We aimed to evaluate the association between levosimendan treatment and acute kidney injury (AKI) as well as assess the clinical sequelae of AKI in cardiac surgery patients with depressed left ...ventricular function (ejection fraction <35%).
Patients in the LEVO-CTS trial undergoing on-pump coronary artery bypass grafting (CABG), valve, or CABG/valve surgery were stratified by occurrence and severity of postoperative AKI using the AKIN classification. The association between levosimendan infusion and AKI was modeled using multivariable regression.
Among 854 LEVO-CTS patients, 231 (27.0%) experienced postoperative AKI, including 182 (21.3%) with stage 1, 35 (4.1%) with stage 2, and 14 (1.6%) with stage 3 AKI. The rate of AKI was similar between patients receiving levosimendan or placebo. The odds of 30-day mortality significantly increased by AKI stage compared to those without AKI (stage 1: adjusted odds ratio aOR 2.0, 95% confidence interval CI 0.8-4.9; stage 2: aOR 9.1, 95% CI 3.2-25.7; stage 3: aOR 12.4, 95% CI 3.0-50.4). No association was observed between levosimendan, AKI stage, and odds of 30-day mortality (interaction P = .69). Factors independently associated with AKI included increasing age, body mass index, diabetes, and increasing baseline systolic blood pressure. Increasing baseline eGFR and aldosterone antagonist use were associated with a lower risk of AKI.
Postoperative AKI is common among high-risk patients undergoing cardiac surgery and associated with significantly increased risk of 30-day death or dialysis. Levosimendan was not associated with the risk of AKI.
Background The efficacy of coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) in patients with coronary artery disease has been well defined by randomized ...controlled trials. However, patients with severe left ventricular dysfunction (ejection fraction <35%) were underrepresented in these trials, and management of these complex patients remains unclear. The purpose of this study was to compare the outcomes of patients with coronary artery disease and left ventricular dysfunction undergoing CABG versus PCI. Methods The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH), a clinical data collection and outcome monitoring initiative for the province of Alberta, Canada, was used to identify 2925 patients with coronary artery disease and left ventricular dysfunction undergoing CABG (n = 1,326) or PCI (n = 1,599) between 1995 and 2008. Patients were propensity matched to obtain comparable subgroups among left ventricular dysfunction patients. Results Cox proportional hazard analysis of the propensity-matched subgroups identified that CABG was significantly associated with lower rates of repeat revascularization and better survival compared with PCI at 1, 5, 10, and 15 years. Other significant independent predictors of poor long-term survival included age, renal failure, heart failure, diabetes mellitus, peripheral vascular disease, prior myocardial infarction, left main coronary artery disease, and prior CABG. Conclusions For patients with coronary artery disease and left ventricular dysfunction, CABG was associated with lower rates of repeat revascularization and improved survival over PCI, after adjustment for baseline risk profile differences. Further research exploring the factors leading to use of a particular revascularization modality in this patient population is required.
Our aim was to address the role of autologous mesenchymal stem cell recellularization of xenogenic valves on the activation of the xenoreactive immune response in an in vivo rat model.
Explanted ...aortic valve constructs from female Hartley guinea pigs were procured and decellularized, followed by recellularization with autologous Sprague-Dawley rat mesenchymal stem cells. Aortic valve xenografts were then implanted into the infrarenal aorta of recipient rats. Grafts were implanted as either autologous grafts, non-decellularized (NGP), decellularized and recellularized xenografts (RGP). Rats were euthanized after 7 and 21 days and exsanguinated and the grafts were explanted.
The NGP grafts demonstrated significant burden of granulocytes (14.3 cells/HPF) and CD3+ T cells (3.9 cells/HPF) compared to the autologous grafts (2.1 granulocytes/HPF and 0.72 CD3+ T cells/HPF) after 7 days. A lower absolute number of infiltrating granulocytes (NGP vs autologous, 6.4 vs 2.4 cells/HPF) and CD3+ T cells (NGP vs autologous, 2.8 vs 0.8 cells/HPF) was seen after 21 days. Equivalent granulocyte cell infiltration in the RGP grafts (2.4 cells/HPF) compared to the autologous grafts (2.1 cells/HPF) after 7 and 21 days (2.8 vs 2.4 cells/HPF) was observed. Equivalent CD3+ T-cell infiltration in the RGP grafts (0.63 cells/HPF) compared to the autologous grafts (0.72 cells/HPF) after 7 and 21 days (0.7 vs 0.8 cells/HPF) was observed. Immunoglobulin production was significantly greater in the NGP grafts compared to the autologous grafts at 7 (123.3 vs 52.7 mg/mL) and 21 days (93.3 vs 71.6 mg/mL), with a similar decreasing trend in absolute production. Equivalent immunoglobulin production was observed in the RGP grafts compared to the autologous grafts at 7 (40.8 vs 52.7 mg/mL) and 21 days (29.5 vs 71.6 mg/mL).
