Background Postoperative bleeding is common after cardiac surgery. Major bleeding (MB) is a determinant of red blood cell (RBC) transfusion, especially in patients with preoperative anemia. ...Preoperative anemia and RBC transfusions are recognized risk factors for operative mortality. The present study investigates the role of MB as an independent determinant of operative mortality in cardiac surgery. Methods A single-center retrospective study based on the institutional database of cardiac surgery in the period 2000–2012 was conducted. Sixteen thousand one hundred fifty-four (16,154) consecutive adult patients undergoing cardiac surgery were analyzed. The impact of postoperative bleeding and MB on operative (30 days) mortality was analyzed univariately and after correction for preoperative anemia, RBC transfusions, and other confounders. Results Postoperative bleeding was significantly ( p < 0.001) associated with operative mortality, both in univariate and multivariable models. The main complications associated with MB were thromboembolic complications, infections, and surgical reexploration. In a multivariable model, MB remained an independent predictor of operative mortality (odds ratio, 3.45; 95% confidence interval, 2.78 to 4.28). Preoperative anemia and RBC transfusions coexist in the model, acting with a multiplying effect when associated with MB. Conclusions Major bleeding is per se a risk factor for operative mortality. However, its deleterious effects are strongly enhanced by RBC transfusions and, to a lesser extent, preoperative anemia. Major bleeding is a partially modifiable risk factor, and adequate preemptive and treatment strategies should be applied to limit this event.
Cardiac operations with cardiopulmonary bypass can be associated with postoperative lung dysfunction. The present study investigates the incidence of postoperative hypoxia after cardiac surgery, its ...relationship with the length of intensive care unit stay, and the role of body mass index in determining postoperative hypoxia and intensive care unit length of stay.
Single-center, retrospective study.
University Hospital. Patients. Adult patients (N = 5,023) who underwent cardiac surgery with CPB.
None.
According to the body mass index, patients were attributed to six classes, and obesity was defined as a body mass index >30. POH was defined as a PaO2/FiO2 ratio <200 at the arrival in the intensive care unit. Postoperative hypoxia was detected in 1,536 patients (30.6%). Obesity was an independent risk factor for postoperative hypoxia (odds ratio 2.4, 95% confidence interval 2.05-2.78, P = 0.001) and postoperative hypoxia was a determinant of intensive care unit length of stay. There is a significant inverse correlation between body mass index and PaO2/FiO2 ratio, with the risk of postoperative hypoxia increasing by 1.7 folds per each incremental body mass index class. The relationship between body mass index and intensive care unit length of stay is U-shaped, with longer intensive care unit stay in underweight patients and moderate-morbid obese patients.
Obese patients are at higher risk for postoperative hypoxia, but this leads to a prolonged intensive care unit stay only for moderate-morbid obese patients. Obese patients are partially protected against the deleterious effects of hemodilution and transfusions. Underweight patients present the "paradox" of a better lung gas exchange but a longer intensive care unit stay. This is probably due to a higher severity of their cardiac disease.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
OBJECTIVES
Different risk models have been introduced and refined in the past in order to improve standards of care. However, the predictive power of any risk algorithms can decline over time due to ...changes in surgical practice and the population's risk profile. The present study aimed to develop and validate a risk model for predicting operative mortality in patients with ischaemic heart failure (HF) undergoing surgical ventricular reconstruction (SVR).
METHODS
The study population included 525 patients with previous myocardial infarction and left ventricular remodelling referred to our centre for SVR. All patients underwent surgical reshaping; coronary artery bypass grafting was performed in 489 (93%) patients and mitral valve (MV) repair in 142 (27%). Operative mortality was defined as death within 30 days after surgery. All patients received an operative risk assessment using the logistic EuroSCORE and the ACEF score.
RESULTS
Better accuracy was achieved by the ACEF score (0.771) compared with the EuroSCORE (0.747). On multivariable logistic regression analysis, forcing the ACEF score in the model, three additional factors remained as independent predictors of operative mortality: atrial fibrillation, NYHA Class 3–4 and MV surgery (odds ratio 2.2, 2.6 and 2.1, respectively) and were computed in the ACEF-SVR. The ACEF-SVR score demonstrated an improved accuracy in respect of the ACEF score (from 0.771 to 0.792) and a better calibration (Hosmer–Lemeshow χ2 of 5.40, P = 0.714).
CONCLUSIONS
The ACEF-SVR score, starting from a simplified model of risk enabled improvement in the accuracy and calibration of the model, tailoring the risk to a specific population of patients with HF undergoing a specific surgical procedure.
