Elderly patients were randomly assigned to CABG with cardiopulmonary bypass (on-pump CABG) or without it (off-pump CABG). At 30 days and at 1 year, there was no significant difference in the ...composite outcome of death, stroke, MI, repeat revascularization, or new renal-replacement therapy.
There is an ongoing debate about the benefits and shortcomings of coronary-artery bypass grafting (CABG) without cardiopulmonary bypass (off-pump CABG). Cardiopulmonary bypass can have detrimental effects.
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Initial trials have shown that off-pump CABG is feasible in selected low-risk patients and offers results similar to those of CABG performed with the conventional on-pump technique (on-pump CABG). In institutions with experience in off-pump CABG, the rate of major adverse events and the rates of complete revascularization and graft patency have been similar to those with on-pump CABG.
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These positive results have been called into question by reports of inferior graft . . .
Objectives
We present 1‐year outcomes of the post‐market registry of a next‐generation transcatheter heart valve used for aortic regurgitation (AR).
Background
Transcatheter aortic valve replacement ...(TAVR) is routine in high‐risk patients with aortic stenosis but is not recommended for AR. The JenaValve™ (JenaValve Technology GmbH, Munich, Germany) overcomes technical challenges in AR patients through a leaflet clipping mechanism.
Methods
The JenaValve EvalUation of Long Term Performance and Safety In PaTients with SEvere Aortic Stenosis oR Aortic Insufficiency (JUPITER) Registry is a European study to evaluate safety and effectiveness of this THV. From 2012‐2015, 30 patients with AR were enrolled.
Results
Mean age was 74.4 ± 9.3 years. Procedural success was 96.7% (29/30). One patient was converted to open surgery. No annular rupture or coronary ostia obstruction occurred. Mortality at 30 days was 10.0% (3/30). Combined safety endpoint was met in 13.3% (4/30). Paravalvular regurgitation was not present/trivial in 84.6% (22/26) and mild in 15.4% (4/26). Rate of permanent pacemaker implantation was 3.8% (1/26). One‐year Kaplan‐Meier survival was 79.9%, one‐year combined efficacy was 73.1% (19/30). No further strokes were observed during 1 year of follow‐up.
Conclusions
The JenaValve overcomes technical challenges of TAVR in AR through a clipping mechanism. We report satisfactory outcomes of a multicenter registry using the JenaValve for predominant AR, as rate of THV embolization, residual AR and permanent pacemaker implantation was low. One‐year results using the JenaValve for AR encourage its use for this indication.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Abstract
OBJECTIVES
The pathophysiology of delirium after cardiac surgery is complex. The present study aims to determine perioperative risk factors and construct a scoring system for postoperative ...delirium based on the type of surgery.
METHODS
Three hundred patients undergoing coronary artery bypass grafting (CABG; n = 150) or valve and/or aortic surgery ± CABG (n = 150) were retrospectively evaluated.
RESULTS
The incidence of delirium (32%) was similar in subgroups (28.7% and 33.33%, P = 0.384). Delirium patients were older 71.3 (standard deviation: 8.5) vs 66.6 (standard deviation: 9.5), P < 0.001; 70.0 (standard deviation: 9.6) vs 62.5 (standard deviation: 12.6), P < 0.001 and required more packed red blood cell units 2.1 (standard deviation: 2.1) vs 4.2 (standard deviation: 4.0), P < 0.001; 2.4 (standard deviation: 3.3) vs 5.4 (standard deviation: 5.9), P < 0.001 and fresh frozen plasma units 6.1 (standard deviation: 2.9) vs. 8.0 (standard deviation: 4.2), P < 0.001; 6.3 (standard deviation: 3.4) vs 10.8 (standard deviation: 7.2), P < 0.001 in CABG and valve/aortic subgroups, respectively. Delirium was associated with longer operation time 298.3 (standard deviation: 98.4) vs 250.6 (standard deviation: 67.8) min, P < 0.001, cardiopulmonary bypass (CPB) time 171.5 (standard deviation: 54.9) vs 140.98 (standard deviation: 45.8) min, P < 0.001 and cardiac arrest time 112 (standard deviation: 35.9) vs 91.9 (standard deviation: 28.6), P < 0.001 only in the valve/aortic group (versus non-delirium). Multivariate regression analysis identified an association between delirium and age odds ratio: 1.056 (95% confidence interval: 1.002–1.113), P = 0.041, CPB time odds ratio: 1.1014 (95% confidence interval: 1.004–1.025), P = 0.007, fresh frozen plasma transfusion odds ratio: 1.127 (95% confidence interval: 1.006–1.262), P = 0.039 and atrial fibrillation odds ratio: 4.801 (95% confidence interval: 1.844–12.502), P < 0.001 after valve/aortic surgery (area under the curve 0.835, P < 0.001) and between delirium and age odds ratio: 1.089 (95% confidence interval: 1.023–1.160), P = 0.007 and ventilation time odds ratio: 1.068 (95% confidence interval: 1.026–1.113), P = 0.001 after isolated CABG (area under the curve 0.798, P < 0.001). The cross-validation of the results by k-fold logistic regression revealed for the entire patient cohort an overall average accuracy of the prediction model of 0.764, with a false-positive rate of 0.052 and a false-negative rate of 0.18.
