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To compare the outcomes of patients with postcardiotomy shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) only compared with VA-ECMO and intra-aortic balloon pump (IABP). A retrospective multicenter registry study. At 19 cardiac surgery units. A total of 615 adult patients who required VA-ECMO from 2010 to 2018. The patients were divided into 2 groups depending on whether they received VA-ECMO only (ECMO only group) or VA-ECMO plus IABP (ECMO-IABP group). The overall series mean age was 63 ± 13 years, and 33% were female. The ECMO-only group included 499 patients, and 116 patients were in the ECMO-IABP group. Urgent and/or emergent procedures were more common in the ECMO-only group. Central cannulation was performed in 47% (n = 54) in the ECMO-IABP group compared to 27% (n = 132) in the ECMO-only group. In the ECMO-IABP group, 58% (n = 67) were successfully weaned from ECMO, compared to 46% (n = 231) in the ECMO-only group (p = 0.026). However, in-hospital mortality was 63% in the ECMO-IABP group compared to 65% in the ECMO-only group (p = 0.66). Among 114 propensity score-matched pairs, ECMO-IABP group had comparable weaning rates (57% v 53%, p = 0.51) and in-hospital mortality (64% v 58%, p = 0.78). This multicenter study showed that adjunctive IABP did not translate into better outcomes in patients treated with VA-ECMO for postcardiotomy shock. [ABSTRACT FROM AUTHOR]

Coronary artery bypass grafting (CABG) without cardiopulmonary bypass and minimal or no aortic manipulation may be associated with a lower risk of neurological complications. We investigated this issue in patients with a high risk of perioperative stroke. Data on 7352 patients who underwent isolated CABG from January 2015 to May 2017 were included in the multicenter study E-CABG (European Coronary Artery Bypass Grafting) registry. Of these, 684 patients had an increased risk of neurological complications, ie, previous stroke or transient ischemic attack, severe carotid artery stenosis or occlusion, or previous carotid artery intervention. In this subgroup, we analyzed the rates of the combined primary endpoint comprising any postoperative stroke or transient ischemic attack. A comparative analysis between CABG with and without aortic cross-clamping was performed. The primary endpoint was more often reached when aortic cross-clamping was used (propensity score matching, without vs with aortic cross-clamp: 0.9% vs 7.2%; P =.016). In comparison with all other revascularization techniques, off-pump CABG with avoidance of aortic manipulation was associated with the lowest rate of neurological complications (0.7%). In patients with increased risk of perioperative stroke, aortic manipulation including the use of cardiopulmonary bypass or partial clamping for central anastomoses is associated with higher rates of postoperative neurological complications. These patients may benefit from off-pump surgery without aortic manipulation if complete revascularization can be ensured. [ABSTRACT FROM AUTHOR]

To investigate the frequency, predictors, and outcomes of neurologic injury in adults treated with postcardiotomy extracorporeal membrane oxygenation (PC-ECMO). A retrospective multicenter registry study. Twenty-one European institutions where cardiac surgery is performed. A total of 781 adult patients who required PC-ECMO during 2010 to 2018 were divided into patients with neurologic injury (NI) and patients without neurologic injury (NNI). Baseline and operative data, in-hospital outcomes, and long-term survival were compared between the NI and the NNI groups. Predictors of neurologic injury were identified. A subgroup analysis according to the type of neurologic injury was performed. Overall, NI occurred in 19% of patients in the overall series, but the proportion of patients with NI ranged from 0% to 65% among the centers. Ischemic stroke occurred in 84 patients and hemorrhagic stroke in 47 patients. Emergency procedure was the sole independent predictor of NI. In-hospital mortality was higher in the NI group than in the NNI group (79% v 61%, p < 0.001). The one-year survival was lower in the NI group (17%) compared with the NNI group (37%). Long-term survival did not differ between patients with ischemic stroke and those with hemorrhagic stroke. Neurologic injury during PC-ECMO is common and associated with a dismal prognosis. There is considerable interinstitutional variation in the proportion of neurologic injury in PC-ECMO-treated adults. Well-known risk factors for stroke are not associated with neurologic injury in this setting. [ABSTRACT FROM AUTHOR]

The optimal duration of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients affected by postcardiotomy cardiogenic shock (PCS) remains controversial. The present study was conducted to investigate the effect of VA-ECMO duration on hospital outcomes. Retrospective analysis of an international registry. Multicenter study including 19 tertiary university hospitals. Between January 2010 and March 2018, data on PCS patients receiving VA-ECMO were retrieved from the multicenter PC-ECMO registry. Patients were stratified according to the following different durations of VA-ECMO therapy: ≤three days, four-to-seven days, eight-to-ten days, and >ten days. A total of 725 patients, with a mean age of 62.9 ± 12.9 years, were included. The mean duration of VA-ECMO was 7.1 ± 6.3 days (range 0-39 d), and 39.4% of patients were supported for ≤three days, 29.1% for four-seven days, 15.3% for eight-ten days, and finally 20.7% for >ten days. A total of 391 (53.9%) patients were weaned from VA-ECMO successfully; however, 134 (34.3%) of those patients died before discharge. Multivariate logistic regression showed that prolonged duration of VA-ECMO therapy (four-seven days: adjusted rate 53.6%, odds ratio [OR] 0.28, 95% confidence interval [CI] 0.18-0.44; eight-ten days: adjusted rate 61.3%, OR 0.51, 95% CI 0.29-0.87; and >ten days: adjusted rate 59.3%, OR 0.49, 95% CI 0.31-0.81) was associated with lower risk of mortality compared with VA-ECMO lasting ≤three days (adjusted rate 78.3%). Patients requiring VA-ECMO therapy for eight-ten days (OR 1.96, 95% CI 1.15-3.33) and >10 days (OR 1.85, 95% CI 1.14-3.02) had significantly greater mortality compared with those on VA-ECMO for 4 to 7 days. PCS patients weaned from VA-ECMO after four-seven days of support had significantly less mortality compared with those with shorter or longer mechanical support. [ABSTRACT FROM AUTHOR]

The authors evaluated the outcome of adult patients with coronavirus disease 2019 (COVID-19)–related acute respiratory distress syndrome (ARDS) requiring the use of extracorporeal membrane oxygenation (ECMO). Multicenter retrospective, observational study. Ten tertiary referral university and community hospitals. Patients with confirmed severe COVID-19–related ARDS. Venovenous or venoarterial ECMO. One hundred thirty-two patients (mean age 51.1 ± 9.7 years, female 17.4%) were treated with ECMO for confirmed severe COVID-19–related ARDS. Before ECMO, the mean Sequential Organ Failure Assessment score was 10.1 ± 4.4, mean pH was 7.23 ± 0.09, and mean PaO 2 /fraction of inspired oxygen ratio was 77 ± 50 mmHg. Venovenous ECMO was adopted in 122 patients (92.4%) and venoarterial ECMO in ten patients (7.6%) (mean duration, 14.6 ± 11.0 days). Sixty-three (47.7%) patients died on ECMO and 70 (53.0%) during the index hospitalization. Six-month all-cause mortality was 53.0%. Advanced age (per year, hazard ratio [HR] 1.026, 95% CI 1.000-1-052) and low arterial pH (per unit, HR 0.006, 95% CI 0.000-0.083) before ECMO were the only baseline variables associated with increased risk of six-month mortality. The present findings suggested that about half of adult patients with severe COVID-19–related ARDS can be managed successfully with ECMO with sustained results at six months. Decreased arterial pH before ECMO was associated significantly with early mortality. Therefore, the authors hypothesized that initiation of ECMO therapy before severe metabolic derangements subset may improve survival rates significantly in these patients. These results should be viewed in the light of a strict patient selection policy and may not be replicated in patients with advanced age or multiple comorbidities. Clinical Trial Registration: identifier, NCT04383678. [ABSTRACT FROM AUTHOR]

