Objectives The purpose of this study was to evaluate the association of the percentage of platelet inhibitory response to clopidogrel as assessed by modified thromboelastography with bleeding and ...transfusion requirement after off-pump coronary artery bypass graft (OPCABG) surgery. Background Interindividual variability of clopidogrel responsiveness may influence bleeding and transfusion requirement. Methods One hundred patients who received clopidogrel within 5 days of OPCABG were prospectively enrolled. The primary end point was to compare post-operative bleeding and transfusion requirement in relation to the tertile distribution of the percentage of platelet inhibitory response to clopidogrel. Results Blood loss in the patients in the third tertile was 914 ± 264 ml compared with 623 ± 249 ml in those in the first and 683 ± 254 ml in those in the second tertiles (p = 0.001). Significantly more patients in the third tertile were transfused, and the number of units transfused was also larger. On multivariate analysis, the third tertile was associated with an 11-fold increased risk of transfusion (95% confidence interval: 2.77 to 47.30, p = 0.001). The optimal cutoff value for the transfusion requirement measured by receiver-operator characteristic curve analysis was 70% platelet inhibitory response to clopidogrel (area under the curve: 0.771; 95% confidence interval: 0.674 to 0.868; p < 0.001). Conclusions A high percentage of platelet inhibitory response to clopidogrel, regardless of the proximity of clopidogrel exposure, predicts increased blood loss and transfusion requirement after OPCABG with a cutoff value of 70% for increased risk of transfusion. These findings might implicate a potential role of modified thromboelastography in deciding the timing of OPCABG in patients who need continued clopidogrel therapy.
Background We aimed to investigate the ability of rotational thromboelastometry (ROTEM) thresholds for coagulopathy to predict increased perioperative blood loss in off-pump coronary artery bypass ...graft surgery (OPCABG) and its association with transfusion requirement. Methods The data of 303 patients undergoing OPCABG were retrospectively analyzed. Perioperative blood loss and transfusion requirement were compared according to the presence of abnormal ROTEM thresholds, which were tested after anesthesia induction and heparin reversal. Logistic regression analyses were performed to predict significant perioperative blood loss (more than 20% of estimated blood volume). Results After graft completion, 92 patients (30%) exhibited abnormal ROTEM thresholds and showed significantly higher perioperative blood loss (median 840 mL interquartile range: 646 to 1,102 mL versus median 690 interquartile range: 530 to 850 mL, p < 0.001) and greater transfusion requirement (both in the number of patients receiving transfusion and the median number of transfused units) of packed erythrocytes and fresh frozen plasma than patients exhibiting no ROTEM thresholds. After multivariate analysis of preoperative anemia, postoperative international normalized ratio greater than 1.3, and ROTEM thresholds, only ROTEM threshold (odds ratio 3.45, 95% confidence interval: 2.00 to 5.97, p < 0.001) remained an independent predictor of significant perioperative blood loss, which occurred in 79 patients (26%). Conclusions Abnormal ROTEM thresholds after heparin reversal were found to be associated with significant perioperative bleeding and transfusion requirement in OPCABG. Rotational thromboelastometry may allow timely hemostatic interventions to reduce blood loss and transfusion in OPCABG.
...few data are available with regard to echocardiographically observed post-operative CP. ...the purpose of this study was to investigate the incidence and clinical course of CP observed on ...post-operative echocardiographic examination in patients who had undergone isolated coronary artery bypass graft (CABG) surgery. Because CABG is a traumatic procedure with intraoperative irritation to the pericardium by the physical manipulation of surgeons, this pericardial trauma and previously mentioned pericardial friction can possibly cause pericardial inflammation, which is enough to cause transient CP but not enough to cause constrictive pericarditis.
Background The effect of prosthesis–patient mismatch (PPM) on clinical outcomes after aortic valve replacement remains controversial. We evaluated effect of PPM on long-term clinical outcomes after ...isolated aortic valve replacement in patients with predominant aortic stenosis. Methods We analyzed data from patients with predominant aortic stenosis who underwent isolated aortic valve replacement between January 1995 and July 2010. The indexed effective orifice area, obtained by dividing the in vivo effective orifice area by the patient’s body surface area, was used to define PPM as clinically nonsignificant (group I, 224 patients), mild (group II, 52 patients), moderate (group III, 39 patients), and severe (group IV, 36 patients). Results Early survival was not significantly different among the groups, but overall survival was decreased gradually in group IV. Overall survival at 12 years was lower in group IV than in group I (92.8% ± 2.7% vs 67.0 ± 10.1, respectively; P = .001). Cardiac-related-death-free survival at 12 years was lower in patients with severe PPM. Left ventricular mass index decreased during the follow-up period in all groups. But left ventricular mass index was less decreased in group IV compared with groups I, II, and III. Age, severe PPM, and ejection fraction <40%, and New York Heart Association Functional Class IV were independent risk factors of overall survival on multivariate analysis. Severe PPM was an independent risk factor for cardiac-related death. Conclusions Severe PPM showed an adverse effect on long-term survival, and was an independent risk factor for cardiac-related death. In addition, patients with severe PPM showed less decreasing left ventricular mass index during follow-up.