CONCLUSIONS
Age, CPB time, ventilation, transfusion and atrial fibrillation are differently associated with delirium depending on the operative characteristics. Optimization of intraoperative parameters and use of risk calculators may enable early institution of pharmacotherapy and improve overall outcome after cardiac surgery.
Delirium is an acute fluctuating disturbance in attention and awareness accompanied by disorganized cognition or perception that is not due to a pre-existing neurocognitive disorder or to coma 1.
Protamine sulfate (PS) is widely used in heart surgery as an antidote for heparin, albeit its pharmacological effects are not fully understood and applications are often accompanied by unwanted side ...effects. Here we show the effect of PS on mitochondrial bioenergetics profile resulting in mitochondrial reactive oxygen species (ROS) production. Polarographic measurements were performed in parallel to membrane potential and ROS measurements by FACS analyzer using tetramethylrhodamine ethyl ester and MitoSOX fluorescent dyes, respectively. PS inhibited intact rat heart mitochondrial respiration (stimulated by ADP) to 76% (
< 0.001) from the baseline of 51.6 ± 6.9 to 12.4 ± 2.3 nmol O
⋅min
⋅ml
The same effect was found when respiration was inhibited by antimycin A (101.0 ± 8.9 vs. 38.0 ± 9.9 nmol O
⋅min
⋅ml
,
< 0.001) and later stimulated by substrates of cytochrome oxidase (CytOx) i.e., ascorbate and tetramethyl phenylene diamine, suggesting that PS exerted its effect through inhibition of CytOx activity. Furthermore, the inhibition of mitochondrial respiration by PS was concentration dependent and accompanied by hyperpolarization of the mitochondrial membrane potential (Δ
), i.e., 18% increase at 50
g/ml and an additional 3.3% increase at 250
g/ml PS compared with control. This effect was associated with a strong consequent increase in the production of ROS, i.e., 85% and 88.6% compared with control respectively. We propose that this excessive increase in ROS concentrations results in mitochondrial dysfunction and thus might relate to the "protamine reaction," contributing to the development of various cardiovascular adverse effects.