Autologous mesenchymal stem cell recellularization of xenogenic valves reduces the xenoreactive immune response in an in vivo rat model and may be an effective approach to decrease the progression of xenograft valve dysfunction.
Coronary artery disease (CAD) is common in candidates for lung transplantation (LTx) and has historically been considered a relative contraindication to transplantation. We look to review the ...outcomes of LTx in patients with CAD and determine the optimum revascularization strategy in LTx candidates. PubMed, Medline and Web of Science were systematically searched by three authors for articles comparing the outcomes of LTx in patients with CAD and receiving coronary revascularization. In total 1668 articles were screened and 12 were included in this review.Preexisting CAD in LTx recipients was not associated with significantly increased postoperative morbidity or mortality. The pooled estimates of mortality rate at 1, 3 and 5 years indicated significantly inferior survival in LTx recipients with a prior history of coronary artery bypass grafting (CABG) odds ratio (OR), 1.84; 95% confidence interval (CI), 1.53-2.22; P < 0.00001; I2 = 0%; OR, 1.52; 95% CI, 1.21-1.91; P = 0.0003; I2 = 0%; OR, 1.62; 95% CI, 1.13-2.33; P = 0.008; I2 = 71%, respectively). However, contemporary literature suggests that survival rates in LTx recipients with CAD that received revascularization either by percutaneous coronary intervention (PCI), previous or concomitant CABG, are similar to patients who did not receive revascularization. Trends in postoperative morbidity favored CABG in the rates of myocardial infarction and repeat revascularization, whereas rates of stroke favored PCI. The composite results of this study support the consideration of patients with CAD or previous coronary revascularization for LTx. Prospective, randomized controlled trials with consistent patient populations and outcomes reporting are required to fully elucidate the optimum revascularization strategy in LTx candidates.
Acute kidney injury (AKI) is a serious complication following lung transplantation (LTx). We aimed to describe the incidence and outcomes associated with AKI following LTx.
A retrospective ...population-based cohort study of all adult recipients of LTx at the University of Alberta between 1990 and 2011. The primary outcome was AKI, defined and classified according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, in the first 7 post-operative days. Secondary outcomes included risk factors, utilization of renal replacement therapy (RRT), occurrence of post-operative complications, mortality and kidney recovery.
Of 445 LTx recipients included, AKI occurred in 306 (68.8%), with severity classified as Stage I in 38.9% (n = 173), Stage II in 17.5% (n = 78) and Stage III in 12.4% (n = 55). RRT was received by 36 (8.1%). Factors associated with AKI included longer duration of cardiopulmonary bypass per minute, odds ratio (OR) 1.003; 95% confidence interval (CI), 1.001-1.006; P = 0.02, and mechanical ventilation per hour (log-transformed), OR 5.30; 95% CI, 3.04-9.24; P < 0.001, and use of cyclosporine (OR 2.03; 95% CI, 1.13-3.64; P = 0.02). In-hospital and 1-year mortality were significantly higher in those with AKI compared with no AKI (7.2 versus 0%; adjusted P = 0.001; 14.4 versus 5.0%; adjusted P = 0.02, respectively). At 3 months, those with AKI had greater sustained loss of kidney function compared with no AKI estimated glomerular filtration rate, mean (SD): 68.9 (25.7) versus 75.3 (22.1) mL/min/1.73 m(2), P = 0.01.
By the KDIGO definition, AKI occurred in two-thirds of patients following LTx. AKI portended greater risk of death and loss of kidney function.