Background Although thoracic endovascular aortic repair is regularly used to treat chronic DeBakey type IIIb aneurysms, persistent retrograde flow into the false lumen through distal reentry tears is ...a common cause of failure. We sought to determine the safety and efficacy of the false lumen procedure (FLP) for aortic remodeling with chronic DeBakey IIIb aneurysms. Methods From 2012 to 2015, 25 patients with chronic DeBakey IIIb aneurysms underwent FLP using vascular plugs, stent grafts, coils, or glues. The FLP was performed as an adjunctive procedure after initial thoracic endovascular aortic repair in 9 patients, in combination with initial thoracic endovascular aortic repair in 13 patients, and as an isolated procedure in 3 patients. All patients were followed up for a mean duration of 10 months after the FLP. Outcomes included the degree of thrombosis and diameter change in the true lumen and false lumen. Diameters were measured at three levels: left subclavian artery, pulmonary artery bifurcation, and abdomen (celiac artery). Results No spinal cord injury, renal failure, or 30-day mortality was observed. Complete false lumen thrombosis after FLP was observed in 20 patients (80%). Compared with before FLP, the mean false lumen diameter for each level (before 22.23 ± 10.18 mm versus after 17.56 ± 10.84 mm; p < 0.001) significantly decreased, whereas the mean true lumen diameter for each level (20.45 ± 5.33 mm versus 25.12 ± 5.60 mm, p < 0.001) increased. Conclusions False lumen procedures were safe, promoted complete thrombosis, and had favorable aortic remodeling in patients with chronic DeBakey IIIb aneurysms.
Objective Prognostic implications of partial thrombosis of the residual aorta after repair of acute DeBakey type I aortic dissection have not been elucidated. We sought to analyze the impact of ...partial thrombosis on segmental growth rates, distal aortic reprocedures, and long-term survival. Methods A total of 118 consecutive patients (55% were male; mean age, 60 years) with acute DeBakey type I aortic dissection underwent surgical repair (1997–2007). The hospital mortality rate was 17.8%. Survivors underwent serial computed tomography scans. Segment-specific average rates of enlargement were analyzed. Distal reprocedures and patient survival were examined. Results Sixty-six patients had imaging data sufficient for growth rate calculations. The median diameters within 2 weeks after repair were as follows: aortic arch, 3.5 cm; descending aorta, 3.6 cm; and abdominal aorta, 2.4 cm. Subsequent growth rates were artic arch, 0.34 mm/y, descending aorta, 0.51 mm/y, and abdominal aorta, 0.35 mm/y. Partial thrombosis of the residual aorta predicted greater growth in the distal aorta ( P = .005). There were 13 distal aortic reprocedures (5 reoperations, 8 stent graft insertions) for 10 years, and reprocedure-free survival was 66%. Partial thrombosis ( P = .002) predicted greater risk of aorta-related reprocedures. Cox analysis revealed that estimated glomerular filtration rate less than 60 mL/min/1.73 m2 ( P = .030), reintubation ( P = .002), and partial thrombosis ( P = .023) were independent predictors for poor survival. Conclusion Partial thrombosis of the false lumen after repair of acute DeBakey type I aortic dissection, compared with complete patency or complete thrombosis, is a significant independent predictor of aortic enlargement, aorta-related reprocedures, and poor long-term survival.
Objectives The use of thoracic endovascular aortic repair (TEVAR) for chronic DeBakey III type b (CDIIIb) aneurysms is controversial. We analyzed the potential prognostic factors affecting aorta ...remodeling after this procedure. Methods A total of 20 patients with CDIIIb aneurysms underwent TEVAR, with full coverage of reentry tears at the descending thoracic aorta. The potential factors affecting false lumen (FL) remodeling were analyzed, including reentry tears (communicating channels visible on the computed tomography angiogram), large intimal tears below the stent graft (≥2 consecutive axial cuts on the computed tomography angiogram), visceral branches arising from the FL, and intercostal arteries (ICAs) arising from the FL. Results All the patients had uneventful in-hospital courses; 2 patients (10%) required reintervention during the follow-up period. Thirteen patients (65%) had complete thrombosis of the FL at stent graft segment. Compared with the complete thrombosis group, the partial thrombosis group had more reentry tears (1.8 vs 2.3, P = .48), large intimal tears (0.8 vs 1.7, P < .05), visceral branches arising from the FL (1.2 vs 2.3, P < .05), and ICAs arising from the FL (3.8 vs 5.1, P = .35). Reentry tears, visceral branches, and ICAs from the FL were significant negative prognostic factors for FL shrinkage ( P < .05). Conclusions Although reentry tears above the celiac trunk were fully covered, the visceral branches and ICAs from the FL and all communicating channels below the celiac trunk kept the FL pressurized and were unfavorable prognostic factors for aorta remodeling after TEVAR for CDIIIb aneurysms.
