) 3 weeks before surgery; methylprednisolone group, a single shot of methylpredniosolone (10mg/kg); and control group. Results: Postoperative IL-6 was higher in the control group when compared to the methylprednisolone and statin groups (p<0.01). IL-6 was higher in the statin-treated patients (p<0.05 versus methylprednisolone). Administration of methylprednisolone as well as statin treatment increased postoperative cardiac index, left ventricular stroke work index, decreased postoperative atrial fibrilation rate and reduced ICU stay (p<0.05 versus control). The number of patients requiring inotropic support was lower in the methylprednisolone group when compared with the other two groups (p<0.01). Tracheal intubation time was reduced in patients who received methylprednisolone (p<0.01 versus control). Conclusions: Preoperative administration of either methylprednisolone or atorvastatin reduced pro-inflammatory cytokine release, improved haemodynamics, decreased postoperative atrial fibrilation rate and reduced ICU stay in patients with significantly impaired cardiac function undergoing coronary revascularization. Treatment with methylprednisolone was associated with less inotropic support requirements and reduced mechanical ventilation time.

Calibration of the EuroSCORE II risk stratification model: is the Hosmer–Lemeshow test acceptable any more?

We read with great interest the article by Nashef et al .[ 1] regarding the construction and validation of the EuroSCORE II risk model. This manuscript is an outstanding contribution in the creation of a risk stratification model that is robust enough for use in cardiac surgery worldwide. However, we would like to know which statistical procedure should be used to determine calibration of the EuroSCORE II? The Hosmer–Lemeshow goodness-of-fit test has been the most popular test to validate calibration [2, 3], measuring the differences between expected and observed outcomes (mortality) over deciles (test results are acceptable with cohort divided in at least terciles) of risk. A well-calibrated model gives a corresponding P value >0.05. Recently, it has been claimed that a nonsignificant Hosmer–Lemeshow test meant that there was no evidence of bad calibration, but that this result did not mean that there was good calibration [4]. In our opinion, statistical results are either significant or nonsignificant, black or white; there are no grey results in statistics. However, if that is true, how has it come to pass that we needed more than 10 years (during which Hosmer–Lemeshow statistics was used in more than 95% of manuscripts to test the calibration of additive and logistic EuroSCORE in cardiac surgery) to find out that Hosmer– Lemeshow test is no longer valid to determine calibration, and that it should be replaced with the risk-adjusted mortality ratio, [RAMR = observed/predicted (expected) – O/E mortality], as it is now suggested by Nashef et al [1]. An O/E ratio of 1.0 means that the score predicts mortality perfectly. An O/E ratio > 1.0 means that the model underpredicts mortality [in EuroSCORE II, for a validation data set of 5553 patients, the O/E ratio was 1.058 (4.18%/3.95%)], while an O/E ratio < 1.0 means that the model overpredicts mortality. However, how are we going to check the statistical significance of the RAMR value? Conceptually, if the observed number of deaths is equal to the expected number of deaths (as predicted by the scoring system), the RAMR would have a value of 1.0. Thus, the statistical test for the significance of the RAMR is whether it is different from 1.0. To gauge the statistical significance of the RAMR, we must first calculate the 95% confidence interval for the RAMR. If the 95% confidence interval excludes the value ‘1.0’, it may be considered statistically significant (no matter whether it overpredicts or underpredicts mortality). On the contrary, Bhatti et al .[ 5] suggested χ 2 statistics

Radial Artery Harvesting for Coronary Artery Bypass Grafting: A Stepwise-Made Decision

BACKGROUND The purpose of this study was to propose a safe, stepwise, testing system to select radial arteries that are suitable for conduits on the basis of their morphologies and characteristics of the collateral circulation. METHODS Before operation, 113 patients underwent the modified Allen test, Doppler ultrasonography, and pulse oximetry testing. Morphologic criteria used for radial artery exclusion were small size of radial or ulnar artery (< 2 mm in inner diameter), diffuse calcifications, and congenital anomalies of forearm arteries. Collateral circulation was interpreted as insufficient if the reverse flow in the anatomic snuffbox was absent or if the increase of the ulnar peak systolic flow velocity was less than 20%. RESULTS A positive modified Allen test was found in 10.6% of patients. As assessed by Doppler ultrasonography, 27 patients (23.9%) were not candidates for radial artery harvesting according to morphologic and functional abnormalities of forearm and hand circulation. Pulse oximetry test results were abnormal in 6.2%. After a follow-up period of 8.9 +/- 1.8 months, 23 patients (29.1% of operated patients) were controlled for Doppler ultrasonographic changes in the ulnar artery. The mean peak systolic flow velocity was significantly higher than the preoperative value measured at rest (p < 0 .001). CONCLUSIONS After preoperative tests, including the modified Allen test, Doppler ultrasonography, and pulse oximetry, 30.1% of patients were not considered candidates for radial artery harvesting. This method provides preoperative radial artery selection according to its morphologies, compensatory capacity of collateral circulation, and anatomic properties of ulnar artery.