Background The very low risk of mitral valve repair performed through median sternotomy must be reproducible when using a port-access approach to justify early repair employing minimally invasive ...platforms. We compared the outcomes of mitral valve repair performed through port access using thoracoscopic assistance (port) versus median sternotomy (open). Methods The early results after mitral valve repair performed by two different surgeons at two separate institutions were analyzed. Between January 1999 and December 2006, isolated mitral valve repair was performed with a port approach in 350 patients and an open approach in 365 patients. Results The mean age was similar between the two groups; however, port patients were more frequently female (148 42% versus 119 33%, p = 0.007), and had a higher likelihood of having New York Heart Association class III to IV symptoms (100 29% versus 48 13%, p < 0.001), diabetes mellitus (19 5% versus 8 2%, p = 0.023), congestive heart failure (90 26% versus 26 7%, p < 0.001), and a lower ejection fraction (53% versus 64%, p < 0.001) preoperatively. Cross-clamp time (104 versus 24 minutes, p < 0.001) and bypass time (140 versus 33 minutes, p = 0.001) were significantly lower for the open group. On univariate analysis, the duration of postoperative ventilatory support was significantly lower in the port group (5.0 versus 11.0 hours, p < 0.001); however, the length of hospital stay was longer (6.95 versus 6.19 days, p < 0.001). There were 2 early deaths (2 port versus 0 open). A propensity score factor was calculated and utilized to account for differences between groups. After adjusting for propensity score and significant factors identified in multivariate models, port mitral repair independently predicted a diminished duration of postoperative ventilatory support ( p = 0.045), but there were no significant differences in other outcomes including postoperative blood transfusion, reoperation for hemorrhage, or length of stay in hospital. Conclusions Despite longer cross-clamp and bypass times, early outcomes using a thoracoscopic port-access approach were similar to those for mitral valve repair performed through median sternotomy. Minimally invasive mitral valve repair was associated with a shorter time to extubation, but that did not translate into a diminished duration of postoperative hospitalization.
The bleaching of cadmium yellows is a problem that affect paintings by famous artists, such as, Matisse, Van Gogh, and Munch. Synchrotron radiation‐based X‐ray techniques, UV‐Vis, and FTIR ...spectroscopies unveils the key role played by moisture and light in the discoloration process of cadmium yellow oil paints. The image shows a simplified version of the proposed mechanism for the photocorrosion of CdS pigments and the photocatalytic oxidation of the oil binder over CdS particles under exposure to moisture. For more details see the Full Paper by L. Monico, C. Miliani and co‐workers on page 11584 ff.
Abstract Purpose Acute kidney injury (AKI) is a common occurrence after lung transplantation (LTx). Whether transient AKI or early recovery is associated with improved outcome is uncertain. Our aim ...was to describe the incidence, factors, and outcomes associated with transient AKI after LTx. Materials and Methods We performed a retrospective cohort study of all adult recipients of LTx at the University of Alberta between 1990 and 2011. Our primary outcome transient AKI was defined as return of serum creatinine below Kidney Disease–Improving Global Outcome AKI stage I within 7 days after LTx. Secondary outcomes included occurrence of postoperative complications, mortality, and long-term kidney function. Results Of 445 LTx patients enrolled, AKI occurred in 306 (68.8%) within the first week after LTx. Of these, transient AKI (or early recovery) occurred in 157 (51.3%). Transient AKI was associated with fewer complications including tracheostomy (17.2% vs 38.3%; P < .001), reintubation (16.4% vs 41.9%; P < .001), decreased duration of mechanical ventilation (median interquartile range, 69 41-142 vs 189 63-403 hours; P < .001), and lower rates of chronic kidney disease at 3 months (28.5% vs 51.1%, P < .001) and 1 year (49.6% vs 66.7%, P = .01) compared with persistent AKI. Factors independently associated with persistent AKI were higher body mass index (per unit; odds ratio OR, 0.91; 95% confidence interval, 0.85-0.98; P = .01), cyclosporine use (OR, 0.29; 0.12-0.67; P = .01), longer duration of mechanical ventilation (per hour log transformed; OR, 0.42; 0.21-0.81; P = .01), and AKI stages II to III (OR, 0.16; 0.08-0.29; P < .001). Persistent AKI was associated with higher adjusted hazard of death (hazard ratio, 1.77 1.08-2.93; P = .02) when compared with transient AKI (1.44 0.93-2.19, P = .09) and no AKI (reference category), respectively. Conclusions Transient AKI after LTx is associated with fewer complications and improved survival. Among survivors, persistent AKI portends an increased risk for long-term chronic kidney disease.
PDF