Many papers evaluated predictive factors for prolonged intensive care unit (ICU) stay after cardiac surgery, but efforts in translating those models in practical clinical tools is lacking. The aim of this study was to build a new nomogram score and test its calibration and discrimination power for predicting a long length of stay in the ICU among patients undergoing coronary artery bypass graft surgery (CABG). Retrospective analysis of an international registry. Multicentric. Based on the european multicenter study on coronary artery bypass grafting (E-CABG) registry (NCT 02319083), a total of 7,352 consecutive patients who underwent isolated CABG were analyzed. A "long length of stay" in the ICU was considered when equal to or more than 3 days. Predictive factors were analyzed through a multivariate logistic regression model that was used for the nomogram. Long length of ICU stay was observed in 2,665 patients (36.2%). Ten independent variables were included in the final regression model: the SYNTAX score class critical preoperative state, left ventricular ejection fraction class, angina at rest, poor mobility, recent potent antiplatelet use, estimated glomerular filtration rate class, body mass index, sex, and age. Based on this 10-risk factors logistic regression model, a nomogram has been designed. The authors defined a nomogram model that can provide an individual prediction of long length of ICU stay in cardiovascular surgical patients undergoing CABG. This type of model would allow an early recognition of high-risk patients who might receive different preoperative and postoperative treatments to improve outcomes. [ABSTRACT FROM AUTHOR]

Epiaortic ultrasonography (EAU) is a valid imaging method to detect atherosclerotic changes of the ascending aorta and to guide surgical strategies for the prevention of cerebral embolism in patients undergoing isolated coronary artery bypass grafting (CABG). However, its use is not widespread. The impact of EAU on the outcome after isolated CABG was investigated in patients from the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry. A systematic review and meta-analysis of the literature was performed to substantiate the findings of this observational study. EAU was performed intraoperatively in 673 of 7241 patients (9.3%) from the E-CABG registry. In the overall series, the rates of stroke without and with aortic manipulation were 0.3% and 1.3%, respectively (P =.003). In 660 propensity score–matched pairs, EAU was associated with significantly lower risk of stroke (0.6% vs 2.6%, P =.007). A literature search yielded 5 studies fulfilling the inclusion criteria. These studies, along with the present one, included 11,496 patients, of whom 3026 (25.7%) underwent intraoperative EAU. Their rate of postoperative stroke was significantly lower than in patients not investigated with EAU (pooled rate, 0.6% vs 1.9%; risk ratio, 0.40; 95% confidence interval, 0.24-0.66; I 2 = 0%). On the basis of these pooled rates, the number needed to treat to prevent 1 stroke is 76.9. Avoiding aortic manipulation is associated with the lowest risk of stroke in patients undergoing CABG. When manipulation of the ascending aorta is planned, EAU is effective in guiding the surgical strategy to reduce the risk for embolic stroke in these patients. [ABSTRACT FROM AUTHOR]

Diseases of the thoracic aorta are increasing in prevalence worldwide. Recent data indicated wide regional variation in the volume and complexity of aortic cases undertaken in United Kingdom cardiac centers, especially in case of acute type A aortic dissection (ATAAD) conditions. Patients treated in high-volume centers with a specific multidisciplinary aortic program had a significant reduction in ATAAD mortality when compared with low-volume centers. Following the initial phase of a national aortic center reorganization, the current study reflects the initial experience of a national collective of cardiothoracic surgeons with expertise in complex aortic surgery, using frozen elephant trunk as standard technique for the surgical treatment of patients affected by ATAAD. Between June 2013 and October 2017, 66 ATAAD patients (45% women) underwent hybrid aortic arch and frozen elephant trunk repair with the Thoraflex hybrid graft at 8 UK high-volume aortic centers. The in-hospital mortality accounted for 8 patients (12%). Postoperative temporary or permanent neurologic events and temporary renal replacement therapy occurred in 17% and 20% of patients, respectively. No spinal cord injury events were documented. Our data were similar to those reported in literature in the 2 largest experiences with the use of frozen elephant technique in ATAAD condition (in-hospital/30-day mortality: 11-12%). This initial experience demonstrated that frozen elephant technique can potentially be adopted as standard approach in life-threatening aortic diseases, with acceptable complication and mortality rates. [ABSTRACT FROM AUTHOR]

We evaluated perioperative bleeding after coronary artery bypass grafting (CABG) in patients preoperatively treated with ticagrelor or clopidogrel, stratified by discontinuation of these P2Y 12 inhibitors. All patients from the prospective, European Multicenter Registry on Coronary Artery Bypass Grafting (E-CABG) treated with ticagrelor or clopidogrel undergoing isolated primary CABG were eligible. The primary outcome measure was severe or massive bleeding defined according to the Universal Definition of Perioperative Bleeding, stratified by P2Y 12 inhibitor discontinuation. Secondary outcome measures included four additional definitions of major bleeding. Propensity score matching was performed to adjust for differences in preoperative and perioperative covariates. Of 2,311 patients who were included, 1,293 (55.9%) received clopidogrel and 1,018 (44.1%) ticagrelor preoperatively. Mean time between discontinuation and the operation was 4.5 ± 3.2 days for clopidogrel and 4.9 ± 3.0 days for ticagrelor. In the propensity score–matched cohort, ticagrelor-treated patients had a higher incidence of major bleeding according to Universal Definition of Perioperative Bleeding when ticagrelor was discontinued 0 to 2 days compared with 3 days before the operation (16.0% vs 2.7%, p = 0.003). Clopidogrel-treated patients had a higher incidence of major bleeding according to the Universal Definition of Perioperative Bleeding when clopidogrel was discontinued 0 to 3 days compared with 4 to 5 days before the operation (15.6% vs 8.3%, p = 0.031). In patients receiving ticagrelor 2 days before CABG and in those receiving clopidogrel 3 days before CABG, there was an increased rate of severe bleeding. Postponing nonemergent CABG for at least 3 days after discontinuation of ticagrelor and 4 days after clopidogrel should be considered. [ABSTRACT FROM AUTHOR]

