Background
Blood glucose level variability has been associated with increased risk of complication in the postoperative setting of cardiovascular surgery. Although interesting for optimization of ...blood glucose management in this context, continuous blood glucose (CBG) devices can have a limited reliability in this context, in particular because of the use of paracetamol. The aim of this study was to evaluate the reliability of Dexcom G6®, a recently developed continuous glucose monitoring device.
Methods
We performed a prospective, observational, non-randomized, single-centre study comparing Dexcom G6® CBG level monitoring with the standard methods routinely used in this context. The standard blood glucose values were paired to the time corresponding values measured with Dexcom G6®. Agreement between the two methods and potential correlation in case of paracetamol use were calculated.
Results
From May 2020 to August 2021, 36 out of 206 patients operated for isolated coronary artery bypass grafting were enrolled; 673 paired blood glucose level were analyzed. Global agreement (ρc) was 0.85 (95% C.I.: 0.84–0.86), intensive care unit agreement was 0.78 (95%C.I.: 0.74–0.82) and ward agreement was 0.91 (95%C.I.: 0.89–0.93). In the diabetic population, it was 0.87 (95%C.I.: 0.85–0.90). When paracetamol was used, the difference was 0.02 mmol/l (95%C.I.: 0.29–0.33).
Conclusions
Dexcom G6® provides good blood glucose level accuracy in the postoperative context of cardiac surgery compared to the standard methods of measurements. The results are particularly reliable in the ward where the need for repeated capillary glucose measurements implies patient discomfort and time-consuming manipulations for the nursing staff.
In hemodialysis, vascular access is a key issue. The preferred access is an arteriovenous fistula on the non-dominant lower arm. If the natural vessels are insufficient for such access, the insertion ...of a synthetic vascular graft between artery and vein is an option to construct an arteriovenous shunt for punctures. In emergency situations and especially in elderly with narrow and atherosclerotic vessels, a cuffed double-lumen catheter is placed in a larger vein for chronic use. The latter option constitutes a greater risk for infections while arteriovenous fistula and arteriovenous shunt can fail due to stenosis, thrombosis, or infections. This review will recapitulate the vast and interdisciplinary scenario that characterizes hemodialysis vascular access creation and function, since adequate access management must be based on knowledge of the state of the art and on future perspectives. We also discuss recent developments to improve arteriovenous fistula creation and patency, the blood compatibility of arteriovenous shunt, needs to avoid infections, and potential development of tissue engineering applications in hemodialysis vascular access. The ultimate goal is to spread more knowledge in a critical area of medicine that is importantly affecting medical costs of renal replacement therapies and patients’ quality of life.
Lipoprotein(a) is a possible causal risk factor for atherosclerosis and related complications. The distribution and prognostic implication of lipoprotein(a) in patients undergoing coronary artery ...bypass grafting remain unknown. This study aimed to assess the impact of high lipoprotein(a) on the long-term prognosis of patients undergoing coronary artery bypass grafting.
Consecutive patients with stable coronary artery disease who underwent isolated coronary artery bypass grafting from January 2013 to December 2018 from a single-center cohort were included. The primary outcome was all-cause death. The secondary outcome was a composite of major adverse cardiovascular and cerebrovascular events. Of the 18 544 patients, 4072 (22.0%) were identified as the high-lipoprotein(a) group (≥50 mg/dL). During a median follow-up of 3.2 years, primary outcomes occurred in 587 patients. High lipoprotein(a) was associated with increased risk of all-cause death (high lipoprotein(a) versus low lipoprotein(a): adjusted hazard ratio aHR, 1.31 95% CI, 1.09-1.59;
=0.005; lipoprotein(a) per 1-mg/dL increase: aHR, 1.003 95% CI, 1.001-1.006;
=0.011) and major adverse cardiovascular and cerebrovascular events (high lipoprotein(a) versus low lipoprotein(a): aHR, 1.18 95% CI, 1.06-1.33;
=0.004; lipoprotein(a) per 1-mg/dL increase: aHR, 1.002 95% CI, 1.001-1.004;
=0.002). The lipoprotein(a)-related risk was greater in patients with European System for Cardiac Operative Risk Evaluation <3, and tended to attenuate in patients receiving arterial grafts.
