Sarunas Kinduris

A case-control study of readmission to the intensive care unit after cardiac surgery

Background The aim of this study was to identify predictors of repeated admission to the intensive care unit (ICU) of patients who underwent cardiac surgery procedures. Material/Methods This retrospective study analyzed 169 patients who underwent isolated coronary artery bypass grafting (CABG) between January 2009 and December 2010. The case group contained 54 patients who were readmitted to the ICU during the same hospitalization and the control group comprised 115 randomly selected patients. Results Logistic regression analysis revealed that independent predictors for readmission to the ICU after CABG were: older age of patients (odds ratio [OR] 1.04; CI 1.004–1.08); body mass index (BMI) >30 kg/m2 (OR 2.55; CI 1.31–4.97); EuroSCORE II >3.9% (OR 3.56; CI 1.59–7.98); non-elective surgery (OR 2.85; CI 1.37–5.95); duration of operation >4 h (OR 3.44; CI 1.54–7.69); bypass time >103 min (OR 2.5; CI 1.37–4.57); mechanical ventilation >530 min (OR 3.98; CI 1.82–8.7); and postoperative central nervous system (CNS) disorders (OR 3.95; CI 1.44–10.85). The hospital mortality of patients who were readmitted to the ICU was significantly higher compared to the patients who did not require readmission (17% vs. 3.8%, p=0.025). Conclusions Identification of patients at risk of ICU readmission should focus on older patients, those who have higher BMI, who underwent non-elective surgery, whose operation time was more than 4 hours, and who have postoperative CNS disorders. Careful optimization of these high-risk patients and caution before discharging them from the ICU may help reduce the rate of ICU readmission, mortality, length of stay, and cost.

Assessment of validity for EuroSCORE risk stratification system

Prognostic scoring helps doctors, patients and their families to weigh the risks and benefits of medical care and clarifies their expectations. Objective We aimed to analyze the risk stratification performance of the EuroSCORE system because of its common use in Lithuania. Design EuroSCORE performance is assessed in terms of sensitivity, specificity, accuracy and area under the receiver operating characteristic (ROC) curve (AUC). Logistic regression is carried out for modeling categorical data and odds ratio calculations of being a non-survivor case for each EuroSCORE risk group. Results The study was completed on 1002 patients. Mean score for EuroSCORE was 4.77±2.8; ROC curve of 0.71; accuracy was 65.5%; 65.4% sensitivity and 67.2% specificity. Conclusions EuroSCORE created a moderately predictive area under the ROC curve for our patient population. Probability of non-survival by logistic regression model for each EuroSCORE risk group is statistically significantly higher compared to the lower risk group. Predictions available from prognostic scoring systems could be useful in decision making when there is uncertainty in whether to carry out surgery or not.

Comparison of results of endovascular stenting and bypass grafting for TransAtlantic Inter-Society (TASC II) type B, C and D iliac occlusive disease.

Introduction The priority use of endovascular techniques in the management of aortoiliac occlusive disease has increased in the last decade. The aim of the present article is to report 1- and 2-year results of iliac artery stenting (IAS) and aortoiliac grafting in the management of patients with TASC II type B, C and D iliac lesions and chronic limb ischaemia. Material and methods In this prospective, non-randomised, one-centre clinical study, iliac artery stents and vascular grafts used for the treatment of patients with symptomatic lesions in the iliac artery were evaluated. This study enrolled 2 groups: 54 patients in the stent group and 47 patient in the surgery group. Results The primary patency rates at 1 and 2 years were 83% and 79.9% after IAS and 97.1% and 97.1% after surgical reconstruction, respectively (p = 0.015). The assisted primary stent patency at 1 and 2 years was 87.9% and 78.2%, respectively. The complication rate was 7.4% in the stent group and 6.3% in the surgery group. There was no perioperative mortality in either group. Conclusions Our results reveal that patients with severe aortoiliac occlusive disease (TASC II types B, C and D) can be treated with IAS or surgically with satisfactory results. Iliac artery stenting is associated with decreased primary patency compared with the surgery group. Iliac artery stenting should be considered with priority in elderly patients or in patients with severe comorbidities.