Objectives Our objectives were (1) to report operative and long-term mortality in patients submitted to anterior surgical ventricular restoration, (2) to report changes in clinical and cardiac status ...induced by surgical ventricular restoration, and (3) to report predictors of death in a large cohort of patients operated on at San Donato Hospital, Milan, Italy. Methods A total of 1161 consecutive patients (83% men, 62 ± 10 years) had anterior surgical ventricular restoration with or without coronary artery bypass grafting and with or without mitral repair/replacement. A complete echocardiographic study was performed in 488 of 1161 patients operated on between January 1998 and October 2005 (study group). The indication for surgery was heart failure in 60% of patients, angina, and/or a combination of the two. Results Thirty-day cardiac mortality was 4.7% (55/1161) in the overall group and 4.9% (24/488) in the study group. Determinants of hospital mortality were mitral valve regurgitation and need for a mitral valve repair/replacement. Mitral regurgitation (>2+) associated with a New York Heart Association class greater than II and with diastolic dysfunction (early-to-late diastolic filling pressure >2) further increases mortality risk. Global systolic function improved postoperatively: ejection fraction improved from 33% ± 9% to 40% ± 10% ( P < .001); end-diastolic and end-systolic volumes decreased from 211 ± 73 to 142 ± 50 and 145 ± 64 to 88 ± 40 mL, respectively ( P < .001) early after surgery. New York Heart Association functional class improved from 2.7 ± 0.9 to 1.6 ± 0.7 ( P < .001) late after surgery. Long-term survival in the overall population was 63% at 120 months. Conclusions Surgical ventricular restoration for ischemic heart failure reduces ventricular volumes, improves cardiac function and functional status, carries an acceptable operative mortality, and results in good long-term survival. Predictors of operative mortality are mitral regurgitation of 2+ or more, New York Heart Association class greater than II, and diastolic dysfunction (early-to-late diastolic filling pressure >2).
Background Contrast media used for coronary angiography may result in a contrast-induced nephropathy. Acute kidney injury (AKI) is a common complication of cardiac surgery. It has been hypothesized ...that cardiac surgery in close succession to coronary angiography may increase the risk of postoperative AKI. However, data from the existing literature are conflicting. The aim of this study is to investigate the risk of AKI in patients undergoing angiography and cardiac surgery on the same day, and to assess the efficacy of a policy limiting this practice. Methods A total of 4,440 consecutive patients receiving coronary angiography and cardiac surgery at our institution were retrospectively analyzed. The AKI was defined as stage 1 or stage 2-3 according to the existing classification. Predictive models for AKI stage 1, stage 2-3, and any AKI were built, including various risk factors and the occurrence of surgery on the same day of angiography. Results Surgery on the day of angiography was an independent risk factor for AKI stage 2-3 (odds ratio 1.58, 95% confidence interval 1.04 to 2.40). An institutional policy limiting the practice of surgery on the same day of angiography (years 2009 to 2012) resulted in a significant ( p = 0.001) 30% decrease of AKI stage 1 and 42% decrease of any AKI with respect to patients operated in the years 2003 to 2008. Conclusions Acute kidney injury after cardiac surgery is a multifactorial event; surgery on the same day of angiography significantly increases the risk of AKI, and limiting this practice results in a containment of the postoperative AKI incidence.
Functional mitral regurgitation (MR) is frequently detected in patients with dilated cardiomyopathy and advanced heart failure, worsening quality of life and predicting poor survival. However, the ...optimal treatment of patients with advanced heart failure and severe MR has been controversial. We present the case of a 55-year-old man with previous aortic valve replacement, severe MR with high-grade pulmonary hypertension, and refractory heart failure (HF). He was listed for cardiac transplant and underwent percutaneous MitraClip implantation as bridge therapy. The postoperative course was uneventful, with significant improvement in New York Heart Association functional class. The patient underwent a successful heart transplant 8 months after the procedure.
