Saad Rustum

Perioperative levels and changes of high-sensitivity troponin T are associated with cardiovascular events in vascular surgery patients.

Objectives:Myocardial infarction after major surgery is frequent, drives outcome, and consumes health resources. Specific prediction and detection of perioperative myocardial infarction is an unmet clinical need. With the widespread use of high-sensitive cardiac troponin T assays, positive tests become frequent, but their diagnostic or prognostic impact is arguable. We, therefore, studied the association of routinely determined pre- and postoperative high-sensitive cardiac troponin T with the occurrence of major adverse cardiac events. Design:This study was a prospective noninterventional trial. Setting:This study was conducted at Hannover Medical School in Germany. Patients:A total of 455 patients undergoing open vascular surgery were followed for 30 days for the occurrence of major adverse cardiac events. Interventions:None. Measurements and Main Results:Preoperative and 24-hour postoperative high-sensitive cardiac troponin T measurements and the respective changes were correlated to medical history and the occurrence of major adverse cardiac events (cardiovascular death, myocardial infarction, and ischemia). Pre- and postoperative high-sensitive cardiac troponin T measurements demonstrated a majority of patients with detectable troponin levels preoperatively and an increase over the 24 hours after surgery. The level of high-sensitive cardiac troponin T was significantly associated with preexisting diseases that constitute the Lee’s Revised Cardiac Risk Index. A preoperative high-sensitive cardiac troponin T greater than or equal to 17.8 ng/L and a perioperative high-sensitive cardiac troponin T change greater than or equal to 6.3 ng/L are independently associated with the occurrence of major adverse cardiac events. Adding high-sensitive cardiac troponin T absolute change to the Revised Cardiac Risk Index improves the risk predictive accuracy of the score as evidenced by increased area under receiver operating characteristic and significant reclassification effects. Conclusions:The risk predictive power of high-sensitive cardiac troponin T change in addition to the Revised Cardiac Risk Index could facilitate 1) detection of patients at highest risk for perioperative myocardial ischemia, 2) evaluation and development of cardioprotective therapeutic strategies, and 3) decisions for admission to and discharge from high-density care units.

Surgical treatment of coronary artery aneurysms

Coronary artery aneurysms (CAA) are rare. We present our experience with the surgical treatment of patients with CAAs.

Renal function interferes with copeptin in prediction of major adverse cardiac events in patients undergoing vascular surgery.

OBJECTIVE Precise perioperative risk stratification is important in vascular surgery patients who are at high risk for major adverse cardiovascular events (MACE) peri- and postoperatively. In clinical practice, the patients perioperative risk is predicted by various indicators, e.g. revised cardiac index (RCRI) or modifications thereof. Patients suffering from chronic kidney disease (CKD) are stratified into a higher risk category. We hypothesized that Copeptin as a novel biomarker for hemodynamic stress could help to improve the prediction of perioperative cardiovascular events in patients undergoing vascular surgery including patients with chronic kidney disease. METHODS 477 consecutive patients undergoing abdominal aortic, peripheral arterial or carotid surgery from June 2007 to October 2012 were prospectively enrolled. Primary endpoint was 30-day postoperative major adverse cardiovascular events (MACE). RESULTS 41 patients reached the primary endpoint, including 63.4% aortic, 26.8% carotid, and 9.8% peripheral surgeries. Linear regression analysis showed that RCRI (P< .001), pre- (P< .001), postoperative Copeptin (P< .001) and Copeptin level change (P= .001) were associated with perioperative MACE, but CKD remained independently associated with MACE and Copeptin levels. Multivariate regression showed that increased Copeptin levels added risk predictive information to the RCRI (P= .003). Especially in the intermediate RCRI categories was Copeptin significantly associated with the occurrence of MACE. (P< .05 Kruskal Wallis test). Subdivision of the study cohort into CKD stages revealed that preoperative Copeptin was significantly associated with CKD stages (P< .0001) and preoperative Copeptin measurements could not predict MACE in patients with more severe CKD stages. CONCLUSION Preoperative Copeptin loses its risk predictive potential for perioperative MACE in patients with chronic kidney disease undergoing vascular surgery.

