Wilko Reents

Effect of a Novel Free Radical Scavenger, Edaravone (MCI-186), on Acute Brain Infarction

Edaravone, a novel free radical scavenger, demonstrates neuroprotective effects by inhibiting vascular endothelial cell injury and ameliorating neuronal damage in ischemic brain models. The present study was undertaken to verify its therapeutic efficacy following acute ischemic stroke. We performed a multicenter, randomized, placebo-controlled, double-blind study on acute ischemic stroke patients commencing within 72 h of onset. Edaravone was infused at a dose of 30 mg, twice a day, for 14 days. At discharge within 3 months or at 3 months after onset, the functional outcome was evaluated using the modified Rankin Scale. Two hundred and fifty-two patients were initially enrolled. Of these, 125 were allocated to the edaravone group and 125 to the placebo group for analysis. Two patients were excluded because of subarachnoid hemorrhage and disseminated intravascular coagulation. A significant improvement in functional outcome was observed in the edaravone group as evaluated by the modified Rankin Scale (p = 0.0382). Edaravone represents a neuroprotective agent which is potentially useful for treating acute ischemic stroke, since it can exert significant effects on functional outcome as compared with placebo.

Simple, effective and safe vascular access site closure with the double‐ProGlide preclose technique in 162 patients receiving transfemoral transcatheter aortic valve implantation

Aim of this study was to analyze feasibility, efficacy, and safety of a double‐ProGlide preclose technique for access site closure after transfemoral transcatheter aortic valve implantation (TAVI).

Acute Kidney Injury After On-Pump or Off-Pump Coronary Artery Bypass Grafting in Elderly Patients

BACKGROUND An exploratory analysis of the German Off Pump Coronary Artery Bypass Grafting in Elderly Patients (GOPCABE) trial was performed to investigate the effect of off-pump coronary artery bypass grafting (CABG) on kidney function after the operation. METHODS Data on kidney function were available from 1,612 patients, representing 67% of the study population. Preoperative kidney function was graded according to the glomerular filtration rate. Acute kidney injury (AKI) within the first week after the operation was defined and classified according to the Acute Kidney Injury Network (AKIN) criteria. The incidence and severity of AKI was compared between patients operated on on-pump or off-pump. RESULTS Impaired kidney function was seen in 642 patients (40%), and 19 patients had preexisting end-stage kidney disease. AKI of any severity occurred in half of all patients undergoing CABG, with AKIN stage 1 accounting for most of the cases. The incidence and severity of AKI in patients undergoing on-pump vs off-pump CABG was AKIN stage 1: 298 (37%) vs 329 (42%); AKIN stage 2: 38 (5%) vs 43 (5%); and AKIN stage 3: 44 (6%) vs 44 (6%), which did not differ significantly (p=0.174). New renal replacement therapy was necessary in 3.2% (on-pump) and in 2.7% (off-pump) of all patients. Stratification according to preoperative kidney function yielded comparable frequencies of AKI for on-pump and off-pump CABG. CONCLUSIONS AKI was common in elderly patients undergoing CABG, but deterioration of kidney function requiring renal replacement therapy was a rare event. Off-pump CABG was not associated with decreased rates or reduced severity of AKI in elderly patients.

Concomitant coronary intervention is associated with poorer early and late clinical outcomes in selected elderly patients receiving transcatheter aortic valve implantation.