Changes of Left Ventricular Diastolic Filling After Sublingual Nitroglycerin in Determining the Severity of Coronary Artery Disease

The aim of the study was to evaluate the left ventricular (LV) diastolic filling (DF) in patients with 1, 2, and 3 vessel and left main (LM) coronary artery disease (CAD) and to determine the response of LV DF to nitroglycerin in age‐matched patient groups. The study covers 74 patients with CAD including ten patients with 1 vessel CAD, ten patients with 2 vessel CAD, 43 patients with 3 vessel CAD, and 11 patients with LM CAD who underwent Doppler echocardiographic measurements of early (E) and late (A) diastolic transmitral velocities, their ratio (E/A) and deceleration time (DT) of E before and after sublingual administration of 0.5 mg nitroglycerin. Baseline studies did not reveal any significant differences in E, A, and DT between groups. Baseline E/A ratio differed between 1, 2, and 3 vessel and LM CAD patients (1.07 ± 0.10; 0.89 ± 0.07; 0.87 ± 0.05 vs 0.67 ± 0.06, P < 0.05). After nitroglycerin, significant differences in E between 1 vessel CAD and all the remaining groups, also between 2 and 3 vessel CAD and LM CAD patient groups (50.1 ± 2.4 cm/sec vs 39.6 ± 2.6; 38.4 ± 1.8; 30.2 ± 3.3 cm/sec and 39.6 ± 2.6; 38.4 ± 1.8 cm/sec vs 30.2 ± 3.3 cm/sec, respectively) were observed. A velocity did not differ significantly between the groups, DT differed between 1 vessel CAD and LM CAD patients (162.2 ± 14.6 msec vs 117.0 ± 12.1 msec), differences in E/A ratio appeared between 1 vessel and the remaining groups (1.13 ± 0.10 vs 0.72 ± 0.08; 0.70 ± 0.05 and 0.55 ± 0.07). Thus, Doppler LV DF indices, except E/A ratio, were not sensitive in reflecting the severity of CAD. Therefore, nitroglycerin resulted in more marked decrease of LV DF indices in patients with more severe CAD and in revealing differences between patients with 1, 2, and 3 vessel and LM CAD. These data suggest that a nitroglycerin Doppler test may be proposed for the assessment of the severity of CAD.

Do age, diabetes and left ventricular function affect the outcomes of ischemic mitral valve repair?

Introduction It is well documented that older age, chronic concomitant diseases (such as diabetes mellitus, chronic obstructive lung disease, etc.), and poor left ventricular function can increase the postoperative complication rate and worsen the general outcomes of coronary artery bypass (CABG) and concomitant repair of ischemic mitral regurgitation (MR). Material and methods Retrospective data of 394 patients after CABG and mitral valve (MV) repair (mainly annuloplasty) were analyzed. Patients were grouped according to age, diabetes mellitus (DM), and left ventricular ejection fraction (LVEF). Echocardiography data, the rate of postoperative complications (cardiogenic shock, preoperative myocardial infarction, bleeding from the gastrointestinal tract, cognitive disorders, stroke, sepsis, deep wound infection), and early and late mortality were compared between paired groups. Results There were no differences between age groups in reverse positive remodeling of LV. A significantly higher incidence of sepsis and deep wound infection in younger patients was observed. Patients with DM had no change in the pre-postoperative NYHA class and a higher rate of perioperative MI (10.3% vs. 3.1% respectively, p < 0.05) in comparison to patients with no DM. In all LVEF groups, MR was significantly decreased, but reverse positive remodeling of LV was pronounced only in those with “poor” and “moderately lowered” LVEF. Postoperative complications did not differ among these three groups. Conclusions Elderly age, concomitant DM and lowered LVEF do not influence either early or late mortality, including early postoperative outcomes after MV repair for ischemic MR following CABG. Concomitant DM increases the rate of perioperative MI and impairs reverse remodeling of LV.

