Abstract Background The development of acute kidney injury (AKI) in cardiac surgery is associated with increased morbidity and mortality. The aim of the study was to assess the incidence and risk ...factors for AKI after thoracic aorta surgery, using antegrade selective cerebral perfusion (ASCP) and moderate hypothermia. Methods We reviewed 641 patients undergoing thoracic aortic surgery, using ASCP and moderate hypothermia, from November 1996 to December 2012. Patient preoperative, intraoperative, and postoperative variables were evaluated for association with AKI with logistic regression analysis. Models including all variables and models, after the sequential removal of postoperative, and both postoperative and intraoperative variables, were assessed using receiver operating characteristic analysis. Results The mean age of the patients was 62.9 years, and 194 patients (30%) were women. The overall incidence of AKI was 19.0%. In-hospital mortality was significantly higher in the AKI group (33.6% vs 6.7%; P < .001). Logistic regression analysis identified 8 predictors of AKI: 4 of them were preoperative (priority, diabetes, preoperative glomerular filtration rate, and weight); 2 intraoperative (mitral valve and aortic valve replacement); and 2 postoperative (overall neurologic complication and reoperation for bleeding). Model-discrimination performance improved from an area under the curve (AUC) of 0.737, for the model including only preoperative variables, to an AUC of 0.798 for the model including all variables ( P = .012). Conclusions The incidence of AKI after thoracic aorta surgery is fairly common, and its occurrence strongly affects outcomes. Preoperative renal status and preoperative conditions are the main influences on AKI development. Predictive models can be improved by adding intraoperative and postoperative variables.
Background The development of acute kidney injury (AKI) after adult cardiac surgery is associated with increased morbidity and mortality. Our aim was to assess the risk factors for postoperative AKI ...and whether the addition of perioperative management variables can improve AKI prediction. Methods We studied 3,219 patients operated from January 2006 to December 2009. The AKI was defined as proposed by the Acute Kidney Injury Network. Patient preoperative characteristics, as well as intraoperative, cardiopulmonary bypass (CPB), and postoperative management variables, were evaluated for association with AKI with logistic regression analysis. The model including all variables was assessed first, then separate models including only preoperative variables followed by the sequential addition of intraoperative, CPB, and postoperative management variables were tested; receiver operating characteristic analysis was used to evaluate and compare models' discriminatory power. Results The AKI occurred in 288 of 3,219 patients (8.9%). Logistic regression analysis identified 15 predictors of AKI; 4 were preoperative (age, diabetes, smoking, and serum creatinine), 4 intraoperative (inotropes, erythrocytes transfusion, cross-clamp time, and need of a new pump run), 2 CPB-related (urine output and furosemide administration during CPB), and 5 postoperative (erythrocytes transfusion, administration of vasoconstrictors, inotropes, diuretics, and antiarrhythmics). Model-discrimination performance improved from an area under the curve of 0.830 (95% confidence interval 0.807 to 0.854) for the model including only preoperative variables to an area under the curve of 0.904 (95% confidence interval 0.886 to 0.921) for the model including all variables ( p < 0.001). Conclusions Several factors influence AKI development after cardiac surgery and perioperative patient management significantly affects AKI occurrence. Predictive models can be sensibly improved by the addition of these variables.
Abstract Peroxisome proliferation-activated receptor gamma (PPARγ) is a nuclear receptor regulating transcription of several genes involved mainly in fatty acid and energy metabolism. PPARγ agonists ...are used as insulin sensitizers for treatment of diabetes. However, according to the results of recent studies, their clinical application can be broadened. Activation of PPARγ has a wide spectrum of biological functions, regulating metabolism, reducing inflammation, influencing the balance of immune cells, inhibiting apoptosis and oxidative stress, and improving endothelial function. These effects appear to be beneficial not only in diabetes and atherosclerosis, but also in a number of other conditions, including cardiovascular surgical interventions. In this review we discuss the role of PPARγ in various conditions associated with cardiovascular risk, including diabetes mellitus, atherosclerosis, and hypertension, and will focus on current applications of PPARγ activators and their therapeutic use. We will also give an overview of the potential use of PPARγ agonists in cardiovascular surgical intervention.