OBJECTIVES Significant coronary artery disease (CAD) is common among patients currently evaluated for transcatheter aortic valve implantation (TAVI). Limited data exist on the outcome of patients undergoing combined transcatheter treatment of aortic valve disease and CAD. The aim of the study was to analyse the impact of concomitant percutaneous coronary intervention (PCI) on early and late clinical outcomes of patients receiving TAVI. METHODS TAVIs were performed through either transfemoral or transapical access using SAPIEN (XT), CoreValve or AcurateTA valves. PCI was decided by the interdisciplinary heart team and performed synchronously or as a staged procedure upfront. Standardized valve academic research consortium (VARC)-2 endpoints were used. In case of a staged approach, TAVI was defined as the index procedure. Thirty-day outcomes and Kaplan-Meier 2-year survival were analysed. RESULTS Of 411 TAVIs, 65 (16%) received PCI. Mean age was 82 years (P = 0.92) and mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 21.7% (TAVI + PCI) and 20.3% (TAVI; P = 0.47). PCI was performed as staged procedure upfront (74%) or synchronously (26%). In 95% of PCIs, a single coronary artery was treated, and 71% received bare metal stents. Incidence of myocardial infarction (6 vs 1%; P = 0.01) and 30-day mortality (15 vs 5%; P = 0.01) were higher in the TAVI + PCI group, compared with the TAVI group. Synchronous (18%) vs staged (15%) approach for PCI had comparable early mortality (P = 1.0). Kaplan-Meier 2-year survival was poorer in the TAVI + PCI group (P = 0.03) with an odds ratio of 1.66 (P = 0.04). CONCLUSIONS Concomitant PCI is--when based on current heart team practice--associated with increased early and late mortality in selected elderly patients undergoing TAVI.

Emergency cardiac surgery during transfemoral and transapical transcatheter aortic valve implantation: Incidence, reasons, management, and outcome of 411 patients from a single center

Transcatheter aortic valve implantation (TAVI) is increasingly performed in high‐risk patients with severe aortic valve stenosis. Incidence and impact of emergency cardiac surgery (ECS) during TAVI is unclear.

Reduced Rate of Microembolism by Optimized Aortic Cannula Position Does Not Influence Early Postoperative Cognitive Performance in CABG Patients

Background and Purpose: The number of microemboli as measured by Doppler ultrasound during coronary artery bypass grafting (CABG) can be reduced by positioning the arterial cannula into the aorta descendens. The aim of this study was to prospectively evaluate whether this alternative aortic cannulation procedure leads to better neuropsychologic outcome early after surgery along with embolus reduction. Methods: Sixty patients with elective CABG were randomized to either using a short aorta ascendens cannula or an elongated cannula placed in the aorta descendens. All patients were tested by seven neuropsychologic tests preoperatively. Intraoperative embolus detection could be performed by transcranial Doppler in 32 patients. The neuropsychologic tests could be repeated serially until the 9th postoperative day in 54 patients. Patient groups did not differ in terms of preoperative psychometric performance and of the surgical characteristics except cannula positioning. All data were analyzed by a blinded assessor. Results: Neuropsychologic test scores showed in all individual patients a transient decline with subsequent recovery, but did not differ significantly between the groups except for the letter cancellation test at discharge favoring the patients with the longer cannula (102.3 ± 11.6 vs. 94.5 ± 11.5 mean ± SD; p = 0.025). In the subgroup who had Doppler sonography, neuropsychologic test scores did not differ between the groups. However, microembolic signals were markedly reduced in patients with the elongated cannula (median 174.5 vs. 413.0; p = 0.011). Conclusions: Though reducing brain microembolism, use of an elongated aortic cannula does not appear to influence overall cognitive performance early after CABG in this pilot study.

Preoperative atrial fibrillation and outcome in patients undergoing on-pump or off-pump coronary bypass surgery: lessons learned from the GOPCABE trial.

OBJECTIVES Patients undergoing coronary bypass grafting (CABG) are at higher risk if they suffer from atrial fibrillation (AF). It was suggested that performing CABG without the use of cardiopulmonary bypass (off-pump) would reduce perioperative risk. We assessed the influence of preoperative AF on outcome in a randomized cohort of patients above the age of 75 undergoing either on-pump or off-pump CABG. METHODS The German Off-Pump Coronary Artery Bypass grafting in the Elderly trial, a randomized, controlled multicentre trial conducted at 12 German institutions, enrolled 2303 patients between 2008 and 2011. The presence of AF was recorded at admission and discharge. There was no record on the rhythm status during hospital stay. RESULTS AF at admission was present in 5% in the on-pump (121/1158) and 5% in the off-pump (112/1145) group. The number of patients with AF at discharge was not different between these two groups (10% on pump, 10% off pump). As expected, AF patients had worse preoperative conditions, which had a negative impact on outcome: The combined end-point of death, infarction, stroke, dialysis and revascularization occurred more often (13 vs 8%, P = 0.008) and 30-day mortality was significantly higher (6 vs 2%, P = 0.003) in AF patients. However, the operative technique used for CABG did not affect these outcome parameters. CONCLUSIONS AF at admission is a significant risk factor for elderly patients undergoing coronary bypass grafting. However, this risk is not altered by performing bypass grafting off pump.