Objective Adult postcardiotomy cardiogenic shock potentially requiring mechanical circulatory support occurs in 0.5% to 1.5% of cases. Risk factors influencing early or long-term outcome after ...extracorporeal membrane oxygenation implantation are not well described. Methods Between May 1996 and May 2008, 517 adult patients received extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock. Procedures were isolated coronary artery bypass grafting (37.4%), isolated valve surgery (14.3%), coronary artery bypass grafting plus valve surgery (16.8%), thoracic organ transplantion (6.5%), and other combinations (25.0%). Fifty-four preoperative and 42 procedural risk factors concerning in-hospital mortality were evaluated by logistic regression analyses. Results Mean age was 63.5 years, 71.5% were male, ejection fraction was 45.9% ± 17.6%, logistic EuroSCORE was 21.6% ± 20.7%. Extracorporeal membrane oxygenation was established through thoracic (60.8%) or extrathoracic (39.2%) cannulation. Extracorporeal membrane oxygenation support was 3.28 ± 2.85 days. Intra-aortic balloon pumps were implanted in 74.1%. Weaning from extracorporeal membrane oxygenation was successful for 63.3%, and 24.8% were discharged. Cerebrovascular events occurred in 17.4%, gastrointestinal complications in 18.8%, and renal replacement therapy in 65.0%. Risk factors for hospital mortality were age older than 70 years (odds ratio, 1.6), diabetes (odds ratio, 2.5), preoperative renal insufficiency (odds ratio, 2.1), obesity (odds ratio, 1.8), logistic EuroSCORE greater than 20% (odds ratio, 1.8), operative lactate greater than 4 mmol/L (odds ratio, 2.2). Isolated coronary artery bypass grafting (odds ratio, 0.44) was protective. Cumulative survivals were 17.6% after 6 months, 16.5% after 1 year, and 13.7% after 5 years. Conclusions Extracorporeal membrane oxygenation support is an acceptable option for patients with postcardiotomy cardiogenic shock who otherwise would die and is justified by good long-term outcome of hospital survivors. Because of high morbidity and mortality, extracorporeal membrane oxygenation must be decided by individual risk profile.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Sleep disordered breathing (SDB) is common in patients with coronary disease, but its impact on post-operative recovery after coronary artery bypass graft surgery (CABG) is unclear. We therefore ...determined the effects of SDB on post-operative outcome after elective CABG.In this prospective two-centre study, 219 patients due to receive elective CABG underwent cardiorespiratory polygraphy for SDB prior to surgery and were monitored for post-operative complications. The primary end-point was a composite of 30-day mortality or major post-operative complications (cardiac, respiratory, surgical, infectious, acute renal failure or stroke). Key secondary end-points were single components of the primary end-point.SDB was present in 69% and moderate/severe SDB in 43% of the CABG patients. There was no difference in the composite of 30-day mortality or major postoperative complications between patients with and without SDB (OR 0.97, 95% CI 0.49-1.96) and between patients with moderate/severe SDB and no/mild SDB (OR 1.07, 95% CI 0.55-2.06). However, moderate/severe SDB was associated with higher rates of mortality (crude OR 10.1, 95% CI 1.22-83.5), sepsis (OR 2.96, 95% CI 1.17-7.50) and respiratory complications (OR 2.85, 95% CI 1.46-5.55).Although SDB was not associated with higher overall morbidity/mortality, moderate/severe SDB may increase the risk of death, and septic and respiratory complications, after elective CABG.
Objective SYNTAX study compares outcomes of coronary artery bypass grafting with percutaneous coronary intervention in patients with 3-vessel and/or left main disease. Complexity of coronary artery ...disease was quantified by the SYNTAX score, which combines anatomic characteristics of each significant lesion. This study aims to clarify whether SYNTAX score affects the outcome of bypass grafting as defined by major adverse cerebrovascular and cardiac events (MACCE) and its components over a 2-year follow-up period. Methods Of the 3075 patients enrolled in SYNTAX, 1541 underwent coronary artery bypass grafting (897 randomized controlled trial patients, and 644 registry patients). All patients undergoing bypass grafting were stratified according to their SYNTAX score into 3 tertiles: low (0–22), intermediate (22–32), and high (≥33) complexity. Clinical outcomes up to 2 years after allocation were determined for each group and further risk factor analysis was performed. Results Registry patients had more complex disease than those in the randomized controlled trial (SYNTAX score: registry 37.8 ± 13.3 vs randomized 29.1 ± 11.4; P < .001). At 30 days, overall coronary bypass mortality was 0.9% (registry 0.6% vs randomized 1.2%). MACCE rate at 30 days was 4.4% (registry 3.4% vs randomized 5.2%). SYNTAX score did not significantly affect overall 2-year MACCE rate of 15.6% for low, 14.3% for medium, and 15.4% for high SYNTAX scores. Compared with randomized patients, registry patients had a lower rate of overall MACCE rate (registry 13.0% vs randomized 16.7%; P = .046) and repeat revascularization (4.7% vs 8.6%; P = .003), whereas other event rates were comparable. Risk factor analysis revealed left main disease ( P = .049) and incomplete revascularization ( P = .005) as predictive for adverse 2-year outcomes. Conclusions The outcome of coronary artery bypass grafting was excellent and independent from the SYNTAX score. Incomplete revascularization rather than degree of coronary complexity adversely affects late outcomes of coronary bypass.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
Acute kidney injury (AKI) is a frequent complication associated with on‐pump cardiac surgery. Early recognition may alter their prognosis. Therefore, the urinary concentrations of TIMP‐2 ...(tissue inhibitor of metalloproteinases‐2) and IGFBP7 (insulin‐like growth factor‐binding protein) as predictors for AKI were studied.