Marfan syndrome is the most frequently inherited disorder of connective tissue and is strongly associated with aortic dilatation, dissection, and rupture; in these patients, type B dissection occurs ...substantially. It is not known whether stent grafting, which is now frequently used in type B aortic dissection and descending thoracic aneurysms in non-Marfan patients, is a valuable option in Marfan patients, and reports from the literature are sparse and sporadic. We performed a systematic review of studies reporting the early and late results of endovascular stent grafting in Marfan patients with type B dissection in the attempt to quantify possible benefits or potential drawbacks of this approach in these usually very sick patients. Although associated with a low operative risk (1.9%), endovascular stent grafting in patients with Marfan syndrome carries a substantial risk of early and late complications, mainly endoleaks and surgical conversions, and of death at midterm follow-up. Because these complications are relatively more frequent in patients undergoing endovascular stent grafting for chronic dissections, these data suggest caution against the routine use of endovascular stent grafting in Marfan patients.
Background The European System for Cardiac Operation Risk Evaluation (EuroSCORE) II has not been tested yet for predicting long-term mortality. This study was undertaken to evaluate the relationship ...between EuroSCORE II and long-term mortality and to develop a new algorithm based on EuroSCORE II factors to predict long-term survival after cardiac surgery. Methods Complete data on 10,033 patients who underwent major cardiac surgery during a 7-year period were retrieved from three prospective institutional databases and linked with the Italian Tax Register Information System. Mortality at follow-up was analyzed with time-to-event analysis. Results The Kaplan-Meier estimates of survival at 1 and 5 were, respectively, 95.0% ± 0.2% and 84.7% ± 0.4%. Both discrimination and calibration of EuroSCORE II decreased in the prediction of 1-year and 5-year mortality. Nonetheless, EuroSCORE II was confirmed to be an independent predictor of long-term mortality with a nonlinear trend. Several EuroSCORE II variables were independent risk factors for long-term mortality in a regression model, most of all very low ejection fraction (less than 20%), salvage operation, and dialysis. In the final model, isolated mitral valve surgery and isolated coronary artery bypass graft surgery were associated with improved long-term survival. Conclusions The EuroSCORE II cannot be considered a direct estimator of long-term risk of death, as its performance fades for mortality at follow-up longer than 30 days. Nonetheless, it is nonlinearly associated with long-term mortality, and most of its variables are risk factors for long-term mortality. Hence, they can be used in a different algorithm to stratify the risk of long-term mortality after surgery.
Objective It is uncertain whether mitral valve replacement is really inferior to mitral valve repair for the treatment of chronic ischemic mitral regurgitation. This multicenter study aimed at ...providing a contribution to this issue. Methods Of 1006 patients with chronic ischemic mitral regurgitation and impaired left ventricular function (ejection fraction < 40%) operated on at 13 Italian institutions between 1996 and 2011, 298 (29.6%) underwent mitral valve replacement whereas 708 (70.4%) received mitral valve repair. Propensity scores were calculated by a nonparsimonious multivariable logistic regression, and 244 pairs of patients were matched successfully using calipers of width 0.2 standard deviation of the logit of the propensity scores. The postmatching median standardized difference was 0.024 (range, 0-0.037) and in none of the covariates did it exceed 10%. Results Early deaths were 3.3% (n = 8) in mitral valve repair versus 5.3% (n = 13) in mitral valve replacement ( P = .32). Eight-year survival was 81.6% ± 2.8% and 79.6% ± 4.8% ( P = .42), respectively. Actual freedom from all-cause reoperation and valve-related reoperation were 64.3% ± 4.3% versus 80% ± 4.1%, and 71.3% ± 3.5% versus 85.5% ± 3.9 in mitral valve repair and mitral valve replacement, respectively ( P < .001). Actual freedom from all valve-related complications was 68.3% ± 3.1% versus 69.9% ± 3.3% in mitral valve repair and mitral valve replacement, respectively ( P = .78). Left ventricular function did not improved significantly, and it was comparable in the 2 groups postoperatively (36.9% vs 38.5%, P = .66). At competing regression analysis, mitral valve repair was a strong predictor of reoperation (hazard ratio, 2.84; P < .001). Conclusions Mitral valve replacement is a suitable option for patients with chronic ischemic mitral regurgitation and impaired left ventricular function. It provides better results in terms of freedom from reoperation with comparable valve-related complication rates.