Background Prothrombin complex concentrate (PCC) has recently emerged as an effective alternative to fresh frozen plasma (FFP) in treating excessive perioperative bleeding. This systematic review and meta-analysis evaluated the safety and efficacy of PCC administration as first-line treatment for coagulopathy after adult cardiac surgery. Methods PubMed/MEDLINE, EMBASE, and the Cochrane Library were searched from inception to the end of March 2018 to identify eligible articles. Adult patients undergoing cardiac surgery and receiving perioperative PCC were compared with patients receiving FFP. Results A total of 861 adult patients from four studies were retrieved. No randomized studies were identified. Pooled odds ratios (ORs) showed that the PCC cohort was associated with a significant reduction in the risk of RBC transfusion (OR, 2.22; 95% confidence interval [CI], 1.45 to 3.40) and units of RBC received (OR, 1.34; 95% CI, 0.78 to 1.90). No differences were observed between the groups for reexploration for bleeding (OR, 1.09; 95% CI, 0.66 to 1.82), chest drain output at 24 hours (OR, 66.36; 95% CI, −82.40 to 216.11), hospital mortality (OR, 0.94; 95% CI, 0.59 to 1.49), stroke (OR, 0.80; 95% CI, 0.41 to 1.56), and occurrence of acute kidney injury (OR, 0.80; 95% CI, 0.58 to 1.12). A trend toward increased risk of renal replacement therapy was observed in the PCC group (OR, 0.41; 95% CI, 0.16 to 1.02). Conclusions In patients with significant bleeding after cardiac surgery, PCC administration seems to be more effective than FFP in reducing perioperative blood transfusions. No additional risks of thromboembolic events or other adverse reactions were observed. Randomized controlled trials are needed to establish the safety of PCC in cardiac surgery definitively. [ABSTRACT FROM AUTHOR]

Objective Transcatheter mitral valve-in-valve/valve-in-ring procedures (TM-VIVoR) are increasing. The authors aimed to identify independent predictors for hospital mortality in redo mitral valve surgery as possible future selection criteria for TM-VIVoR. Design Retrospective multicenter registry. Setting Tertiary university and community hospitals. Participants Two-hundred and sixty patients (out of 920 enrolled) who are potentially candidates for TM-VIVoR undergoing redo-surgery. Interventions Redo mitral surgery. Measurements and Main Results Regression analyzes and receiver operating characteristic (ROC) curves identified independent predictors of death. Patients potentially candidates for TM-VIVoR reported significant hospital mortality (9.2%; EuroSCORE II: 13.2 ± 13.1, Society of Thoracic Surgeons [STS] score: 6.2 ± 3.1) and major morbidity (3.8% acute myocardial infarction, 5% stroke, 16.9% perioperative respiratory failure, 16.5% acute renal insufficiency, 25% massive transfusions). EuroSCORE II (odds ration [OR] 1.06; confidence interval [CI] 1.01-1.10; p = 0.005), STS score (OR 1.58; CI 1.27-1.97; p = 0.001), age at surgery (OR 1.05; CI 1.00-1.15; p = 0.05), preoperative dialysis (OR 2.5; CI 1.8-12.6; p = 0.042), left ventricular ejection fraction (LVEF) <30% (OR 4.8; CI 1.12-37.1; p = 0.021), severe pulmonary hypertension (OR 7.5; CI 1.9-29.4; p = 0.003), and previous coronary artery bypass grafting (CABG) (OR 11.8; CI 1.7-36.9; p = 0.002) were independent predictors of hospital mortality. ROC analyses reported good prediction for EuroSCORE II (AUC: 0.76; cut-off value: >13.1; 70.8% sensitivity and 68.2% specificity) and better prediction for STS score (AUC: 0.81; cut-off value: 7.4; 75.0% sensitivity and 66.2% specificity). Quintiles stratification identified EuroSCORE II ≥18.7 (5th quintile, observed mortality: 19.3%) and STS score >9.1 as strong predictors of death within each risk-categorization (OR 5.9 and 12.1, respectively). Conclusions High EuroSCORE II and STS scores, advanced age at surgery, LVEF <30%, previous CABG, severe pulmonary hypertension or preoperative dialysis might represent in the future preferred indications for TM-VIVoR in the redo-mitral surgery scenario. [ABSTRACT FROM AUTHOR]

Objective The aim of this paper is to report midterm results of thoracic endovascular aortic repair (TEVAR) for ascending aortic pseudoaneurysms (AAPs) and penetrating aortic ulcers (PAUs) of the ascending aorta. Methods This study was retrospective and performed at tertiary centers. Eight patients with AAPs (n = 5) and PAUs (n = 3) received total endovascular repair of the ascending aorta. Patients with a history of type A aortic dissection or fusiform aneurysm were excluded. All patients analyzed were considered to be at high risk for open repair at the time of presentation. Results Urgent intervention was performed in 6 (75%) cases. Primary clinical success was achieved in 7 (87.5%) cases. A low-flow type 3 endoleak remained asymptomatic and was managed conservatively. No TEVAR-related in-hospital mortality, primary conversion, cerebrovascular accidents, valve impairment, or myocardial infarction occurred. All patients were discharged home, alive and independent, after a median length of stay of 6 (range: 5-24) days. No patient was lost at a mean follow-up of 40 ± 33 (range: 4-93) months. Ongoing primary clinical success was maintained in all but 1 patient (type 3 endoleak): aortically related reintervention was never required. No endograft breakage or migration was observed. At 1-year follow-up, 7 (87.5%) aortic lesions had significant reduction in diameter (≥5 mm). Conclusions Ascending TEVAR was feasible, safe, and effective for AAPs and PAUs. In a very select subset of lesions, midterm results were favorable, with both standard and custom-designed endografts. [ABSTRACT FROM AUTHOR]

Background This study evaluated the prognostic significance of a novel bleeding severity classification in adult patients undergoing cardiac operations. Methods The European multicenter study on Coronary Artery Bypass Grafting (E-CABG) bleeding severity classification proposes 4 grades of postoperative bleeding: grade 0, no need of blood products with the exception of 1 unit of red blood cells (RBCs); grade 1, transfusion of platelets, plasma, or 2 to 4 units of RBCs, or both; grade 2, transfusion of 5 to 10 units of RBCs or reoperation for bleeding, or both; grade 3, transfusion of more than 10 units of RBCs. This classification was tested in a cohort of 7,491 patients undergoing CABG or valve operations, or combined procedures. Results The E-CABG bleeding severity grading method was an independent predictor of in-hospital death, stroke, acute kidney injury, renal replacement therapy, deep sternal wound infection, atrial fibrillation, intensive care unit stay of 5 days or more, and composite adverse events of death, stroke, renal replacement therapy, and intensive care unit stay of 5 days or more. The area under the receiver operating characteristic curve of the E-CABG bleeding severity grading method for predicting in-hospital death was 0.858 (95% confidence interval, 0.827 to 0.889). E-CABG bleeding severity grades 0 to 3 were associated with in-hospital mortality rates of 0.2%, 1.1%, 7.9%, and 29.0%, respectively ( p <0.001), and with composite adverse events of 2.7%, 9.6%, 29.7%, and 75.8%, respectively ( p <0.001). Conclusions The E-CABG bleeding severity classification seems to be a valuable tool in the assessment of the severity and prognostic effect of perioperative bleeding in cardiac operations. [ABSTRACT FROM AUTHOR]