More than 1 in 5 patients with stable coronary artery disease who underwent coronary artery bypass grafting were exposed to high lipoprotein(a), which is associated with higher risks of death and major adverse cardiovascular and cerebrovascular events. The adverse effects of lipoprotein(a) were more pronounced in patients with clinically low-risk profiles or not receiving arterial grafts.
Arterial grafts are sometimes used in microvascular reconstruction and their clinical benefit over standard venous grafts is unknown. To determine arterial graft utilization in clinical microvascular ...arterial reconstruction, a review of the literature was done. PubMed search resulted with 4,352 finds, and after screening for relevance, 11 articles reporting on 55 arterial grafts were analyzed. All reports were retrospective studies, case reports, and case series, with no randomized controlled trials. Two retrospective series reported better patency of arterial versus venous grafts in upper-limb revascularization for chronic occlusion, but the findings were highly biased. Better patency of arterial grafts did not lead to higher rate of clinical improvement. Antiplatelet and lipid-lowering agents seem to be underused in venous graft recipients and use of no-touch venous grafting has not been reported. Based on the available data, routine use of arterial grafts cannot be recommended. Studies that show better patency of arterial grafts in hand revascularization for chronic vascular insufficiency are retrospective and biased, so a randomized controlled trial is needed.
Background:The use of bilateral internal thoracic artery (BITA) grafting concomitant with other cardiac operations is regarded as a risky strategy and the long-term advantages of BITA use remain ...unproven.Methods and Results:Pooled results from 3 series of patients (totaling 1,123 patients; mean age, 71.3 years; mean EuroSCORE II, 7.4%) undergoing combined coronary surgery using BITA were reviewed. Predictors of immediate and long-term adverse outcomes were identified by multivariable analyses. In-hospital and 30-day mortality was 7.9% and 6.3%, respectively. Diabetes on insulin (P=0.045), severe renal impairment (P<0.0001), extracardiac arteriopathy (P=0.0058), New York Heart Association class III−IV (P=0.017), recent myocardial infarction (P=0.0009), left ventricular dysfunction (P=0.0054), pulmonary hypertension (P=0.0016), active infective endocarditis (P=0.0011), and prolonged cross-clamp time (P=0.04) were predictors of in-hospital death. Multiple transfusions (27.3%), prolonged mechanical ventilation or reintubation (16.7%), acute kidney injury (11.5%), and sternal wound infections (10.4%) were relevant postoperative complications. Any neurological dysfunction occurred in 5.4% of cases. Median follow-up was 4.2 years. Female sex, chronic dialysis, extracardiac arteriopathy, and left ventricular dysfunction were predictors of both cardiac/cerebrovascular death and major adverse cardiac/cerebrovascular events (MACCE). The 10-year adjusted survival free of cardiac/cerebrovascular death, cerebrovascular accident after discharge, and MACCE was 84.2%, 94.8% and 54.6%, respectively.Conclusions:BITA grafting concomitant with other cardiac operations may be performed with satisfactory results. Long-term outcomes mostly depend on sex, preoperative comorbidities, and baseline cardiac function.
Objective: This study was undertaken to evaluate transit-time flow (TTF) as a tool to detect technical errors in arterial bypass grafts intra-operatively and predict outcomes. Methods: TTF’s three ...parameters, pulsatility index (PI, index of resistance), flow (cc min−1) and diastolic filling (DF, proportion of diastole with coronary flow), were measured in 990/1000 (99%) of arterial grafts in 336 consecutive patients, prospectively enrolled in a database. Grafts were revised when TTF findings supported the otherwise suspected graft malfunction. If no other signs/suspicion of graft malfunction existed (normal electrocardiogram (EKG), stable haemodynamics and unchanged ventricular function on trans-oesophageal echocardiography (TEE)), and the PI was >5, grafts were not revised. Major adverse cardiac events (MACEs: recurrent angina, perioperative myocardial infarction, postoperative angioplasty, re-operation and/or perioperative death) were related to TTF measurements. Results: The average number of grafts per patient was 3.02, of which 99% were arterial. Satisfactory grafts were achieved in 916/990 (93%) of the grafts, with flows from 34 to 61 cc min−1, PI ≤5 and DF of 62–85%. Fourteen conduits, 20 grafts (2%) suspected to be problematic, were revised. Patients were divided into two groups: 277 (82%) with at least one graft with PI ≤5 and 59 (18%) with a PI >5. MACE occurred in 25 (7.4%) patients — 15/277 patients with a PI ≤5 (5.4%) and 10/59 with a PI >5 (17%, p = 0.005). Mortality following non-emergent surgery was significantly higher in patients with a PI >5 (5/54, 9%) than in patients with a PI ≤5 (5/250, 2%, p = 0.02). Flow and DF were not predictive of outcomes. Conclusion: A high PI predicts technically inadequate arterial grafts during surgery — even if all other intra-operative assessments indicate good grafts; it also predicts outcomes, particularly mortality.