Background The European System for Cardiac Operative Risk Evaluation (EuroSCORE) was developed to predict immediate outcomes after adult cardiac operations, but less than 30% of the cases used to ...develop this score were valve procedures. We studied EuroSCORE performance in valve procedures. Methods We performed a meta-analysis of published studies reporting the assessment of discriminatory power of the EuroSCORE by receiver operating characteristics (ROC) curve analysis in adult valve operations. A comparison of observed and predicted mortality rates was also performed. Results A literature search identified 37 potentially eligible studies, and 12 were selected for meta-analysis comprising 26,621 patients with 1250 events (mortality rate, 4.7%). Meta-analysis of these studies provided an average area under the curve (AUC) value of 0.730 (95% confidence interval CI, 0.717 to 0.743). The same results were obtained when meta-analyses were performed separately in studies categorized on reliability of uncertainty estimation: in the seven studies reporting reliable uncertainty estimation (8175 patients with 358 events; mortality rate, 4.4%), the ROC curve provided an average AUC value of 0.724 (95% CI, 0.699 to 0.749). The five studies not reporting reliable uncertainty estimation (18,446 patients with 892 events; mortality rate, 4.8%) had an average AUC of 0.732 (95% CI, 0.717 to 0.747). We documented a constant trend to overpredict mortality by EuroSCORE, both in the additive and especially in the logistic form. Conclusions The EuroSCORE has low discrimination ability for valve surgery, and it sensibly overpredicts risk. Alternative risk scoring algorithms should be seriously considered.
Background Contemporary scores for estimating perioperative death have been proposed to also predict also long-term death. The aim of the study was to evaluate the performance of the updated European ...System for Cardiac Operative Risk Evaluation II, The Society of Thoracic Surgeons Predicted Risk of Mortality score, and the Age, Creatinine, Left Ventricular Ejection Fraction score for predicting long-term mortality in a contemporary cohort of isolated aortic valve replacement (AVR). We also sought to develop for each score a simple algorithm based on predicted perioperative risk to predict long-term survival. Methods Complete data on 1,444 patients who underwent isolated AVR in a 7-year period were retrieved from three prospective institutional databases and linked with the Italian Tax Register Information System. Data were evaluated with performance analyses and time-to-event semiparametric regression. Results Survival was 83.0% ± 1.1% at 5 years and 67.8 ± 1.9% at 8 years. Discrimination and calibration of all three scores both worsened for prediction of death at 1 year and 5 years. Nonetheless, a significant relationship was found between long-term survival and quartiles of scores ( p < 0.0001). The estimated perioperative risk by each model was used to develop an algorithm to predict long-term death. The hazard ratios for death were 1.1 (95% confidence interval, 1.07 to 1.12) for European System for Cardiac Operative Risk Evaluation II, 1.34 (95% CI, 1.28 to 1.40) for the Society of Thoracic Surgeons score, and 1.08 (95% CI, 1.06 to 1.10) for the Age, Creatinine, Left Ventricular Ejection Fraction score. Conclusions The predicted risk generated by European System for Cardiac Operative Risk Evaluation II, The Society of Thoracic Surgeons score, and Age, Creatinine, Left Ventricular Ejection Fraction scores cannot also be considered a direct estimate of the long-term risk for death. Nonetheless, the three scores can be used to derive an estimate of long-term risk of death in patients who undergo isolated AVR with the use of a simple algorithm.
