Umberto Benedetto

Surgical management of aortic root disease in Marfan syndrome: a systematic review and meta-analysis

Context Surgical treatment of aortic root aneurysm in Marfan syndrome (MFS) patients. Objective To compare results of total root replacement versus valve-sparing aortic root replacement in MFS patients. Data Sources PubMed, Embase and Cochrane library were searched from January 1966 until February 2010 looking for papers reporting on aortic root operations in MFS patients. 530 studies were retrieved. Study Selection Finally, 11 publications were enrolled. Inclusion criteria were observational studies reporting valve-related morbidity and mortality after total root replacement (TTR) and/or valve-sparing root replacement (VSRR) in patients with MFS and study size n≥30, reflecting the centres experience. Data Extraction Data obtained from papers reporting both TRR and VSRR cohorts were analysed separately. In case of multiple publications, the most recent and complete report was selected. If the total number of patient-years was not provided, we calculated it by multiplying the number of hospital survivors with the mean follow-up duration of that study. Results Overall, 1385 patients were analysed (972 patients had TTR and 413 patients had VSRR). Reintervention rate was 0.3%/year (95% CI 0.1 to 0.5) versus 1.3%/year (95% CI 0.3 to 2.2) (p=0.02) and thromboembolic events rate was 0.7%/year (95% CI 0.5 to 0.9) versus 0.3%/year (95% CI 0.1 to 0.6) (p=0.01) after TRR and VSRR, respectively. When composite valve-related events were compared, no difference existed between the two surgical strategies (p=0.41). Among patients undergoing VSRR, reimplantation was associated with a reduced rate of reintervention compared with remodelling (0.7%/year vs 2.4%/year, p=0.02). Conclusions VSRR may represent a valuable option for patients with MFS with aortic aneurysm. However, this technique should be used with caution in patients with valve characteristics at risk for decreased durability.

Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery

OBJECTIVEnProgression of functional tricuspid regurgitation is not uncommon after mitral valve surgery and is associated with poor outcomes. We tested the hypothesis that concomitant tricuspid valve annuloplasty in patients with tricuspid annulus dilatation (≥40 mm) prevents tricuspid regurgitation progression after mitral valve surgery.nnnMETHODSnWe enrolled 44 patients undergoing mitral valve surgery (both repair or replacement) showing less than moderate (≤+2) tricuspid regurgitation and dilated tricuspid annulus (≥40 mm) at preoperative echocardiography. They were randomized to receive (nxa0=xa022) or not receive (nxa0=xa022) concomitant tricuspid annuloplasty (Cosgrove-Edwards annuloplasty ring; Edwards Lifesciences, Irvine, Calif) at the time of mitral valve surgery. Clinical and echocardiographic follow-up was 100% completed at 12 months after surgery.nnnRESULTSnPreoperative clinical and echocardiographic characteristics were comparable in the 2 groups. Operative mortality was 4.4% (1 death in each group). At 12 months follow-up, tricuspid regurgitation was absent in 71% (nxa0=xa015) versus 19% (nxa0=xa04) of patients in the treatment and control groups, respectively (Pxa0=xa0.001). Moderate to severe tricuspid regurgitation (≥+3) was present in 0% versus 28% (nxa0=xa06) of patients in the treatment and control groups, respectively (Pxa0=xa0.02). Pulmonary artery systolic pressure significantly decreased from baseline in all cases (Pxa0<xa0.001) and was comparable in the 2 groups (41 ± 8 mm Hg vs 40 ± 5 mm Hg; Pxa0=xa0.4). Right ventricular reverse remodeling was marked in the treatment group (right ventricular long axis: 71 ± 7 mm vs 65 ± 8 mm; Pxa0=xa0.01; short axis: 33 ± 4 mm vs 27 ± 5 mm; Pxa0=xa0.001) but only minimal in the control group (right ventricular long axis: 72 ± 6 mm vs 70 ± 7 mm; Pxa0=xa0.08; short axis: 34 ± 5 mm vs 33 ± 5 mm; Pxa0=xa0.1). The 6-minute walk test improved from baseline in both groups (Pxa0<xa0.001), but this improvement was greater in the treatment group (+115 ± 23 m from baseline vs +75 ± 35 m; Pxa0=xa0.008).nnnCONCLUSIONSnProphylactic tricuspid valve annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery was associated with a reduced rate of tricuspid regurgitation progression, improved right ventricular remodeling, and better functional outcomes.