Objective The authors aimed to validate the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) classification of postoperative complications in patients undergoing coronary artery bypass grafting (CABG). Design Retrospective, observational study. Setting University hospital. Participants A total of 2,764 patients with severe coronary artery disease. Complete baseline, operative, and postoperative data were available for patients who underwent isolated CABG. Interventions Isolated CABG. Measurements and Main Results The E-CABG complication classification was used to stratify the severity and prognostic impact of adverse postoperative events. Primary outcome endpoints were 30-day, 90-day, and long-term all-cause mortality. The secondary outcome endpoints was the length of intensive care unit stay. Both the E-CABG complication grades and additive score were predictive of 30-day (area under the receiver operating characteristics curve 0.866, 95% confidence interval [CI] 0.829-0.903; and 0.876; 95% CI 0.844-0.908, respectively) and 90-day (area under the receiver operating characteristics curve 0.850, 95% CI 0.812-0.887; and 0.863, 95% CI 0.829-0.897, respectively) all-cause mortality. The complication grades were independent predictors of increased mortality at actuarial (log-rank: p<0.0001) and adjusted analysis (p<0.0001; grade 1: hazard ratio [HR] 1.757, 95% CI 1.111-2.778; grade 2: HR 2.704, 95% CI 1.664-4.394; grade 3: HR 5.081, 95% CI 3.148-8.201). When patients who died within 30 days were excluded from the analysis, this grading method still was associated with late mortality (p<0.0001). The grading method (p<0.0001) and the additive score (rho, 0.514; p<0.0001) were predictive of the length of intensive care unit stay. Conclusions The E-CABG postoperative complication classification seems to be a promising tool for stratifying the severity and prognostic impact of postoperative complications in patients undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to evaluate the immediate and late outcome of emergency coronary artery bypass grafting (CABG) in a multicenter setting. Design Multicenter, retrospective study. Setting Four university hospitals. Participants 596 patients were included in this study. Interventions Included patients underwent isolated, emergency CABG. Measurements and Main Results Sixty patients (absolute rate: 10.1%, pooled rate: 8.7%) died during the in-hospital stay period. Increasing emergency CABG classes (p<0.0001), recent myocardial infarction (p = 0.019), left ventricular ejection fraction≤30% (p = 0.034), on-pump surgery (p = 0.012), and participating centers (p<0.0001) were independent predictors of in-hospital mortality. Survival rates at 1, 3, and 5 years were 86.4%, 81.6%, and 76.1%, respectively. Extracorporeal membrane oxygenation was used in 6 patients and 3 of them (50.0%) survived the immediate postoperative period. Patient populations of participating centers differed significantly in most of baseline characteristics. The preoperative use of intra-aortic balloon pump (8% to 51%) and off-pump surgery (2.8% to 56.3%) varied significantly between institutions. In-hospital mortality (2.8%, 5.9%, 7.7% and 19.8%, p<0.0001), as well as midterm survival, significantly differed between institutions (at 3 years, 90.6%, 89.8%, 81.2%, and 67.2%, p<0.0001). Conclusions The outcome after emergency CABG is satisfactory despite a significant operative risk. However, the results of emergency CABG significantly differed between the participating institutions, likely due to differences in the referral pathways and perioperative treatment strategies. Evaluation of these factors is crucial for implementation of treatment in centers with suboptimal results. [ABSTRACT FROM AUTHOR]

Acute bowel ischemia is a perioperative complication that is frequently unrecognized as a cause of death after cardiac surgical procedures, with an in-hospital mortality of 50% to 100%. In recent years, controversy regarding the most appropriate approach to resolve clinical or laboratory suspicion and the limited therapeutic options have led to very little improvement in patient prognosis. This article reviews the related literature examining the actual prevalence, pathophysiologic mechanisms, predisposing factors, diagnostic tests, and therapeutic approaches providing a glance at new promising tools in diagnostic workup. [ABSTRACT FROM AUTHOR]

Abstract: Background: Acute kidney injury (AKI) is a vexing complication of cardiac surgery. Since exposure to contrast agents is a relevant contributing factor in the development of postoperative AKI, the optimal timing between cardiac catheterization and surgery is decisive. Methods: A total of 2504 consecutive nonemergent patients undergoing isolated coronary artery bypass grafting (CABG), valve surgery (with or without concomitant CABG), and proximal aortic procedures were enrolled. AKI was defined by consensus RIFLE (Risk, Injury, Failure, Loss of function, End-stage renal disease) criteria. The association of postoperative AKI and time between cardiac catheterization and operation was evaluated using multivariable logistic regression modeling and propensity-matched analysis. Results: Postoperative AKI occurred in 230 (9%) patients. The median number of days from cardiac catheterization to operation was 5 (25th to 75th percentile: 2 to 10). The incidence of AKI was significantly higher in patients operated on ≤1day after cardiac catheterization compared to those operated on >1day after (13% vs. 8%, p =0.004). The time interval between cardiac catheterization and surgery (tested both as a continuous and a categorical variable) was not an independent AKI predictor in the propensity-matched population or the pre-matched one. Contrast exposure ≤1day before surgery was independently associated with postoperative AKI in patients undergoing valve surgery with concomitant CABG only (post-matched: OR 3.68, 95%CI 1.30 to 10.39, p =0.014). Conclusions: Delaying cardiac surgery beyond 24h of exposure to contrast agents seems to be justified only in patients undergoing valve surgery with concomitant CABG. [Copyright &y& Elsevier]

Background: Octogenarians undergoing surgical aortic valve replacement (AVR) after prior cardiac surgery are expected to be at high risk of adverse events. This finding has recently popularized transcatheter AVR in this cohort. Methods: This multicenter study includes 744 patients (99 were 80 years or older) who underwent surgical AVR after prior cardiac surgery. The outcome of octogenarians was compared with younger patients in the entire cohort and in a propensity score–matched population. Results: Octogenarians and younger patients had similar immediate outcome (in-hospital mortality, 3.0% versus 5.9%; p = 0.34; stroke, 5.1% versus 6.7%; p = 0.66; dialysis, 9.1% versus 6.5%; p = 0.34), as confirmed also in 84 propensity score–matched pairs. Octogenarians and younger patients had similar late survival (5-year survival, 83.1% versus 78.0%; p = 0.68; propensity score–adjusted relative risk [RR], 0.23; 95% confidence interval [CI], 0.59 to 1.88). Octogenarians and younger patients had similar freedom from heart failure episodes (at 5 years, 84.5% versus 89.2%; p = 0.311; propensity score–adjusted RR, 1.37; 95% CI, 0.62 to 3.04) and from reoperation (at 5 years, 94.9% versus 97.9%; p = 0.51; propensity score–adjusted RR, 1.93; 95% CI, 0.35 to 10.56). However, octogenarians had poorer freedom from late stroke (at 5 years, 89.8% versus 97.5%; p = 0.016; propensity score–adjusted RR, 6.137; 95% CI, 1.776 to 21.208) and peripheral thromboembolism (at 5 years, 90.0% versus 98.2%; p = 0.003; propensity score–adjusted RR, 4.00; 95% CI, 1.07 to 15.00). Conclusions: Octogenarians undergoing surgical AVR after prior cardiac surgery have similar immediate postoperative outcome as younger patients, and their 5-year outcome is excellent. These data suggest that indications to undergo transcatheter AVR should not rely only on coexistence of advanced age and history of prior cardiac surgery. [Copyright &y& Elsevier]

Despite criticisms over the last decade, heart valve surgery through right anterior minithoracotomy (MT) prove excellent short-term and long-term-term results, becoming a feasible and popular alternative to the sternotomy approach. The rapid development and refinements of techniques have led to MT valve surgery being considered safe, effective, and durable. Minithoracotomy has been demonstrated to be a valid cost-effective and cost-saving strategy for valve surgery, being associated with reduced morbidity and mortality. Tangible benefits include less pain, faster postoperative recovery, and better cosmetic results. As a result, MT has been increasingly used as a routine approach in many centers for both aortic and mitral valve surgery. [ABSTRACT FROM AUTHOR]