Is the frozen elephant trunk procedure superior to the conventional elephant trunk procedure for completion of the second stage

OBJECTIVES Our goal was to compare the results and outcomes of second‐stage completion in patients who had previously undergone the elephant trunk (ET) or the frozen elephant trunk (FET) procedure for the treatment of complex aortic arch and descending aortic disease. METHODS Between August 2001 and December 2014, 53 patients [mean age 61 ± 13 years, 64% (n = 34) male] underwent a second‐stage completion procedure. Of these patients, 32% (n = 17) had a previous ET procedure and 68% (n = 36) a previous FET procedure as a first‐stage procedure. RESULTS The median times to the second‐stage procedure were 7 (0‐78) months in the ET group and 8 (0‐66) months in the FET group. The second‐stage procedure included thoracic endovascular aortic repair in 53% (n = 28) of patients and open surgical repair in 47% (n = 25). More endovascular interventions were performed in FET patients (61%, n = 22) than in the ET group (35%, n = 6, P = 0.117). The in‐hospital mortality rate was significantly lower in the FET (8%, n = 3) group compared with the ET group (29%, n = 5, P = 0.045). The median follow‐up time after the second‐stage operation for the entire cohort was 4.6 (0.4‐10.4) years. The 5‐year survival rate was 76% in the ET patients versus 89% in the FET patients (log‐rank: P = 0.11). CONCLUSIONS We observed a significantly lower in‐hospital mortality rate in the FET group compared to the ET group. This result might be explained by the higher rate of endovascular completion in the FET group. We assume that the FET procedure offers the benefit of a more ideal landing zone, thus facilitating endovascular completion.

Coronary artery bypass grafting in young patients - insights into a distinct entity

ObjectivesCoronary artery bypass grafting (CABG) is the ‘Gold Standard’ for patients with multiple vessel coronary artery disease (CAD). Younger patients presenting with coronary artery disease requiring surgery may represent a distinct subgroup with the main goal for coronary revascularization being long term patency of the performed grafts to improve outcome.MethodsBetween January 2010 and August 2013, 126 patients below the age of 50 years underwent CABG for CAD in our hospital. We retrospectively analyzed the perioperative data and evaluated patients’ outcome.ResultsIn 25% of the patients CABG was performed as an emergency procedure for STEMI or NSTEMI within 36 hours. Another 27% of the patients were operated urgently for unstable angina or myocardial infarction within the last weeks and only 48% of the patients were purely elective cases. We performed only venous bypass grafts in 12%, total arterial revascularisation in 52% of all cases and combined venous and arterial revascularization in 43%. Six patients needed cardiac support using an extracorporeal membrane oxygenation (Mortality n = 1 out of 6) and 17 patients received an intraaortic ballon pump perioperativly. Patients received 2.8 ± 1 bypass grafts overall. Overall in-hospital mortality in this cohort was low with 1% (n = 1).ConclusionsIn conclusion, the majority of the young patients below the age of 50 years present urgently for operative revascularization. Besides the potential advances regarding long term patency using total arterial revascularization, only about half of the young patients are feasible for this approach. Overall early outcome in this group is excellent with mortality below one percent.

Unusual Case of an Arterial Thoracic Outlet Syndrome due to Srb Anomaly

A thoracic outlet syndrome (TOS) is caused by arterial or nervous obstruction because of skeletal or muscular anomalies and hypertrophies. Congenital rib anomalies occur with low incidences (0.15–0.31%), predominantly affect the right side and are normally diagnosed at a young age or remain asymptomatic throughout life. Here, we report on the unusual case of a 71-year-old female patient with subacute ischemia of the left arm due to a TOS resulting from Srb anomaly, a very rare congenital rib anomaly.

Left-sided mini-maze procedure via the left atrial appendage

This study presents a novel way to perform the mini-maze procedure through the left atrial appendage. By this way, the usual additional incision of the intra-atrial groove is avoided, especially in patients receiving coronary artery bypass grafting (CABG) or aortic valve replacement without mitral valve disease. We retrospectively analysed 23 consecutive patients who received this novel mini-maze procedure between 2009 and 2011. In recognition of a learning curve, we divided the patients into two groups (Group 1: Patients 1-11 versus Group 2: Patients 12-23), according to the date of operation. In Group 2, 7 patients (58.33%) were completely free of atrial fibrillation at the time of the follow-up. In Group 1, only 2 (18.18%) patients were successfully treated resulting in a stable sinus rhythm at the time of the follow-up. The mini-maze procedure performed through the left atrial appendage is a safe and feasible technique; however, it seems to be less effective than the Cox-maze III procedure and is associated with a learning curve.