Preoperative Angiotensin-Converting Enzyme Inhibitors and Acute Kidney Injury After Coronary Artery Bypass Grafting

BACKGROUNDnAngiotensin-converting enzyme (ACE) inhibitors confer renal protection in different clinical settings. No final conclusions are available on the renal benefits of ACE inhibitors after coronary artery bypass grafting (CABG). Because ACE inhibitors decrease glomerular perfusion pressure, they may exacerbate kidney injury during cardiopulmonary bypass (CPB)-related hypoperfusion. We evaluated the effect of preoperative ACE inhibitors on acute kidney injury (AKI) after CABG.nnnMETHODSnA propensity score-based analysis of 536 patients undergoing CABG on CPB was performed, among which 281 received ACE inhibitors preoperatively. Patients with preoperative end-stage renal failure requiring dialysis were excluded. Postoperative AKI was defined as 50% or more decrease in the glomerular filtration rate from preoperative or postoperative mechanical renal support.nnnRESULTSnAfter CABG, AKI developed in 49 patients (9.1%), and 23 (4.2%) required dialysis. The incidence of AKI was 6.4% in patients who received preoperative ACE inhibitors and 12.2% in patients who did not (p = 0.02). The incidence of AKI requiring dialysis was 2.4% in the treatment group and 6.3% in controls (p = 0.03). After adjusting for propensity score and covariates, preoperative ACE inhibitors were found to reduce the incidence of postoperative AKI (odds ratio, 0.48; 95% confidence interval, 0.23 to 0.77; p = 0.04). Other independent predictors were age, preoperative glomerular filtration rate, left ventricular ejection fraction of less than 0.35, preoperative use of intraaortic balloon pump, emergency operation, and CPB time.nnnCONCLUSIONSnPreoperative ACE inhibitors are associated with a reduced rate of AKI after on-pump CABG surgery.

Coronary artery bypass grafting versus drug-eluting stents in multivessel coronary disease. A meta-analysis on 24,268 patients

OBJECTIVEnCoronary artery bypass grafting (CABG) has been shown to provide better results than percutaneous coronary intervention (PCI) in multivessel coronary disease. Drug-eluting stents (DES) have significantly improved results of PCI in terms of restenosis but the advantages of such a treatment compared to CABG remain uncertain. This meta-analysis summarizes available data from observational cohorts comparing DES-PCI versus CABG.nnnMETHODSnWe performed a systematic literature search for observational cohorts comparing CABG versus DES-PCI in patients with multivessel coronary disease. The mixed model method was used to obtain the pooled hazard ratio (HR) for outcomes of interest.nnnRESULTSnA total of nine observational nonrandomized studies were identified and analyzed including a total of 24,268 patients with multivessel coronary disease who underwent DES-PCI (n=13,540) and CABG (n=10,728). Mean follow-up time was 20 months. Pooled analysis showed that DES-PCI and CABG were comparable in terms of composite occurrence of death, acute myocardial infarction and cerebrovascular accidents (HR=0.94; 95% CI=0.72-1.22; p=0.66). However, there was a significantly higher risk of repeat revascularization in the DES-PCI group (HR=4.06; 95% CI=2.64-6.24; p<0.001). Overall major adverse cardiac and cerebrovascular events rate in the DES-PCI was higher compared to the CABG group (HR=1.86; 95% CI=1.36-2.54; p<0.001).nnnCONCLUSIONSnIn the real world clinical practice, overall major adverse cardiac and cerebrovascular events rate continues to be higher after DES-PCI due to an excess of redo revascularization compared with CABG.

Current results of open total arch replacement versus hybrid thoracic endovascular aortic repair for aortic arch aneurysm: A meta-analysis of comparative studies

For aortic arch aneurysm, conventional open total aortic arch replacement (OTAAR) has long been considered the standard therapy. Despite improvement of surgical technology and strategy, however, OTAAR remains a procedure associated with some morbidity and mortality, particularly among high-risk patients. In an attempt to reduce the complications associated with OTAAR, hybrid thoracic endovascular aortic repair (HTEAR), with aortic arch debranching end endovascular graft placement, has emerged as an attractive option for high-risk patients. Randomized controlled trial comparing the strategies are not available, however, and potential advantages of the hybrid strategy relative to the conventional procedure remain to be demonstrated. To gain insights into the role of the hybrid approach in the management of aortic arch aneurysm, we conducted a meta-analysis of available comparative studies.