Aortic arch pathologies remain a technical challenge. The major difficulties in endovascular repair involve anatomic factors and technical aspects. The location of the disease may restrict an adequate proximal sealing zone, and alignment of the endograft is fundamental to acute success and long-term stability. We describe the successful endovascular repair of a 61-mm aortic arch aneurysm using a new branched device. [ABSTRACT FROM AUTHOR]

Background: This study analyzed the incidence and the predictive factors of postoperative acute kidney injury (AKI) after thoracic endovascular aortic repair (TEVAR) and evaluated the effect of AKI on postoperative survival. Methods: Between November 2000 and April 2011, all consecutive patients undergoing TEVAR of the descending thoracic or thoracoabdominal aorta were enrolled at four teaching hospitals. Estimated glomerular filtration rate (eGFR) was evaluated during the entire hospitalization. AKI was defined by the RIFLE (Risk, Injury, Failure, Loss of function, End-stage renal disease) consensus criteria. Results: The study included 171 patients (80% men) who were a mean age of 69 ± 14 years (range, 18-87 years). AKI occurred in 24 patients (14%). Independent predictors of postoperative AKI were preoperative depressed eGFR, thoracoabdominal extent, and postoperative transfusion. Patients with AKI experienced major postoperative complications (P = .001), longer hospitalization (P = .008), and higher hospital mortality (29% vs 4%; P < .001). Kaplan-Meier analysis showed a survival of 82%, 51%, and 51% at 1, 3, and 5 years for patients who developed AKI, which was significantly worse than the 99%, 89%, and 80% for patients who did not experience AKI (P = .001). Conclusions: Preoperative poor renal function, blood transfusions, and the thoracoabdominal extent of the aortic disease were the most important predictors for AKI. [Copyright &y& Elsevier]

Background: Delirium after cardiac operations is associated with significant morbidity and death. Statins have been recently suggested to exert protective cerebral effects. This study investigated whether preoperative statins were associated with decreased incidence of postoperative delirium in patients undergoing coronary artery bypass grafting. Methods: The study enrolled 4,659 consecutive patients (21% women; age, 67.8 ± 9.2 years) undergoing coronary artery bypass grafting. A propensity score-based optimal-matching algorithm was used to match 1,577 patients receiving preoperative statins with a control group (1:1). Patients were screened for delirium in the intensive care unit according to the Confusion Assessment Method for the intensive care unit. Results: Delirium affected 89 patients (3%), and preoperative statin administration was not multivariably associated with a decreased incidence of delirium (odds ratio, 1.52; 95% confidence interval, 0.97 to 2.37; p = 0.18) and was also unrelated to a delirium decrease in patient subgroups undergoing isolated coronary artery bypass grafting (odds ratio, 1.31; 95% confidence interval, 0.68 to 2.52; p = 0.51) or combined valvular procedures (odds ratio, 1.72; 95% confidence interval, 0.96 to 3.07, p = 0.08). Similar results were observed for age groups and cardiopulmonary bypass durations. Patients affected by postoperative delirium experienced a longer hospital stay (25th to 75th percentile) of 11 (7 to 18 days) vs 7 days (7 to 8 days, p < 0.001) and 12% hospital mortality vs 1% ( p < 0.001). Conclusions: Preoperative statins were not associated with a decreased incidence of delirium in patients undergoing coronary revascularization. [ABSTRACT FROM AUTHOR]

Abstract: Background: A balance between angiogenic and anti-angiogenic factors is critical in tissue development, tissue repair and homeostasis. Aberrant angiogenesis has been implicated in several pathologic conditions, including valvular heart disease. The aim of this study was to ascertain the pathogenetic role of angiogenesis in rheumatic and mixomatous mitral valve diseases. Methods: Leaflets from mixomatous (n=20) and rheumatic (n=20) mitral valves removed from surgical patients, and normal mitral valve (n=6) obtained at autopsy were collected. Immunohistochemical studies were performed on sequential valve sections, evaluating CD31, CD34, α smooth muscle actin (α-SMA), vascular endothelial growth factor (VEGF), VEGF receptor-1 (VEGFR1), VEGF receptor-2 (VEGFR-2), and chondromodulin-I (Chm-I). Results: Immunohistochemistry revealed significant differences among groups in CD31 (p=0.001), CD34 (p<0.001), α-SMA (p<0.001), VEGF (p<0.001), VEGFR1 (p=0.007), VEGFR2 (p=0.011), and Chm-I (p<0.001) expressions. Rheumatic valves demonstrated a severe up-regulation and down-regulation in pro-angiogenic and anti-angiogenic factors, respectively, compared with mixomatous and normal mitral valves. On the contrary, mixomatous valves showed a significant up-regulation of anti-angiogenic factors with respect to rheumatic and normal valves. Conclusions: These findings provide evidence that an imbalance between pro-angiogenic and anti-angiogenic factors is implicated in mitral valve disease. Pro-angiogenic factors are up-regulated in rheumatic disease, while anti-angiogenic ones in mixomatous mitral valves. [Copyright &y& Elsevier]

Acute kidney injury (AKI) occurs in as many as 40% of patients after cardiac surgery and requires dialysis in 1% of cases. Acute kidney injury is associated with an increased risk of mortality and morbidity, predisposes patients to a longer hospitalization, requires additional treatments, and increases the hospital costs. Acute kidney injury is characterized by a progressive worsening course, being the consequence of an interplay of different pathophysiologic mechanisms, with patient-related factors and cardiopulmonary bypass as major causes. Recently, several novel biomarkers have emerged, showing reasonable sensitivity and specificity for AKI prediction and protection. The development and implementation of potentially protective therapies for AKI remains essential, especially for the relevant impact of AKI on early and late survival. [ABSTRACT FROM AUTHOR]

Background: Chronic obstructive pulmonary disease is a risk factor for postoperative lung injury. Contradictory results have been published about leukocyte filtration (LF) because of the heterogeneity of patients and interventions, type of LF, and comorbidities. Methods: Sixty patients with mild moderate chronic obstructive pulmonary disease (forced expiratory volume in 1 second 40% to 80%) undergoing aortic valve surgery were randomly assigned to receive systemic arterial and cardioplegic LF during cardiopulmonary bypass (group L, 30 patients) or standard cardiopulmonary bypass (group S). Perioperative interleukin-6, interleukin-8, and tumor necrosis factor-alpha were sampled at different time points. The PaO2/inspired oxygen fraction (FiO2) and alveoloarterial oxygen gradient (AaDO2) were measured preoperatively, at intensive care unit arrival, and at 24, 48, and 72 hours postoperatively; lung compliance was measured after intubation, at intensive care unit arrival, and at 4 and 8 hours postoperatively; and radiographic lung injury score was determined preoperatively and at 24, 48 and 72 hours. Length of intubation, intensive care unit stay, hospital stay, need for noninvasive positive-pressure ventilation, acute lung injury, and pneumonia were recorded. Repeated-measures analysis of variance assessed group, time, and group by-time interactions. Results: Preoperative and intraoperative data were comparable. Proinflammatory cytokine leakage was reduced by LF. Group L showed shorter intubation time (median 9.5 hours versus group S, 15.0 hours; p = 0.0001), and intensive care unit length of stay (median 19.0 hours versus group S, 24.5; p = 0.0001), lower need for noninvasive positive-pressure ventilation (5 of 30, 16.7%, versus 12 of 30, 40%; p = 0.042). The AaDO2, PaO2/FiO2, lung compliance, and radiographic lung injury score worsened early postoperatively, followed by progressive improvements (time p ≤ 0.001 for all). Such decline of AaDO2, PaO2/FiO2, lung compliance, and radiographic lung injury score was significantly attenuated by LF (group by-time p = 0.0001 for AaDO2, PaO2/FiO2, and lung compliance; p = 0.004 for radiographic lung injury score). Conclusions: Arterial plus cardioplegic LF significantly reduced proinflammatory cytokine release after cardiopulmonary bypass, thus ameliorating postoperative indexes of lung function and overall respiratory outcome. [Copyright &y& Elsevier]