Background There is still a wide debate concerning the performance of commonly used risk prediction models in assessing the risk of patients undergoing isolated aortic valve surgery. This study was ...designed to compare the performances of European System for Cardiac Operative Risk Evaluation (EuroSCORE) II and age, creatinine, and ejection fraction (ACEF) score with those of The Society of Thoracic Surgeons (STS) score and logistic EuroSCORE in patients undergoing isolated aortic valve surgery. Methods Data on 1,758 consecutive patients who underwent isolated aortic valve replacement in a 6-year period were retrieved from 3 prospective institutional databases. Discriminatory power was assessed using the c-index. Calibration was evaluated with calibration curves and associated statistics. Results In-hospital mortality rate was 1.4%. The discriminatory power was similar in all algorithms (area under the curve 0.80, 95% confidence interval CI 0.72 to 0.88 for logistic EuroSCORE; 0.81, 95% CI 0.73 to −0.88 for EuroSCORE II; 0.78, 95% CI 0.68 to 0.88 for ACEF; 0.85, 95% CI 0.78–0.93 for STS score) and not significantly different ( p values > 0.05 for all tests). The EuroSCORE II had a better calibration, being the only score with nonsignificant associated statistics (unreliability test, Hosmer-Lemeshow test, and Spiegelhalter Z -test for calibration accuracy). Nonetheless, EuroSCORE II calibration plot highlighted a trend over under-prediction. Conclusions The EuroSCORE II is a good predictor of perioperative mortality in isolated aortic valve surgery, with lower discrimination if compared with STS and a better calibration when compared with logistic EuroSCORE, ACEF, and STS scores. Its performance is optimal in the lowest tertile of patients, whereas it under-predicts mortality afterward. None of these algorithms seems suitable for risk estimation in mid and high-risk patients that are the ones who might benefit most from transcatheter procedures.
Reliability of new scores in predicting perioperative mortality after mitral valve surgery Barili, Fabio, MD, PhD, MStat; Pacini, Davide, MD; Grossi, Claudio, MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
03/2014, Letnik:
147, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Objective The study was designed to validate euroSCORE II and ACEF (age, creatinine, and ejection fraction) scores in patients undergoing isolated or associated mitral valve surgery and compare them ...with logistic euroSCORE and Society of Thoracic Surgeons scores. Methods Data on 3441 consecutive patients undergoing isolated or associated mitral valve surgery in a 6-year period were retrieved from 3 prospective institutional databases. Discriminatory power was assessed with the C index. Calibration was evaluated with calibration curves and associated statistics. Results In-hospital mortality was 3.4%. Discriminatory power was uniformly good (for euroSCORE II: area under curve, 0.79; 95% confidence interval, 0.74-0.84; for logistic euroSCORE: area under the curve, 0.78; 95% confidence interval, 0.74-0.83; for ACEF: area under the curve, 0.73; 95% confidence interval, 0.69-0.79) but significantly higher in euroSCORE models ( P < .05 for Delong, bootstrap, Venkatraman methods). Calibration pattern was slightly better for the ACEF score, although related summary statistics (unreliability, Hosmer-Lemeshow test, Spiegelhalter z -test for calibration accuracy) were not significant even for euroSCORE II. The euroSCORE II demonstrated a performance similar to Society of Thoracic Surgeons score. Logistic euroSCORE confirmed the progressive trend toward overprediction previously demonstrated in the general cardiac surgical population (summary statistics P < .05). Analysis of score performances in the surgical group studied showed results comparable to the global population. Conclusions The euroSCORE II and ACEF scores are good predictors of perioperative mortality in patients undergoing isolated or associated mitral valve surgery, with better discrimination for the first and better calibration for the second. No algorithm seems suitable for risk estimation in mid and high-risk patients.
PDF
