Intensive hyperglycemia control reduces postoperative infections after open heart surgery

Background: Diabetes mellitus increases the risk of infections in patients undergoing cardiac surgery. We hypothesized that intensive perioperative hyperglycemia control by intravenous insulin infusion reduces postoperative infections in all patients undergoing open heart surgical procedures. Methods: Sixty diabetics patients who underwent CABG operation (Group 1) were compared with fifty-five patients who underwent other cardiac surgery (Group 2) between January 2004 and March 2005. A continuous infusion of insulin was used in all these patients. Results: There were no 30-day mortalities in either group. There was no difference in the incidence of infections between the two groups: in Group 1, 3 (5%) patients were diagnosed to have postoperative infection (superficial sternal wound infections in 1 (1.66%) and lung infection in 2 (3.33%) patients); postoperative infection occurred in only 2 patients (3.63%) in Group 2, 1 superficial sternal wound infections (1.81%) and 1 lung infection (1.81%). Conclusions: Our analysis indicates that continuous intravenous insulin infusion improves outcome and reduces postoperative infections in patients undergoing CABG as well as those undergoing other cardiac surgery procedures.

Coronary rotational atherectomy via transradial approach: A study using radial artery intravascular ultrasound

The use of coronary rotational atherectomy via radial artery (RA) has been limited because of the large diameter of guiding catheters. We studied the feasibility of this approach by sizing the RA by intravascular ultrasound (IVUS) and using 7 Fr (2.31 mm) guiding catheters. Seventeen transradial percutaneous transluminal coronary rotational atherectomy (PTCRA) procedures were performed in 16 patients, mean age 62 +/- 12 years, for a total of 19 vessels treated. The mean RA diameter was 2.9 +/- 0.36 mm and the mean reference diameter of the treated coronary vessels was 2.7 +/- 0.45 mm. The mean coronary percent stenosis was 74% +/- 10%, the mean minimum lumen diameter was 0.76 +/- 0.35 mm, and the mean lesion length was 16 +/- 19 mm. Ten vessels were treated with rotational atherectomy alone, or with adjunctive high pressure balloon angioplasty, achieving an acute lumen gain of 0.8 +/- 0.4 mm (P = 0.001). Nine arteries had stent implantation in addition to rotational atherectomy, resulting in an acute lumen gain of 2.4 +/- 0.5 mm (P = 0.001). The success rate was 94%. There were no vascular complications. Two patients had a non-Q myocardial infarction. In conclusion, transradial PTCRA when used in conjunction with IVUS of the RA is a safe and feasible procedure in selected cases. This may be an alternative approach of revascularization technique especially for patients with limited vascular access and for those who require early ambulation or early discharge from the hospital. Cathet. Cardiovasc. Intervent. 51: 234-238, 2000. (C) 2000 Wiley-Liss, Inc

Cardiac Troponin I vs EuroSCORE: myocardial infarction and hospital mortality

Perioperative myocardial infarction is the most common cause of morbidity and mortality in cardiac surgery. It occurs in 8% to 35% of patients. The primary aim of this prospective study was to determine the level of cardiac troponin I that indicates perioperative myocardial infarction in patients undergoing coronary artery bypass. A secondary goal was to establish the best independent predictor of hospital death. There were 180 consecutive patients undergoing isolated coronary artery bypass surgery enrolled in this study. Values of cardiac troponin I > 12.9 ng.mL(-1) at 8 hours postoperatively predicted perioperative myocardial infarction with a sensitivity of 100% and a specificity of 93.2%. Compared to patients who survived, those who suffered hospital death were significantly older (74 +/- 7 vs 63 +/- 10 years), had significantly higher levels of cardiac troponin I at 24 hours (9 +/- 17 vs 27.3 +/- 16 ng.mL(-1)) and 48 hours (6.9 +/- 19 vs 30.3 +/- 24 ng.mL(-1)) postoperatively, and a significantly higher EuroSCORE (9 +/- 2 vs 4 +/- 3). At 8 hours postoperatively, cardiac troponin I led to an earlier diagnosis of perioperative myocardial infarction, while EuroSCORE was the strongest independent predictor of hospital death

Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery

Objective: Progression of functional tricuspid regurgitation is not uncommon after mitral valve surgery and is associated with poor outcomes. We tested the hypothesis that concomitant tricuspid valve annuloplasty in patients with tricuspid annulus dilatation (>= 40 mm) prevents tricuspid regurgitation progression after mitral valve surgery. Methods: We enrolled 44 patients undergoing mitral valve surgery (both repair or replacement) showing less than moderate (= 40 mm) at preoperative echocardiography. They were randomized to receive (n = 22) or not receive (n = 22) concomitant tricuspid annuloplasty (Cosgrove-Edwards annuloplasty ring; Edwards Lifesciences, Irvine, Calif) at the time of mitral valve surgery. Clinical and echocardiographic follow-up was 100% completed at 12 months after surgery. Results: Preoperative clinical and echocardiographic characteristics were comparable in the 2 groups. Operative mortality was 4.4%(1 death in each group). At 12 months follow-up, tricuspid regurgitation was absent in 71% (n 15) versus 19%(n 4) of patients in the treatment and control groups, respectively (P = .001). Moderate to severe tricuspid regurgitation (>=+3) was present in 0% versus 28%(n = 6) of patients in the treatment and control groups, respectively (P = .02). Pulmonary artery systolic pressure significantly decreased from baseline in all cases (P < .001) and was comparable in the 2 groups (41 +/- 8 mmHg vs 40 +/- 5 mm Hg; P = .4). Right ventricular reverse remodeling was marked in the treatment group (right ventricular long axis: 71 +/- 7mmvs 65 +/- 8 mm; P = .01; short axis: 33 +/- 4 mm vs 27 +/- 5 mm; P = .001) but only minimal in the control group (right ventricular long axis: 72 +/- 6 mm vs 70 +/- 7 mm; P = .08; short axis: 34 +/- 5 mm vs 33 +/- 5 mm; P = .1). The 6-minute walk test improved from baseline in both groups (P < .001), but this improvement was greater in the treatment group (+115 +/- 23 m from baseline vs +75 +/- 35 m; P = .008). Conclusions: Prophylactic tricuspid valve annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery was associated with a reduced rate of tricuspid regurgitation progression, improved right ventricular remodeling, and better functional outcomes. (J Thorac Cardiovasc Surg 2012;143:632-8

VENOUS THROMBOEMBOLISM IN PREGNANCY: CURRENT STATE OF THE ART

Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality during pregnancy or early after delivery and it remains a diagnostic and therapeutic challenge. The latest Confidential Enquiry into Maternal Deaths (2006-2008) showed that VTE is now the third leading cause of direct maternal mortality, beside sepsis and hypertension. In particular the prevalence of VTE has been estimated to be 1 per 1000-2000 pregnancies. The risk of VTE is five times higher in a pregnant woman than in non-pregnant woman of similar age and postpartum VTE is more common than antepartum VTE. A literature search was carried out on Pubmed using the following key words: "venous thromboembolism", "pregnancy", "risk factors", "prophylaxis", "anticoagulants". Studies from 1999 onwards were analyzed. This review aimed to provide an update of whole current literature on VTE in pregnancy highlighting the most recent findings in diagnostic and therapeutic strategies, considering in detail risks and benefits of various techniques and drug classes, for both mother and fetus. Large trials of anticoagulants administration in pregnancy are lacking and recommendations are mainly based on case series and on expert opinions. Nonetheless, anticoagulants are believed to improve the outcome of pregnancy for women with current or previous VTE

Metabolic Syndrome Affects Midterm Outcome After Coronary Artery Bypass Grafting

Background. Metabolic syndrome (MetS) is frequently associated with coronary artery disease, but data on the impact of MetS on long-term outcome of patients undergoing coronary artery bypass grafting are still lacking. The aim of the present study was to assess the effect of MetS on mortality and morbidity late after coronary artery bypass grafting. Methods. A total of 1,726 consecutive patients who had elective coronary artery bypass grafting were retrospectively reviewed and clinical follow-up was completed (mean follow-up time, 34.4 months; range, 6 to 79 months). The MetS was diagnosed using the modified Adult Treatment Panel III criteria, and to eliminate covariate differences, a propensity score adjustment was used. Major adverse cerebral and cardiovascular events were investigated, and C-reactive protein levels were assessed both preoperatively, postoperatively, and at follow-up. Results. A total of 798 of 1,726 patients (46.2%) met the diagnostic criteria for MetS. At follow-up, all-cause mortality (7% versus 4.6%; p = 0.04), cardiac arrhythmias (35.3% versus 25.2%; p < 0.0001), renal failure (12% versus 8.7%; p = 0.03), and major adverse cerebral and cardiovascular events (52.4% versus 39.5%; p < 0.0001) showed a significantly higher incidence in MetS patients. Variables correlated with late mortality at propensityadjusted Cox proportional-hazards regression were age (p = 0.0008), preoperative left ventricular ejection fraction (p = 0.001), preoperative renal failure (p = 0.001), and MetS (p = 0.006). Higher C-reactive protein levels were found preoperatively (8.6 +/- 2.3 versus 5.14 +/- 3.1 mg/L; p < 0.0001) and both early (71.2 +/- 9 versus 49.6 +/- 8.7 mg/L; p < 0.0001) and late (7.4 +/- 2.7 versus 4.8 +/- 2.5mg/L; p < 0.0001) after surgery. Conclusions. The main finding of our study was the association between MetS and mortality both early and late after coronary artery bypass grafting. Thus, MetS should be recognized as an independent preoperative variable that can lead to the identification of high-risk patients and as a risk factor to correct with lifestyle modifications and pharmacologic therapy. (Ann Thorac Surg 2012;93:537-44) (C) 2012 by The Society of Thoracic Surgeon