Radial artery versus saphenous vein graft patency: Meta-analysis of randomized controlled trials

The excellent patency rate achieved with the internal thoracic artery in coronary artery bypass grafting (CABG) prompted cardiac surgeons to explore other arteries as second conduits instead of the saphenous vein graft (SVG). Initially described in 1973 by Carpentier and colleagues, the radial artery (RA) was soon abandoned as a bypass graft because reports documented dismal early angiographic outcomes. Because of improvements in graft-harvesting techniques and the use of postoperative calcium-channel blocker therapy to prevent early vasospasm, the RA is newly popular as a second conduit in association with the left internal thoracic artery. However, concerns about the high incidence of RA graft failure caused by a compromised flow state continue to be raised. Thus ongoing debate remains regarding the superiority of the RA as an aortocoronary conduit over the SVG, which continues to be widely used as a second conduit. Therefore, we conducted a meta-analysis on available randomized controlled trials (RCTs) to evaluate whether the RA is associated with a better patency rate when compared with the SVG as a second conduit in CABG.

Miniaturized Cardiopulmonary Bypass and Acute Kidney Injury in Coronary Artery Bypass Graft Surgery

BACKGROUNDnAcute kidney injury (AKI) is one of the most important complications after on-pump coronary artery bypass graft surgery (CABG). Miniaturized cardiopulmonary bypass (mini-CPB) systems have been developed to allow the ease of on-pump surgery but tempering the disadvantages. Whether mini-CPB reduces the incidence of AKI remains to be determined.nnnMETHODSnUsing a propensity score matched analysis, we investigated the occurrence of AKI among patients undergoing CABG on mini-CPB (n = 104) versus conventional CPB (n = 601). Acute kidney injury was defined according to the recent Acute Kidney Injury Network classification.nnnRESULTSnOverall, acute kidney injury developed in 274 of 705 patients (38.8%). A total of 27 of 705 patients (3.8%) required renal replacement therapy. The median postoperative length of intensive care unit stay in survivors with AKI was 5.4 (3.9 to 6.8) days compared with 2.0 (1.0 to 3.0) days for patients without AKI (p = 0.0002). The overall incidence of AKI for patients undergoing mini-CPB was 30 of 104 (28.8%) compared with 244 of 601 (40.5%) for patients undergoing conventional CPB (p = 0.03). In the propensity score matched-pair statistical analysis, mini-CPB was independently associated with a decreased incidence of AKI (adjusted odds ratio [OR] 0.61; 95% confidence interval [CI]: 0.38 to 0.97). Other variables independently associated with AKI were preoperative glomerular filtration rate (OR 0.988 for 1 mL.min(-1).1.73 m(-2) increase; 95% CI: 0.98 to 0.99), postoperative red blood cell transfusion (OR 1.58; 95% CI: 1.12 to 2.23); CPB time (OR 1.005 for 1-minute increase; 95% CI: 1.0 to 1.009), and postoperative low output syndrome (OR 1.72; 95% CI: 1.23 to 2.41).nnnCONCLUSIONSnThe present study showed that mini-CPB is associated with a lower incidence of AKI when compared with conventional CPB among patients undergoing CABG.

Is minimized extracorporeal circulation effective to reduce the need for red blood cell transfusion in coronary artery bypass grafting? Meta-analysis of randomized controlled trials

DISCUSSION The patient described had parietal pericardial bovine bioprostheses in both the mitral and aortic valve positions for 77 months and during that period developed huge quantities of calcium on the cusps of the bioprosthesis in the aortic valve position and only small quantities of calcium on the cusps of the bioprosthesis in the mitral valve position. Because the closing pressure on the mitral bioprosthesis is usually about a third higher than that on the aortic bioprosthesis (peak left ventricular systolic pressure vs end-diastolic aortic pressure; normally approximately 120 vs 80 mm Hg), it might be expected that the degeneration of a bioprosthesis in the mitral position would be greater (more calcium and more tears) and more rapid than that of a bioprosthesis in the aortic position, but the opposite was the case in the patient described herein. Why might that be the case? Some possibilities include the following:

Acute kidney injury after coronary artery bypass grafting: Does rhabdomyolysis play a role?