How to Use the Left Internal Thoracic Artery Which Has Been Damaged During Harvesting

The established superiority of the internal thoracic artery as a coronary arterial conduit has led to its mandatory use in coronary artery bypass grafting surgery. Therefore, the damage of the internal thoracic artery during harvesting is an abysmal complication, after which the conduit is usually discarded. An alternative approach is presented here, which has allowed us to use the distal two thirds of the proximally damaged left internal thoracic artery as an in situ (with retrograde blood supply from superior epigastric and musculophrenic arteries), reversed arterial conduit to revascularize the left anterior descending coronary artery.

Cor Triatriatum Dexter and Atrial Septal Defect in a 43-Year-Old Woman

Cor triatriatum dexter is a rare congenital heart anomaly in which a membrane divides the right atrium into 2 chambers. We report the case of a 43-year-old woman who had cor triatriatum dexter and a large atrial septal defect. During attempted percutaneous closure, the balloon disrupted the membrane and revealed that the defect had no inferior rim, precluding secure placement of an Amplatzer Septal Occluder. Surgical treatment subsequently proved to be successful. In patients with an incomplete membrane and a septal defect with well-defined rims, percutaneous treatment can be the first choice. In patients who have cor triatriatum dexter and unfavorable anatomic features or concomitant complex heart anomalies, open-heart surgery remains the gold standard for treatment.

Preoperative Insight Into the Quality of Radial Artery Grafts.

We investigated the impact of preoperative ultrasonography of the forearm circulation on radial artery conduit selection. Preoperative ultrasound of the forearm circulation was performed routinely in 536 patients planned for radial artery harvesting. The safety assessment of the harvest included the following algorithm of tests: the ultrasound, the Allen test, and pulse oximetry. The quality criteria that were used to exclude a radial artery from harvesting were small size of the artery, diffuse atherosclerosis, calcifications, and severe neointimal hyperplasia. The overall rejection rate due to safety reasons was 16.4%. Seventy-one (13.2%) radial arteries did not fulfill the conduit quality criteria and consequently these arteries were not harvested. In 13.4% of radial arteries, localized arterial wall disease was found in the distal third of the artery. The distal part of the artery was discarded and the rest was used as a conduit. Our results indicate that the ultrasound provides an accurate preoperative insight into the radial artery morphology, enabling selection of the arteries with favorable morphological features.

Concomitant reconstruction of arch vessels during repair of aortic dissection.

Surgery for acute aortic dissection is challenging, especially in cases of cerebral malperfusion. Should we perform only the aortic repair, or should we also reconstruct the arch vessels when they are severely affected by the disease process? Here we present a case of acute aortic dissection with multiple tears that involved the brachiocephalic artery and caused cerebral and right upper-extremity malperfusion. The patient successfully underwent complete replacement of the brachiocephalic artery and the aortic arch during deep hypothermic circulatory arrest, with antegrade cerebral protection. We have found this technique to be safe and reproducible for use in this group of patients.

The current role of surgery in treating adult patients with patent ductus arteriosus.

OBJECTIVE Surgical closure of patent ductus arteriosus (PDA) is still required in selected adult patients. We analyzed the morphology of the anomaly and coexisting pathological findings in adult patients who were recently referred to our institute for surgical PDA repair. PATIENTS AND INTERVENTIONS Six adult PDA patients who were not considered candidates for percutaneous closure underwent surgical PDA correction. In three patients with isolated PDA, computed tomographic scan revealed short, wide, and distorted ductus. In the remainder three patients, concomitant heart or aortic disease was found. Transpulmonary approach under total cardiopulmonary bypass or hypothermic circulatory arrest was performed. RESULTS In all patients, a Dacron patch was used to close the duct. The balloon occlusion technique with normothermic cardiopulmonary bypass was performed in four patients. In one of these patients, the balloon occlusion was not feasible because of unfavorable ductal anatomy, and PDA was closed in short hypothermic circulatory arrest. In two patients with aortic aneurysm, PDA closure and aortic reconstruction were performed in deep hypothermic circulatory arrest. No significant complications occurred during postoperative course. After the mean follow-up period of 48 months, neither ductal reopening nor aneurysmal degeneration of remnant ductal tissue was found. CONCLUSION Surgical PDA closure in adults remains the treatment of choice in wide, deformed PDAs unsuitable for percutaneous closure and PDAs associated with surgical aortic or heart disease.

Evaluation of Radial Artery Atherosclerosis by Intravascular Ultrasound

We read with great interest the article by Moon et al published in Angiology. The radial artery is increasingly used as conduit in coronary surgery. The extent of preexisting atherosclerosis determines the suitability of radial artery usage as graft in cardiac surgery. We acknowledge the authors’ contribution to existing literature about the relationship between established risk factors (male gender, age, hypertension, etc) and the extent of atherosclerotic plaques in the radial artery. In our opinion, the concept of evaluation of radial artery atherosclerosis by intravascular ultrasound (IVUS), based on transradial approach, has not much appeal to most surgeons due to several reasons:

Letter by Nezić et al regarding article, "The impact of diabetic status on coronary artery bypass graft patency: insights from the Radial Artery Patency Study".

To the Editor: We read with great interest the article by Singh and associates1 that was recently published in Circulation . We respect all subsequent analysis arising from an excellent, prospective, randomized basic study presented by Desai and colleagues2 a few years ago that compared the angiographic patency of radial artery (RA) grafts with that of saphenous vein (SV) grafts 1 year after surgery. Although that study demonstrated significantly better angiographic patency of RA conduits compared with SV grafts …