Off-pump or on-pump coronary-artery bypass grafting.

To the Editor: In the CABG Off or On Pump Revascularization Study (CORONARY) described by Lamy et al. (March 28 issue),1 the investigators used the approach of an expertise-based, randomized, controlled trial.2 The qualified surgeons were those with more than 2 years of experience after residency training who had completed more than 100 cases of the specific technique. Lamy and colleagues also emphasized that “trainees were not allowed to be the primary surgeon.” But the authors do not specify who harvested saphenous-vein grafts. In many centers, trainees are the primary surgeons for this procedure. Graft harvesting is an important part of the coronaryartery bypass grafting (CABG) operation. One study showed that rates of vein-graft failure were higher among patients with poor-quality grafts, and vein-graft failure was associated with repeat revascularization.3 Xiaoning Sun, M.D. Chunsheng Wang, M.D. Zhongshan Hospital Shanghai, China wang.chunsheng@zs-hospital.sh.cn No potential conflict of interest relevant to this letter was reported.

Ascending-to-descending bypass for simultaneous surgery of aortic coarctation with other cardiac pathologies.

BACKGROUND The appropriate approach for aortic coarctation associated with other cardiac diseases necessitating surgery is still controversial. The aim of this study was to evaluate the results after simultaneous surgery performed via median sternotomy and consisting of extra-anatomical ascending-to-descending aortic bypass and various other cardiac procedures. METHODS Between January 1999 and February 2009, 13 consecutive patients with aortic coarctation coexistent with other cardiac diseases necessitating surgery underwent simultaneous surgery via median sternotomy. An extra-anatomical ascending-to-descending aortic bypass for coarctation repair was performed in all patients accompanied by various cardiac procedures (5 aortic root and valve replacement; 2 aortic valve replacement; 2 coronary artery bypass grafting; 2 mitral valve repair; 1 aortic valve replacement and coronary artery bypass grafting; 1 mitral and tricuspid valve repair). There were 3 women and 10 men with a mean age of 52 years (range 25-69). Two patients had recurrent or residual coarctation 37 and 46 years after previous surgical repair, respectively. RESULTS Early mortality was 0 and there was only 1 late death during the follow-up of up to 11 years. New York Heart Association (NYHA) functional class improved on average from 2.4 to 1.2. At the last follow-up, blood pressure measured at the upper and lower extremities showed no gradient in any patient, indicating a durable function of the extra-anatomical bypass. Only 3 patients were on reduced antihypertensive therapy; 8 patients were on the same medication and 1 patient required increased medication therapy compared with the medication prior to surgery. CONCLUSIONS Ascending-to-descending bypass can be performed via median sternotomy simultaneously with various cardiac procedures without considerable extension of the procedure. The operative and long-term results are excellent, and this approach can be recommended as the procedure of choice in patients with aortic coarctation and additional cardiac diseases necessitating surgery.

False aneurysm with aortopulmonary shunt after replacement of the ascending aorta.

From the Departments of Cardiothoracic Surgery and Radiology, University Hospital Wurzburg, Wurzburg, Germany and the Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany. Disclosures: None. Received for publication Sept 22, 2008; accepted for publication Nov 19, 2008; available ahead of print Feb 9, 2009. Address for reprints: Wilko Reents, MD, Department of Cardiothoracic Surgery, University Hospital Wurzburg, Oberdurrbacher Strasse 6, 97080 Wurzburg, Germany. (E-mail: wilko.reents@herzchirurgie.de). J Thorac Cardiovasc Surg 2010;139:e62-3 0022-5223/