Abstract Background Hyperglycemia exacerbates renal ischemia-reperfusion (IR) injury via aggravated inflammatory response and excessive production of reactive oxygen species. This study aimed to ...investigate the ability of propofol, a known antioxidant, to protect kidneys against IR injury in hyperglycemic rats in comparison with normoglycemic rats. Methods Sixty rats were randomly assigned to four groups: normoglycemia–etomidate, normoglycemia–propofol, hyperglycemia–etomidate, and hyperglycemia–propofol. Anesthesia was provided with propofol or etomidate depending on the group. Also, the rats received 1.2 g/kg dextrose or the same volume of normal saline depending on the group. Renal ischemia was induced for 25 min. The rats were killed, and samples were collected 65 min after starting intravenous anesthetics (sham) and 15 min and 24 h after reperfusion injury to compare the histologic degree of renal tubular damage and levels of inflammatory markers and enzymes related to reactive oxygen species. Results Compared with etomidate, propofol significantly attenuated tubular damage after reperfusion in hyperglycemic rats. Also, tubular damage was greater under hyperglycemia compared with normoglycemia in the etomidate group, whereas it was similar in the propofol group. Propofol preserved superoxide dismutase level and attenuated the increase in levels of myeloperoxidase, interlukin-1β, and tumor necrosis factor-α after reperfusion compared with etomidate especially in hyperglycemic rats. Propofol also attenuated the production of inducible nitric oxide synthase and phosphorylation of inhibitor of κB and nuclear factor-κB after reperfusion, which were more prominent under hyperglycemia. Conclusions Propofol conveyed renoprotection against IR injury by preserved antioxidation ability and attenuated inflammatory response, which were more prominent under hyperglycemia.
Abstract Background The purpose of this study was to examine the impact of previous percutaneous coronary intervention with stent on long-term outcomes after off-pump coronary artery bypass grafting ...(OPCAB). Methods Between January 2001 and December 2014, 1668 patients with triple-vessel disease undergoing OPCAB were reviewed and divided into two groups. The No-Stent group (n=1409) included patients who underwent OPCAB as a primary revascularization procedure and the Stent group (n=259) included patients with a history of percutaneous coronary intervention with stent. The mean follow-up duration was 5.32±3.39 years. Results After propensity score-matching, characteristics of both groups were comparable (n=259 in each group). In-hospital mortality (n=3 1.2% in both groups, p>0.999) was similar. The 14-year overall survival rate (75.6±6.6% in No-Stent group vs. 71.9±8.5% in Stent group, p=0.917) and freedom from major adverse cardiac and cerebrovascular events (MACCEs) rate (68.3±6.6% vs. 54.6±8.5%, p=0.239) were also similar. However, freedom from target vessel revascularization rate at 14-years was significantly higher in No-Stent group (97.2±1.7% vs. 76.9±6.5%, p<0.001). The independent risk factor for late target vessel revascularization was in-stent restenosis at OPCAB (HR: 3.355, 95% CI: 1.925-5.848, p<0.001) and also risk factor for MACCEs (HR: 1.645, 95% CI: 1.105-2.448, p=0.014). Conclusions Previous intracoronary stenting does not increase long-term mortality, but grafting to previously stented target vessels with in-stent restenosis increases the risk of repeat target vessel revascularization and MACCEs.
Objectives The object of this study was to introduce the KORean Observational study Network for Arthritis (KORONA) registry with an emphasis on the design of the Korean rheumatoid arthritis (RA) ...national database, as well as to provide an overview of the RA patients who are currently registered in KORONA. Methods The KORONA was established in July 2009 by the Clinical Research Center for Rheumatoid Arthritis (CRCRA) in South Korea. KORONA is based on a prospective protocol and standard, defined data collection instruments. Demographic and clinical features, laboratory and radiologic data, health-related outcomes, treatment side effects, resource utilization, and health behaviors of the RA cohort patients are recorded in a database. Results A total of 23 institutions, which are about 38% of the rheumatologic departments at tertiary academic hospitals across South Korea, are part of KORONA. The quality control of data collection and management has been performed through annual monitoring and auditing, staff training, and providing standard operation protocol by the executive committee of CRCRA. As of 31 December 2010, 4721 patients with established RA were included in KORONA, because an annual survey had started to be performed in July 2010. Conclusions KORONA is the first nationwide Korean RA-specific cohort and it will provide valuable “real-world” information for Korean RA patients.
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