Background and Aim of the study
The mammary artery shows excellent long‐term patency and encourages the use of skeletonized bilateral internal thoracic arteries (BITA) for coronary surgery. We ...analyzed the long‐term outcome of patients operated for myocardial revascularization with BITA in a single center.
Materials and Methods
Clinical data and surgical details of patients undergoing coronary surgery with BITA were prospectively collected and retrospectively analyzed. Selected variables were studied as risk factors for sternal wound complication and a subanalysis of clinical outcome for patients aged 70 years or greater was performed. A long‐term follow‐up of the study group is provided.
Results
From January 2001 to November 2021, 750 patients underwent myocardial revascularization using BITA grafts (mean age: 61 ± 9.5 years; males: 91%) at our institute. Patients with triple‐vessel disease were 81%, 15.3% of all procedures were performed off‐pump and 3.6% were urgent cases. Hospital mortality was 0.5%. Sternal wound complication was observed in 67 patients (9.0%) with 7 deep sternal wound infections (0.9%). Female gender (odds ratios OR: 3.7, p < 0.01), BMI >30 (OR: 1.8, p = 0.04), smoking (OR: 1.8, p = 0.02), and chronic kidney failure (OR: 3.7, p = 0.05) were independent predictors for sternal complications. During a mean follow‐up time of 8.7 ± 5.3 years, 34 patients (4.5%) underwent a repeated myocardial revascularization, and there were 89 all‐cause deaths (11.9%) and the cumulative survival at 5, 10, 15, and 20 years was 97%, 89%, 76%, and 60% for the whole study group 92%, 74%, 47%, and 43% for the subgroup of elderly patients (mean age: 74 ± 3.5 years).
Conclusions
Use of skeletonized bilateral thoracic arteries shows low‐rate of wound infection and good long‐term outcome with low risk of repeated revascularizations, regardless of patients' age.
Background
Combining preoperative angiography findings with intraoperative transit time flow measurements (TTFM) may improve patency of coronary artery bypass grafts. Nevertheless, graft flow might ...be impaired by native coronary flow based on the severity of stenoses, with inferior long‐term outcomes. This study investigates the impact of left anterior descending artery (LAD) stenosis on competitive flow measured in left internal mammary artery (LIMA) grafts during off‐pump coronary artery bypass grafting.
Methods
Fifty patients were included in this prospective single‐center cohort study. LAD stenosis was assessed with quantitative coronary analysis (QCA) and stratified into three groups based on its severity. TTFM of LIMA grafts were performed with LAD open and temporarily occluded. Change in mean graft flow after LAD snaring was the primary endpoint. Secondary endpoints included further TTFM parameters, clinical outcomes, and competitive flow index (CFI), defined as the ratio of mean graft flow with open or closed LAD.
Results
Mean LAD stenosis as objectified with QCA was 58 ± 15%. Mean LIMA graft flow increased from 20 ml/min with open LAD to 30 ml/min with snared LAD (p < .001). TTFM cut‐off values for graft patency improved in 26%–42% of patients after LAD occlusion. Median CFI was 0.66 (IQR: 0.56–0.82). Postoperative myocardial infarction occurred in 2.0% of patients, 120‐day mortality was 0%, and 2‐year mortality was 6.0%.