Objectives: The objective of this study was to evaluate the effects of different lesion sets of ablation in patients undergoing mitral surgery plus maze. Background: The role of lesion sets on outcome after maze is poorly defined. Methods: A total of 141 patients were prospectively followed up. Two different lesion sets were prepared: 32 patients underwent a radiofrequency left atrial lesion set of maze (“limited”), and 109 had combined left and right atrial lesion sets of maze ± ganglionic plexi isolation (“extensive”). A longitudinal observational study assessed the role of “extensive” versus “limited” ablation on atrial fibrillation (AF), New York Heart Association (NYHA) functional class II/III, treatment with antiarrhythmic drugs, follow-up recovery of the ratio of E- to A-wave (E/A), and survival and time to hospitalization (overall and for heart failure). Results: The prevalence of AF over time was lower in the “extensive” arm (adjusted relative risk [RR]: 0.10; 95% confidence interval [CI]: 0.03 to 0.31; p < 0.001), with significantly lower prevalence at discharge, 3 months, and 18 months. The prevalence of patients in NYHA functional class II/III over time was lower in the “extensive” arm (adjusted RR: 0.11; 95% CI: 0.03 to 0.34; p < 0.001), with significant differences at any assessment (except the third month). The differences in E/A recovery and use of antiarrhythmic drugs were less marked, with an RR of 1.55 (95% CI: 0.99 to 2.42; p = 0.05) and RR of 0.76 (95% CI: 0.54 to 1.06; p = 0.11), respectively, with a significantly lower prevalence of antiarrhythmic drugs in the “extensive” ablation arm at 12, 18, and 24 months. Rates of hospitalization for heart failure, overall hospitalization, and the combined event death/hospitalization were lower in the “extensive” arm (p = 0.11, p = 0.003, and p = 0.002, respectively). Conclusions: The addition of right-sided ablation improves clinical and electrophysiologic results after maze procedure. [Copyright &y& Elsevier]

Background: Leukocyte filtration has been reported to reduce inflammatory damage during cardiopulmonary bypass. We evaluated the role of leukocyte filtration on hospital outcome and postoperative morbidity. Methods: Eighty-two consecutive patients who underwent isolated coronary artery bypass grafting were randomly assigned (1:1) to receive leukocyte filters on both arterial and cardioplegia lines or standard arterial filters during cardiopulmonary bypass. Hospital outcome, postoperative markers of morbidity, and biochemical assays were compared. Data were collected preoperatively, intraoperatively, and postoperatively. Costs for patients receiving intraoperative leukofiltration were compared with control patients getting standard arterial filters. Results: Hospital mortality and intensive care unit and hospital length of stay were similar. Although duration of ventilation and incidence of pneumonia were comparable, leukocyte-depleted patients showed a higher ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (p = 0.008) and lower need for postoperative noninvasive ventilation (p = 0.041). Control patients showed higher need for continuous furosemide infusion (p = 0.013) and for renal replacement therapy (p = 0.014), in association with higher serum creatinine (p = 0.038) and blood urea (p = 0.18) and lower glomerular filtration rate (p = 0.038). Leukocyte-depleted patients required lower doses of inotropic agents (p = 0.56), whereas troponin I leakage and incidence of postoperative atrial fibrillation were comparable. No differences were found in terms of postoperative cerebral dysfunction or neutrophil and platelet counts, as well as postoperative bleeding and need for transfusions. Finally, leukodepletion proved significantly cost-beneficial, with a 37% cost reduction. Conclusions: Although hospital outcomes were similar in terms of mortality and length of stay, the improvements in pulmonary, renal, and myocardial function, in association with the cost benefit, justify the use of leukocyte-depletion filters in the clinical practice. [Copyright &y& Elsevier]

Endovascular intervention has emerged as a less traumatic alternative treatment for several diseases of the thoracic aorta. However, depending on the different aortic pathologies, procedure related complications have become increasingly evident: severe complications include type I endoleaks, migration, and endograft (EG) collapse, as well as those observed during conventional surgery (eg, stroke and paraplegia). One of the emerging and most alarming complication of thoracic endografting is iatrogenic retrograde type A acute dissection (RTAAD).5 Retrograde type A acute dissection is defined as acute aortic dissection that originates distally to the ascending aorta with a retrograde flap progression into the ascending aorta.6 This complication has been previously described during conventional cardiac surgery with high mortality rate; previous case reports suggested that the fragility of the aortic wall and Marfan disease were predisposing factors to such a life-threatening complication. This report presents a case of iatrogenic RTAAD after EG repair of a descending thoracic penetrating aortic ulcer, requiring emergent surgical replacement of the ascending aorta and the aortic arch. The available English literature on RTAAD was also reviewed, in order to recognize potential predisposing factors and specific strategies to prevent it. [Copyright &y& Elsevier]

Background: Cerebrovascular accidents are devastating and worrisome complications after thoracic endovascular aortic repair. The aim of this study was to determine cerebrovascular accident predictors after thoracic endovascular aortic repair. Methods: Between January 2001 and June 2008, 76 patients treated with thoracic endovascular aortic repair were prospectively enrolled. The study cohort included 61 men; mean age was 65.4 ± 16.8 years. All patients underwent a specific neurologic assessment on an hourly basis postoperatively to detect neurologic deficits. Cerebrovascular accidents were diagnosed on the basis of physical examination, tomography scan or magnetic resonance imaging, or autopsy. Results: Cerebrovascular accidents occurred in 8 (10.5%) patients, including 4 transient ischemic attack and 4 major strokes. Four cases were observed within the first 24-hours. Multivariable analysis revealed that anatomic incompleteness of the Willis circle (odds ratio [OR] 17.19, 95% confidence interval [CI] 2.10 to 140.66), as well as the presence of coronary artery disease (OR 6.86, 95 CI% 1.18 to 40.05), were independently associated with postoperative cerebrovascular accident development. Overall hospital mortality was 9.2%, with no significant difference for patients hit by cerebrovascular accidents (25.0% vs 7.3%, p = 0.102). Conclusions: Preexisting coronary artery disease, reflecting a severe diseased aorta and anomalies of Willis circle are independent cerebrovascular accident predictors after thoracic endovascular aortic repair procedures. A careful evaluation of the arch vessels and cerebral vascularization should be mandatory for patients suitable for thoracic endovascular aortic repair. [Copyright &y& Elsevier]