Interleukin-15 (IL-15) is a pro-inflammatory cytokine which signals via a specific alpha receptor subunit (IL-15Rα). Increased IL-15 level has been observed in cardiovascular patients and IL-15 ...immunoreactivity has been detected at vulnerable atherosclerotic plaques. Due to the association between adipose tissue distribution, inflammation and coronary artery disease (CAD), we quantified IL-15 and IL-15Rα in CAD patients with different adiposity and adipose tissue distribution and we evaluated whether epicardial adipose tissue (EAT), a visceral fat depot surrounding and infiltrating myocardium, may be a source of both molecules. IL-15 and IL-15Rα proteins were quantified by enzyme-linked immunosorbent assays. Gene expression of IL-15 and IL-15Rα in EAT depots was evaluated by one colour microarray platform. EAT thickness was measured by echocardiography. Plasmatic IL-15 and IL-15Rα levels were higher in CAD than non-CAD patients. After classification according to adipose tissue distribution, IL-15 was higher in CAD patients with increased abdominal adiposity. Increased level of IL-15Rα was observed both in CAD and non-CAD patients with increased abdominal fat. EAT was a source of IL-15 and IL-15Rα and their expression was higher in CAD patients with increased EAT thickness. In conclusion, our data suggest that circulating levels of IL-15 and IL-15Rα seem to reflect visceral distribution of adipose tissue and that EAT may be a potential source of both IL-15 and IL-15Rα. Future studies on the relationship between IL-15, visceral fat and characteristics of atherosclerotic plaques could help to better understand the complex biology of this cytokine.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background Preoperative anemia and the lowest registered hematocrit value on cardiopulmonary bypass are recognized risk factors for morbidity and mortality after coronary operations. A low hematocrit ...often results in blood transfusions with all of the associated possible complications. The relative contribution of these three factors to long-term outcome is still not well established. This study aimed to identify the role of preoperative anemia and hemodilution during cardiopulmonary bypass as determinants of morbidity and mortality after coronary operations. Methods A consecutive series of 3,003 patients was analyzed. They had all undergone isolated coronary operations without receiving blood transfusions during their hospital stay. The preoperative hematocrit and the lowest hematocrit on cardiopulmonary bypass were analyzed in a multivariable model as predictors of major morbidity and operative mortality. Results After adjustment for the other explanatory variables, both the preoperative hematocrit and the lowest hematocrit on cardiopulmonary bypass were found to be independent risk factors for major morbidity, but not for operative mortality. However, low values of preoperative hematocrit were not associated with an increased morbidity, provided that the lowest hematocrit on cardiopulmonary bypass was maintained above 28%. Median values of the lowest hematocrit on cardiopulmonary bypass below 25% were associated with an increased major morbidity rate. Conclusions Excessive hemodilution during cardiopulmonary bypass is a risk factor for major morbidity even in the absence of blood transfusions. Techniques that aim to reduce the fall in hematocrit during cardiopulmonary bypass, including blood cardioplegia, may be useful, especially in patients with a low preoperative hematocrit.
Noncoding RNAs (ncRNAs), which include circular RNAs (circRNAs) and microRNAs (miRNAs), regulate the development of cardiovascular diseases (CVD). Notably, circRNAs can interact with miRNAs, ...influencing their specific mRNA targets' levels and shaping a competing endogenous RNAs (ceRNA) network. However, these interactions and their respective functions remain largely unexplored in ischemic heart failure (IHF). This study is aimed at identifying circRNA-centered ceRNA networks in non-end-stage IHF. Approximately 662 circRNA-miRNA-mRNA interactions were identified in the heart by combining state-of-the-art bioinformatics tools with experimental data. Importantly, KEGG terms of the enriched mRNA indicated CVD-related signaling pathways. A specific network centered on circBPTF was validated experimentally. The levels of let-7a-5p, miR-18a-3p, miR-146b-5p, and miR-196b-5p were enriched in circBPTF pull-down experiments, and circBPTF silencing inhibited the expression of
and
, which are targets of miR-196b-5p. Furthermore, as suggested by the enriched pathway terms of the circBPTF ceRNA network, circBPTF inhibition elicited endothelial cell cycle arrest. circBPTF expression increased in endothelial cells exposed to hypoxia, and its upregulation was confirmed in cardiac samples of 36 end-stage IHF patients compared to healthy controls. In conclusion, circRNAs act as miRNA sponges, regulating the functions of multiple mRNA targets, thus providing a novel vision of HF pathogenesis and laying the theoretical foundation for further experimental studies.
Background Nadir hematocrit on cardiopulmonary bypass (CPB) is a known risk factor for worse outcomes after cardiac surgery. Whether women, because of lower nadir hematocrit on CPB, are more prone to ...worse outcomes than men after cardiac surgery remains unknown. Methods We evaluated 13,734 patients (31.3% women) undergoing cardiac surgery (6/1/2001 to 06/30/2011) to study the association of hematocrit on CPB and gender with postoperative acute kidney injury (AKI) stage 2-3 (increase in creatinine at least twice the baseline), and operative mortality. Results Women were older (68 ± 12 vs 65 ± 12 years, p < 0.001), with more comorbidities. Baseline (37.4% ± 4.4% vs 39.8% ± 4.6%, p < 0.001) and nadir (24.5% ± 3.5% vs 27.4% ± 3.6%, p < 0.001) hematocrit were lower, whereas the hematocrit drop on CPB (baseline and nadir) was greater in women (12.9% ± 4.35 vs 12.4% ± 4.2%, p < 0.001). Observed AKI stage 2-3 and mortality rates were significantly higher in women than in men (5.8% vs 4.9%, p = 0.025 and 4.3% vs 3.4%, p = 0.009, respectively). While nadir hematocrit was inversely related to AKI stage 2-3 and death in both genders, the subgroup of patients with severe hemodilution (nadir hematocrit ≤ 22%) demonstrated a nonsignificant higher rate of AKI stage 2-3 in men (9.2% vs 7.8%) and a significant higher mortality in men (11% vs 7.6%) compared with women. Conclusions Both men and women undergoing cardiac surgery on CPB were prone to the deleterious effects of hemodilution on renal function and death. Yet, despite greater hemodilution, women had a lower relative risk of AKI and death than men at lower nadir hematocrit values on CPB suggesting better tolerance to hemodilution in women.
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