Conclusions
Routine snaring of the LAD with CFI calculation during coronary artery bypass grafting is useful to detect significant competitive flow in LIMA grafts, potentially preventing unnecessary intraoperative graft revisions.
Actualmente existe controversia respecto a los beneficios y riesgos de la revascularización coronaria con injertos arteriales múltiples.
Analizar la supervivencia a medio plazo entre pacientes ...sometidos a cirugía coronaria aislada sin circulación extracorpórea (CEC) según recibiesen, o no, más de un injerto arterial. Evaluar el objetivo primario en una muestra ajustada mediante puntuación de propensión.
Revisión retrospectiva de pacientes sometidos a cirugía coronaria sin CEC entre 2005 y 2017. Con el propósito de limitar sesgos, se realizó un análisis de supervivencia tras ajustar la muestra mediante puntuación de propensión (1:1; nearest neighbor) y un análisis de riesgos proporcionados de Cox para identificar variables asociadas al evento primario.
Se incluyeron 1.875 pacientes. En la cohorte total, los pacientes con solo un injerto arterial presentaron edad media más avanzada (70,3 vs 60,4años; p<0,00), más comorbilidades y riesgo quirúrgico (EuroScoreI: 6,2 vs 3,1; p<0,00). Tras ajustar la muestra (n=654) los grupos no presentaron diferencias significativas en características preoperatorias (EuroScoreI: 2,1% vs 1,9%; p=0,49). A 7años, tanto en la cohorte total como en la ajustada observamos una mayor supervivencia en el grupo sometido a revascularización arterial múltiple (88,7% vs 80%; p=0,021), siendo esta estrategia de revascularización un predictor independiente de mayor supervivencia a medio plazo (HR: 0,67; IC95%: 0,51-0,89; p=0,005).
La revascularización arterial múltiple se asocia a una mayor supervivencia en comparación con el uso aislado de un solo injerto arterial a medio plazo.
Currently, there is controversy regarding outcomes between the use of multiple or single arterial grafts for coronary artery revascularization.
Mid-term survival analysis of patients undergoing off-pump coronary artery revascularization with multiple or single arterial grafts. Analysis of the primary outcome in a propensity score-matched cohort.
Retrospective analysis of patients who underwent off-pump coronary artery revascularization between 2005 and 2017. In order to reduce bias, an analysis was performed in a propensity score matched sample (1:1; nearest neighbor) and a Cox proportional hazard model was developed to identify variables associated with the primary outcome.
A total of 1,875 patients included. In the total cohort, patients with single arterial graft were older (70.3 vs 60.4 years; P<.00) had more comorbidities and higher surgical risk (EuroScoreI: 6.2 vs 3.1; P<.00). After adjustment, both groups were balanced and had similar perioperative risk. At 7-year follow up, patients with multiple arterial grafts had better survival than patients with single arterial graft, this result was consistent in the total and adjusted cohorts (88.7% vs 80%; P=.021). This revascularization strategy was an independent predictor for better mid-term survival (HR: 0.67; 95%CI: 0.51-0.89; P=.005).
Multiple arterial graft revascularization is associated with better mid-term survival than single arterial graft revascularization.
Purpose: In this article, we reported on the up-to-date literature regarding skeletonized bilateral internal mammary artery (BIMA) flow and the effect on sternal perfusion. We also reviewed the pros ...and cons of the skeletonization technique versus the conventional pedicle technique for harvesting the BIMA.Methods: We performed an up-to-date review using the PubMed database, with a specific focus on the contemporary published literature.Results: BIMA skeletonization can preserve the sternal microcirculation, minimize tissue damage, and maintain blood supply to the chest wall at the tissue level. This effect is also apparent in diabetics. Deep sternal wound infection (DSWI) rates are significantly less with skeletonization versus the conventional pedicle technique and are comparable to single internal mammary artery harvesting.Conclusions: Contemporary large-scale studies demonstrate that skeletonization of the BIMA increases conduit length, provides superior flow, reduces the incidence of DSWIs, and improves late survival. Hopefully, this review will increase awareness of the compelling evidence in favor of using skeletonized internal mammary arteries and stimulate increased uptake of BIMA revascularization surgery.
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