Prognostic value of myocardial perfusion abnormalities for long-term prognosis in patients after coronary artery bypass grafting

Aims: The objective was to evaluate the prognostic value of exercise myocardial perfusion scintigraphy (MPS) in patients who underwent coronary artery bypass grafting (CABG). Subjects and Methods: A retrospective, one-center study of 361 patients with multivessel coronary artery disease was carried out. All the patients underwent MPS after CABG due to worsened health status. MPS was performed at 4.5 years standard deviation (SD: 0.2), based on symptoms. MPS was carried out using Tc-99m methoxy isobutyl isonitrile and following a 1-day protocol (stress-rest). The end points were analyzed at 6.5 years (SD: 3.3) after MPS, on the average. Statistical Analysis Used: SPSS software for Windows, version 13.0. The t-test or the χ2-test was used. Survival times were calculated. A multivariate Cox proportional hazards model was developed. Results: During the follow-up, death occurred in 54 patients, and 37 patients experienced major adverse cardiovascular events (MACE). In the multivariate analysis, advanced age hazard ratio (HR: 1.45; 95% confidence interval [CI]: 1.4–2.02; P = 0.027), previous myocardial infarction (HR: 3.17; 95% CI: 1.22–8.2; P = 0.018), left ventricular ejection fraction of <40% (HR: 2.16; 95% CI: 1.2–3.89; P = 0.01), and the summed stress score (SSS) of ≥4 (HR: 1.87; 95% CI: 1.02–3.41; P = 0.04) were independent predictors of all-cause death. The summed difference score (SDS) was the only independent predictor of MACE (HR: 1.26; 95% CI: 1.06–1.48; P = 0.034). Conclusions: The parameters of MPS were found to have prognostic value in the long-term period after CABG. Advanced age, previous myocardial infarction, decreased left ventricular ejection fraction, and the abnormal SSS were associated with an increased risk of all-cause death. The SDS was found to be the only significant risk factor for MACE.

Simultaneous nephrectomy and coronary artery bypass grafting through extended sternotomy

BackgroundThe advances in surgical techniques, resuscitation and anesthesiology support over the last years have allowed simultaneous thoracic and abdominal operations to be made for cancer and concomitant severe heart vessel disease relieving the patient from several diseases simultaneously and achieving long lasting remission or cure.Clinical caseA simultaneous nephrectomy and coronary artery bypass grafting procedure through extended sternotomy is reported. A 63-year-old man with severe coronary artery disease was found to have renal carcinoma.DiagnosisPostoperative pathological investigation of the tumor revealed the presence of renal cell carcinoma pT3a N0 M0, G2. Coronarography revealed advanced three-vessel coronary artery disease.TreatmentWe successfully performed a simultaneous curative surgery for renal carcinoma and coronary artery bypass graft surgery under cardiopulmonary bypass using a novel technique of extended sternotomy. Simultaneous surgery thus appears to be a beneficial and safe approach for the treatment of coronary artery disease and resectable renal cancer in carefully selected patients.

Doppler echocardiography during transesophageal atrial pacing in the detection of coronary artery disease: stress Doppler echocardiography in the detection of coronary artery disease

The aim of this study was to assess the applicability of the Doppler echocardiogram (EchoKG) during transesophageal atrial pacing (TAP) with respect to the detection of coronary artery disease (CAD). Aortic flow peak velocity (PV), mean acceleration (MA), stroke distance (SD), minute distance (MD) and time to PV were measured using pulsed Doppler EchoKG during sinus rhythm and at pacing rates of 120 and 140 bpm in 11 patients, taken as subjects, with CAD defined by coronary arteriography and 15 patients without CAD (the control group). Similar changes of PV, SD, MD and time to PV during TAP were observed in subjects with and without CAD. Only changes of MA were different between subjects with and without CAD:MA during TAP remained unchanged in the control group and decreased from 1055.2±49.7 cm/s2 (baseline) to 829.0±55.9 cm/s2 at a pacing rate 140 bpm (p<0.05) in subjects with CAD. On the basis of these data we suggest a new criterion for the detection of hemodynamically significant CAD: decrease of MA at a pacing rate of 140 bpm>15% of initial value. Its specificity and sensitivity in the detection of CAD were respectively 87% and 82%.We conclude that the Doppler EchoKG during TAP is a relatively simple and reliable method for the diagnosis of CAD, and that the response of the Doppler EchoKG parameter of MA to TAP is a sensitive and specific index, useful for the detection of significant coronary artery stenosis.