Methods
Repetitive blood and urine samples were collected consecutively from 50 patients. Demographic, intra‐, and postoperative data were recorded prospectively. To calculate the production of the TIMP‐2 and IGFBP‐7 protein concentrations, urinary samples were taken preoperatively, intraoperatively at 30 and 60 min after aortic clamping and at 0, 6, 12, and 24 h after admission to the intensive care unit (ICU).
Results
AKI occurred in 14 patients (28%), all of them at Kidney Disease: Improving Global Outcomes stage 1. Predictive value for TIMP‐2 × IGFBP7 was shown at 0 and 24 h after admission to ICU. At 0 h, the sensitivity was 84.6% and the specificity 55.6% for an ideal calculated cutoff at 0.07. After 24 h, the ideal cutoff amounted to 0.35 with a sensitivity of 53.8% and a specificity of 88.2%. The receiver operating characteristic curves demonstrated areas under the curve of 0.725 and 0.718. The suggested cutoffs of 0.3 and 2.0 could not be confirmed. The serum creatinine was reached to the peak median within 48 h after admission to ICU.
Conclusion
Postoperative risk assessment for the development of AKI can be established by TIMP−2×IGFBP7. Previously suggested cutoff values could not be confirmed. A correlation with urinary dilution parameters may enable the identification of more universal cutoffs.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
We evaluated the feasibility of hybrid percutaneous coronary intervention (PCI) and minimally invasive mitral valve surgery (MIMVS) in patients with concomitant coronary and mitral disease. Of 534 ...patients who underwent MIMVS at our institution between 2012 and 2018, those with combined mitral and single vessel coronary pathologies who underwent MIMVS and PCI were included. Patients were excluded if they had endocarditis or required emergency procedures. Preprocedural, procedural, and postprocedural data were retrospectively analyzed. In total, 10 patients (median age, 75 years; 7 males) with a median ejection fraction (EF) of 60% were included. Nine patients underwent PCI before and one after MIMVS. The success rate was 100% in both procedures. There were no postoperative myocardial infarctions or strokes. Two patients developed delirium and one required re-thoracotomy for bleeding. The median stay in intensive care and the hospital was 3 and 8 days, respectively. The 30-day survival rate was 100%. A hybrid PCI and MIMVS approach is feasible in patients with mitral valve and single vessel coronary disease. In combined pathologies, the revascularization strategy should be evaluated independent from the mitral valve pathology in the presence of MIMVS expertise. Extension of this recommendation to multivessel disease should be evaluated in future studies.
Friedrich Wilhelm Mohr from the very beginning of his career as a cardiac surgeon was involved in the refinements of coronary artery bypass grafting (CABG). At the Leipzig Heart Center, his spirit of ...early adapting to new technologies inspired the entire team and led to a matchless scientific atmosphere to find solutions to improve almost all fields of cardiac surgery, including CABG. In combination with a tremendous number of patients with indications for isolated coronary artery bypass Prof. Mohr as the surgical principle investigator and the Leipzig Heart Center were able to include patients in the Synergy between PCI percutaneous coronary intervention with Taxus and Cardiac Surgery (SYNTAX) trial, the first randomized trials comparing CABG and PCIs using the drug-eluting stents. Final SYNTAX results after 5 years gave direction and scientific evidence for contemporary European revascularization guidelines. These guidelines recommend PCI as an alternative first-line treatment option in patients with coronary three-vessel disease and left main stenosis having low coronary complexity based on the angiographic SYNTAX score. However, the study demonstrated the significant superiority of CABG over PCI in all other patients, especially in these with complex three-vessel disease. The specific characteristic of the SYNTAX study is that the distinguished results were confirmed by several post-SYNTAX comparative randomized trials on coronary revascularization including left main disease and clinical registries even when contemporary drug-eluting stent designs were used. When performing CABG the question of the best second graft remains unclear. While several mono-institutional reports and large meta-analyses demonstrated clear superiority in terms of long-term survival when using bilateral mammary versus single mammary revascularization, this benefit could not be confirmed in randomized trials after 5 years.
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