Acute kidney injury after coronary artery bypass grafting: Does rhabdomyolysis play a role?

Objective: In clinical situations in which rhabdomyolysis is common, renal dysfunction association with myoglobinemia is well described. After coronary artery bypass grafting, a rapid increase in serum myoglobin concentration is generally seen, but whether it might independently increase the risk of acute kidney injury remains to be determined. Methods: The study population consisted of 731 consecutive patients undergoing coronary artery bypass grafting. Creatine kinase, myoglobin, and creatinine concentrations were assessed in each patient preoperatively and postoperatively. Acute kidney injury was defined as an absolute increase in serum creatinine concentration of 0.3 mg/dL or greater. Results: Overall, 295 (40.3%) of 731 patients had acute kidney injury. Patients' risk profiles were significantly worse in those with acute kidney injury, and 31 (4.2%) of 731 patients required dialysis. Acute kidney injury was associated with a higher increase in serum myoglobin concentration after 1 hour from aortic declamping (534 mu g/mL [interquantile range, 354-733 mu g/mL] vs 377 mu g/mL [interquantile range, 278-528 mu g/mL], P<.0001), which persisted at 24 and at 48 hours. After adjusting for confounding factors, myoglobin concentration was found to independently predict postoperative acute kidney injury (odds ratio, 1.0011 [1 mu g/mL increase]; 95% confidence interval, 1.0003-1.0019; P=.005), and this result persisted when patients with perioperative myocardial infarction were excluded from the analysis (odds ratio, 1.0007; 95% confidence interval, 1.0002-1.0009; P=.01). Myoglobin concentration had a better accuracy to discriminate patients having acute kidney injury than creatine kinase concentration at any time. Conclusions: An increase in laboratory findings of muscle injury postoperatively, especially serum myoglobin concentration, predicts the incidence of acute kidney injury and renal replacement therapy requirement, as reported in other surgical settings. Perioperative myocardial injury cannot totally explain the occurrence of increased myoglobinemia. These results suggest an important role of skeletal muscle breakdown and necrosis in determining an increased myoglobinemia concentration after coronary artery bypass grafting. (J Thorac Cardiovasc Surg 2010; 140: 464-70

Perioperative administration of enoximone and renal function after cardiac surgery: A propensity-matched analysis

Background: Perioperative administration of enoximone has been shown to improve hemodynamics, organ function, and inflammatory response. Aim of the present study is to evaluate the impact of enoximone on postoperative renal function after on-pump cardiac surgery. Methods: A total of 3727 patients undergoing cardiac surgery at one Institution between May 2004 and November 2010 were reviewed. A propensity score was built and a 1: 1 perfect matching was performed, providing two fairly comparable cohorts of 712 patients each, receiving or not enoximone after surgery. Renal function was evaluated by lower glomerular filtration rate (GFR) value reached postoperatively. Results: Overall 30-day mortality rate was 4.3% (62/1424). Cumulative incidence of postoperative renal failure (RF) was 157/1424(11%), of which 99/1424(7%) needed renal replacement therapy. Mean lower postoperative GFR in patients who received or not enoximone was 63 +/- 30.1 and 53.5 +/- 26.1 ml/min/1.73 m(2) (p<0.0001), respectively. At multivariable analysis age (OR2.75, p=0.0004), diabetes (OR1.82, p=0.006), preoperative GFR (OR3.81, p<0.0001), preoperative cardiogenic shock (OR1.65, p=0.004), previous cardiac surgery (OR2.12, p=0.0002), type of intervention (OR1.96, p=0.005), and enoximone (OR0.38, p=0.001) were found to be independently associated with postoperative RF. Logistic regression analysis showed that the administration of enoximone (OR0.41, p=0.0001), and of no inotropes (OR0.27, p<0.0001) were protective vs. the occurrence of postoperative RF. Conclusion: Patients perioperatively receiving enoximone showed a statistically significant better renal function after cardiac surgery. (C) 2012 Elsevier Ireland Ltd. All rights reserved