Background: Numerous studies have attempted to determine the etiology and prophylactic measures concerning atrial fibrillation (AF) after cardiac surgery. However, limited data are available analyzing the association between postoperative AF and late mortality. We sought to determine if AF after cardiac surgery affects postoperative survival. Methods: All cardiac surgery patients (n = 9,495) undergoing cardiac surgery between January 1994 and December 2004 were studied. The study population comprised coronary artery bypass graft surgery (CABG [n = 7,621]), valvular surgeries (n = 995), and their combination (n = 879). Patients affected by postoperative AF were identified, and long-term survival was obtained from Swedish population registry and evaluated using Cox proportional hazards methods to adjust for baseline differences. Results: The overall AF incidence was 26.7%, subdivided into 22.9%, 39.8%, and 45.2% for CABG, valve surgery, and combined procedures, respectively. The median follow-up for the entire study population was 7.9 years (maximum, 13.4). Postoperative AF independently affected long-term survival in CABG patients (hazard ratio 1.22; 95% confidence interval: 1.08 to 1.37). For isolated valvular surgery or combined procedures, AF was not significantly associated with long-term survival (hazard ratio 1.21, 95% confidence interval: 0.92 to 1.58; and hazard ratio 1.15, 95% confidence interval: 0.90 to 1.46, respectively). Conclusions: Postoperative AF increases late mortality after isolated CABG surgery only. This finding was not statistically confirmed after isolated or combined valvular procedures. Our results draw the attention to possible AF recurrence after hospital discharge, indicating a strict postoperative surveillance. [Copyright &y& Elsevier]

Background: Our prospective investigation aimed to determine and analyze the incidence and the determinants of endoleaks after thoracic stent graft. Methods: Sixty-one patients affected by thoracic aortic aneurysms were treated between January 2000 and March 2008. The study cohort contained 54 men, with a mean age of 63.6 ± 17.9 years. The follow-up imaging protocol included chest radiographs and triple-phase computed tomographic angiography performed at 1, 4, and 12 postoperative months and annually thereafter. Results: Median follow-up was 32.4 months (range: 1–96 months). Endoleaks were detected in 9 (14.7%) patients, of which 7 were type 1. Five endoleaks were detected at 30 postoperative days, and the other 4 developed with a mean delay of 12 months. Endovascular or hybrid interventions were used to treat the endoleaks. Secondary technical success rate was 100%. Multivariate analysis demonstrated that the diameter of the aneurysmal aorta (odds ratio 1.75, 95% confidence interval 1.07–2.86) and the coverage of the left subclavian artery (odds ratio 12.05, 95% confidence interval 1.28–113.30) were independently associated with endoleak development. The percentages of patients in whom reinterventions were unnecessary were 94.6% ± 3.0%, 88.3% ± 4.5%, and 85.4% ± 5.2%, at 1, 2, and 5 years, respectively. The actuarial survival estimates at 1, 2, and 5 years were 85.2% ± 4.6%, 78.1% ± 5.4%, and 70.6% ± 6.4%, respectively. Conclusions: The diameter of the aneurysmal aorta and the position of the landing zone are independent predictors of endoleak occurrence after thoracic stent-graft procedures. A careful follow-up program should be considered in patients in whom these indices are unfavorable, because most of the endoleaks may be successfully and promptly treated by additional endovascular procedures. [Copyright &y& Elsevier]

Abstract: Objective: Postoperative atrial fibrillation (AF) is a vexing problem in cardiac surgery. Our aim was to identify risk factors between surgical procedures, all having cardiopulmonary bypass (CPB) in common, and how AF contributes to early and late mortality. Methods: Patients were reviewed during a 10-year period, comprising coronary artery bypass grafting (CABG, n =7056), aortic valve replacement (AVR, n =690) and their combination (COMB, n =688). The study assessed 43 variables of which pre-/intraoperative data were evaluated for uni/multivariate analysis in relation to AF and type of surgery. Data were reviewed versus hospital and 1-year mortality; the latter being obtained from the Swedish population registry. Results: The surgery subgroups exhibited obvious differences. The overall incidence of AF was 25.6%, ranging from 22.7% for CABG to 44.0% for COMB procedures. Numerous interaction patterns were seen among the analyzed parameters. In multivariate fashion, age was encountered in all groups, whereas coronary disease superimposed risk factors with reference to myocardial conditions at CPB weaning. Postoperative AF increased the length of hospitalization, whereas it did not affect hospital mortality. In CABG patients only, AF gave rise to increased 1-year mortality (p <0.001). Conclusions: In addition to the accepted risk factors of AF, primarily age, we emphasize the importance of considering details at CPB weaning, a correlation that was coronary specific. The weaning period hides valuable information that can be useful for more specific AF-prophylactic strategies. The AF-related increase in late mortality after CABG but not after valve procedures is intriguing, and draws attention to possible AF recurrence during patient follow-up and management. [Copyright &y& Elsevier]

Background: Recent evidence supports the important role of inflammation in atrial fibrillation (AF) after coronary artery bypass grafting (CABG) and there is growing evidence that statin has cardiac antiarrhythmic effects. The aim of this study was to assess the efficacy of preoperative statins in preventing AF after CABG in a longitudinal observational study. Methods: Over a two-year period, 405 consecutive patients underwent isolated CABG procedures. Univariate analysis was performed exploring the relationship regarding statin use and AF development. A propensity score for treatment with statins was obtained from core patient characteristics. The role of statin therapy on postoperative AF was assessed by means of a conditional logistic model, while stratifying on the quintiles of the propensity score. All analysis was performed retrospectively. Results: Postoperative AF occurred in 29.5% of the patients with preoperative statin therapy compared with 40.9% of those patients without it (p = 0.021). No statistical differences among development of AF and type, dose, or duration of preoperative statin therapy were observed. Preoperative statins were associated with a 42% reduction in risk of AF development after CABG surgery (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.37 to 0.91, p = 0.017, while stratifying on the propensity score). No different effect of statins on AF was observed with respect to age groups (≤ 70 and >70 years) (interaction p = 0.711). Conclusions: Preoperative statins may reduce postoperative AF after CABG. Patients undergoing elective revascularization may benefit from a preventive statin approach. [Copyright &y& Elsevier]

Background: Postoperative atrial fibrillation is common after coronary surgery. The cellular condition of atrial myocytes might play a part in the postoperative development of atrial fibrillation. Our study aimed to investigate whether patients in whom postoperative atrial fibrillation develops show pre-existent alterations in histopathology of the right atrium and how such changes are expressed in relation to the use of cardiopulmonary bypass. Methods: Seventy patients undergoing elective coronary revascularization were prospectively randomized to on-pump conventional surgery (conventional coronary artery bypass grafting, n = 35) or off-pump surgery on the beating heart (off-pump coronary artery bypass grafting, n = 35). Samples from the right atrial appendage were immediately collected after opening the pericardium. In the on-pump group samples were also taken after weaning from cardiopulmonary bypass. Focusing on degenerative alterations, histology was studied by means of light microscopy and for confirmation of particular findings by means of electronic microscopy. Results: Twenty-two (31%) patients had postoperative atrial fibrillation, with the rate not being different between the off-pump coronary artery bypass grafting and conventional coronary artery bypass grafting groups (P = .797). Left atrial enlargement and inotropic requirement were related to atrial fibrillation. Interstitial fibrosis, vacuolization, and nuclear derangement of myocytes were the histologic abnormalities associated with the development of postoperative atrial fibrillation. However, in multivariate analysis fibrosis was confounded by myocyte vacuolization (P = .002) and nuclear derangement (P = .016), representing independent atrial fibrillation predictors. As expected, the conventional coronary artery bypass grafting and off-pump coronary artery bypass grafting groups showed similar histology, but more importantly, no atrial changes were detected in relation to cardiopulmonary bypass exposure in the conventional coronary artery bypass grafting group. Atrial histology showed degenerative changes that correlated with advanced age and left atrial enlargement. Conclusions: Our study supports the contention that atrial fibrillation after coronary surgery is associated with pre-existing histopathologic changes of the right atrium. Patients randomly allocated to off-pump coronary artery bypass grafting procedures showed a similar rate of atrial fibrillation and a similar relationship to atrial histology as did those exposed to cardiopulmonary bypass. Cardiopulmonary bypass did not cause additional changes in tested histology variables. [Copyright &y& Elsevier]