OBJECTIVEnIn clinical situations in which rhabdomyolysis is common, renal dysfunction association with myoglobinemia is well described. After coronary artery bypass grafting, a rapid increase in serum myoglobin concentration is generally seen, but whether it might independently increase the risk of acute kidney injury remains to be determined.nnnMETHODSnThe study population consisted of 731 consecutive patients undergoing coronary artery bypass grafting. Creatine kinase, myoglobin, and creatinine concentrations were assessed in each patient preoperatively and postoperatively. Acute kidney injury was defined as an absolute increase in serum creatinine concentration of 0.3 mg/dL or greater.nnnRESULTSnOverall, 295 (40.3%) of 731 patients had acute kidney injury. Patients risk profiles were significantly worse in those with acute kidney injury, and 31 (4.2%) of 731 patients required dialysis. Acute kidney injury was associated with a higher increase in serum myoglobin concentration after 1 hour from aortic declamping (534 microg/mL [interquantile range, 354-733 microg/mL] vs 377 microg/mL [interquantile range, 278-528 microg/mL], P < .0001), which persisted at 24 and at 48 hours. After adjusting for confounding factors, myoglobin concentration was found to independently predict postoperative acute kidney injury (odds ratio, 1.0011 [1 microg/mL increase]; 95% confidence interval, 1.0003-1.0019; P = .005), and this result persisted when patients with perioperative myocardial infarction were excluded from the analysis (odds ratio, 1.0007; 95% confidence interval, 1.0002-1.0009; P = .01). Myoglobin concentration had a better accuracy to discriminate patients having acute kidney injury than creatine kinase concentration at any time.nnnCONCLUSIONSnAn increase in laboratory findings of muscle injury postoperatively, especially serum myoglobin concentration, predicts the incidence of acute kidney injury and renal replacement therapy requirement, as reported in other surgical settings. Perioperative myocardial injury cannot totally explain the occurrence of increased myoglobinemia. These results suggest an important role of skeletal muscle breakdown and necrosis in determining an increased myoglobinemia concentration after coronary artery bypass grafting.

Metabolic Syndrome Affects Midterm Outcome After Coronary Artery Bypass Grafting

BACKGROUNDnMetabolic syndrome (MetS) is frequently associated with coronary artery disease, but data on the impact of MetS on long-term outcome of patients undergoing coronary artery bypass grafting are still lacking. The aim of the present study was to assess the effect of MetS on mortality and morbidity late after coronary artery bypass grafting.nnnMETHODSnA total of 1,726 consecutive patients who had elective coronary artery bypass grafting were retrospectively reviewed and clinical follow-up was completed (mean follow-up time, 34.4 months; range, 6 to 79 months). The MetS was diagnosed using the modified Adult Treatment Panel III criteria, and to eliminate covariate differences, a propensity score adjustment was used. Major adverse cerebral and cardiovascular events were investigated, and C-reactive protein levels were assessed both preoperatively, postoperatively, and at follow-up.nnnRESULTSnA total of 798 of 1,726 patients (46.2%) met the diagnostic criteria for MetS. At follow-up, all-cause mortality (7% versus 4.6%; p=0.04), cardiac arrhythmias (35.3% versus 25.2%; p<0.0001), renal failure (12% versus 8.7%; p=0.03), and major adverse cerebral and cardiovascular events (52.4% versus 39.5%; p<0.0001) showed a significantly higher incidence in MetS patients. Variables correlated with late mortality at propensity-adjusted Cox proportional-hazards regression were age (p=0.0008), preoperative left ventricular ejection fraction (p=0.001), preoperative renal failure (p=0.001), and MetS (p=0.006). Higher C-reactive protein levels were found preoperatively (8.6±2.3 versus 5.14±3.1 mg/L; p<0.0001) and both early (71.2±9 versus 49.6±8.7 mg/L; p<0.0001) and late (7.4±2.7 versus 4.8±2.5 mg/L; p<0.0001) after surgery.nnnCONCLUSIONSnThe main finding of our study was the association between MetS and mortality both early and late after coronary artery bypass grafting. Thus, MetS should be recognized as an independent preoperative variable that can lead to the identification of high-risk patients and as a risk factor to correct with lifestyle modifications and pharmacologic therapy.