Abstract: Objectives: To review our experience of surgical repair of post-infarction ventricular septal defect (VSD). Methods: In the period 1983–2002, 50 patients underwent repair of VSD. Mean age was 66 years, male sex 52%. Infarct location was anterior in 60% and posterior in 40% of cases. Median interval between rupture and surgery was 2 days. Preoperative intra-aortic balloon counterpulsation was employed in 56%; a coronary angiogram was performed in 98% of cases. A patch repair technique was used in 90% of cases. Coronary bypass grafting was associated in 50% of patients. Results: Mean aortic clamp time was 101±31 min. Global operative mortality was 36%, respectively 26.7% in anterior and 50% in posterior location (p =ns). Emergency operation and interval from rupture to surgery less than 3 days were univariate predictor of early mortality. Five years survival excluding operative deaths was 76%. Conclusions: The surgical repair of post-infarction VSD entails a high operative mortality; different techniques were employed with similar results. Emergency operation is associated with a worse short-term prognosis; long-term survival is acceptable. [Copyright &y& Elsevier]

Abstract: Background: Coronary artery aneurysm (CAA) is a dilatation that exceeds 1.5 times the diameter of a normal adjacent coronary artery. Several studies suggest that pathogenetic mechanisms involved in this disease and in abdominal aortic aneurysm (AAA) are similar. Surgery for CAA is mandatory when the aneurysm is three to four times larger than the original vessel diameter. We reviewed our experience in the surgical treatment of this unusual disease and analyzed its association with AAA. Materials and methods: Between October 1993 and March 2005, 11 patients (9 men; mean age=66 years) underwent surgery for CAA. In all cases, coronary aneurysms were diagnosed as incidental findings in coronary angiographies. The coronary aneurysms were isolated and longitudinally incised: the proximal and distal openings were identified and sutured. The sacs were obliterated with running sutures. Myocardial protection was achieved by retrograde cardioplegia only. Coronary artery bypass grafting was performed distally to the excluded aneurysms in all patients. Results: One patient died of respiratory failure early after the operations; all other patients are alive, asymptomatic for angina, and free from repeated acute myocardial infarction after a median follow-up of 76 months (range=4–141 months). A total of six patients underwent surgical repair or endoprosthesis implantation because of AAAs. Conclusions: Our operative techniques ensured durable results. We recommend screening for abdominal aneurysms in all affected patients because of the frequent association between CAA and AAA as a result of their similar pathogenetic mechanism. [Copyright &y& Elsevier]

We hypothesized that cannulation strategy in venoarterial extracorporeal membrane oxygenation (VA-ECMO) could play a crucial role in the perioperative survival of patients affected by postcardiotomy shock. Between January 2010 and March 2018, 781 adult patients receiving VA-ECMO for postcardiotomy shock at 19 cardiac surgical centers were retrieved from the Postcardiotomy Veno-arterial Extracorporeal Membrane Oxygenation study registry. A parallel systematic review and meta-analysis (PubMed/MEDLINE, Embase, and Cochrane Library) through December 2018 was also accomplished. Central and peripheral VA-ECMO cannulation were performed in 245 (31.4%) and 536 (68.6%) patients, respectively. Main indications for the institution VA-ECMO were failure to wean from cardiopulmonary bypass (38%) and heart failure following cardiopulmonary bypass weaning (48%). The doubly robust analysis after inverse probability treatment weighting by propensity score demonstrated that central VA-ECMO was associated with greater hospital mortality (odds ratio 1.54; 95% confidence interval, 1.09-2.18), reoperation for bleeding/tamponade (odds ratio, 1.96; 95% confidence interval, 1.37-2.81), and transfusion of more than 9 RBC units (odds ratio, 2.42; 95% confidence interval, 1.59-3.67). The systematic review provided a total of 2491 individuals with postcardiotomy shock treated with VA-ECMO. Pooled prevalence of in-hospital/30-day mortality in overall patient population was 66.6% (95% confidence interval, 64.7-68.4%), and pooled unadjusted risk ratio analysis confirmed that patients undergoing peripheral VA-ECMO had a lower in-hospital/30-day mortality than patients undergoing central cannulation (risk ratio, 0.92; 95% confidence interval, 0.87-0.98). Adjustments for important confounders did not alter our results. In patients with postcardiotomy shock treated with VA-ECMO, central cannulation was associated with greater in-hospital mortality than peripheral cannulation. [ABSTRACT FROM AUTHOR]

The aim of this study was to identify the risk factors associated with early mortality after postcardiotomy venoarterial extracorporeal membrane oxygenation. This is an analysis of the postcardiotomy extracorporeal membrane oxygenation registry, a retrospective multicenter cohort study including 781 patients aged more than 18 years who required venoarterial extracorporeal membrane oxygenation for cardiopulmonary failure after cardiac surgery from 2010 to 2018 at 19 cardiac surgery centers. After a mean venoarterial extracorporeal membrane oxygenation therapy of 6.9 ± 6.2 days, hospital and 1-year mortality were 64.4% and 67.2%, respectively. Hospital mortality after venoarterial extracorporeal membrane oxygenation therapy for more than 7 days was 60.5% (P =.105). Centers that had treated more than 50 patients with postcardiotomy venoarterial extracorporeal membrane oxygenation had a significantly lower hospital mortality than lower-volume centers (60.7% vs 70.7%, adjusted odds ratio, 0.58; 95% confidence interval, 0.41-0.82). The postcardiotomy extracorporeal membrane oxygenation score was derived by assigning a weighted integer to each independent pre–venoarterial extracorporeal membrane oxygenation predictors of hospital mortality as follows: female gender (1 point), advanced age (60-69 years, 2 points; ≥70 years, 4 points), prior cardiac surgery (1 point), arterial lactate 6.0 mmol/L or greater before venoarterial extracorporeal membrane oxygenation (2 points), aortic arch surgery (4 points), and preoperative stroke/unconsciousness (5 points). The hospital mortality rates according to the postcardiotomy extracorporeal membrane oxygenation score was 0 point, 45.6%; 1 point, 40.5%; 2 points, 51.1%; 3 points, 57.8%; 4 points, 70.7%; 5 points, 68.3%; 6 points, 77.5%; and 7 points or more, 89.7% (P <.0001). Age, female gender, prior cardiac surgery, preoperative acute neurologic events, aortic arch surgery, and increased arterial lactate were associated with increased risk of early mortality after postcardiotomy venoarterial extracorporeal membrane oxygenation. Center experience with postcardiotomy venoarterial extracorporeal membrane oxygenation may contribute to improved results. [ABSTRACT FROM AUTHOR]