Significance of preoperative acute kidney injury in patients with acute type A aortic dissection

Background/purpose: Acute type A aortic dissection (AAD) is a medical emergency with high mortality even with emergency repair. We explored the risk factors for in-hospital mortality and the impact of preoperative acute kidney injury (AKI) in patients with AAD. Methods: Our hospital database contained records for 156 consecutive patients who underwent AAD repair between March 2000 and February 2013. They were assigned to the in-hospital mortality or the survival group. All data were collected retrospectively. Results: The 30-day mortality, including intraoperative deaths, was 14.1% (22/156). Total in-hospital mortality was 19.2% (30/156). Patients who required preoperative cardiopulmonary resuscitation (CPR) (16.7 vs 3.2%; P = 0.012), or who presented with preoperative cardiac tamponade (46.7 vs 19.0%; P = 0.002), shock/hypotension (56.7 vs 21.4%; P < 0.001), or coma (20.0 vs 6.3%; P = 0.019) had a higher in-hospital mortality rate. There was no difference in in-hospital mortality rate between patients with preoperative AKI or not. Mortality and major complications were significantly correlated with the severity of AKI. Multivariate analysis confirmed that preoperative shock or hypotension (odds ratio = 5.2; 95% CI = 2.2–12.3), and preoperative AKI stage 3 (odds ratio = 4.9; 95% CI = 1.3–19.3) were independent preoperative prognostic factors of in-hospital mortality. Conclusion: On the basis of our results, preoperative stage 3 AKI is a crucial prognostic risk factor for patients with AAD repair, Cardiac surgeons should be aware of this condition when dealing with AAD patients. Keywords: Acute kidney injury, Acute type A aortic dissection, Mortalit

An Avoidable Complication of Percutaneous Coronary Intervention—Entrapment of Stent and Disconnected Balloon Catheter

During percutaneous coronary intervention, entrapment of catheter materials is a rare but life-threatening complication that sometimes requires emergency surgical treatment. Coronary artery stents have been developed to prevent acute coronary closure and reduce restenosis after coronary angioplasty. The most frequently reported complications of coronary stents are related to stent thrombosis and anticoagulation problems. This case study describes a 60-year-old female who had stable angina pectoris and underwent stent insertion into the left circumflex artery. Unfortunately, the coronary stent with balloon catheter was entrapped while crossing the angulated segment between the left circumflex and left main coronary artery. The stent catheter was surgically removed, and the patient underwent coronary artery bypass grafting successfully. Physicians should keep in mind that extremely angulated segments may reduce the successful rate of coronary stenting and contribute to the stent entrapment complication

Mitral tissue inhibitor of metalloproteinase 2 is associated with mitral valve surgery outcome.

BACKGROUND: Matrix metalloproteinases play a role in regulating cardiac remodeling. We previously reported an association between tissue inhibitor of metalloproteinase 2 (TIMP-2) expression and mitral valve (MV) disease. However, the determinants and prognostic value of mitral TIMP2 after MV surgery are unknown. METHODS: This retrospective study of 164 patients after MV surgery in a tertiary medical center in Taiwan assessed mitral TIMP2 on a semiquantitative scale (0-2) by immunohistochemical staining. The primary endpoints were the composite of cardiovascular death and heart failure admission. RESULTS: Mean age was 50.4±13.7 years. After a mean follow-up period of 101±59 months, primary endpoints had occurred in 25 (15.2%) subjects. Patients with and without primary endpoint events significantly differed in terms of age (56.6±14.4 vs. 49.2±13.4 years, respectively; p = 0.013) and left ventricular end-systolic diameter (LVESD) (39.7±8.2 vs. 35.5±7.5 mm, p = 0.010) at surgery. The TIMP2 had a significant dose-dependent association with development of a primary endpoint (p = 0.002). Kaplan-Meier analysis showed that TIMP2 expression has a significant positive association with primary endpoint-free survival (log-rank test; p = 0.004). Cox regression analysis showed that independent predictors of primary endpoints were TIMP2 (hazard ratio [HR] 0.28; 95% confidence interval [CI] 0.12-0.65; p = 0.003), age (HR 1.05; 95% CI 1.02-1.09; p = 0.003) and LVESD (HR 1.05; 95% CI 1.01-1.10; p = 0.020). CONCLUSIONS: The lack of mitral TIMP2 expression is associated with increases in cardiovascular death and heart failure following MV surgery

Representative images of TIMP2 expression from patients without and with primary endpoints.

<p>(A). Grade 2 (B). Grade 0 (original magnification 400×).</p

Semiquantitative scoring system for TIMP2 immunostaining.

<p>The samples were ranked into 3 grades based on the percentage of positive cells (see arrows): grade 0, negative (A); grade 1, positive staining in small number of cells (B); grade 2, positive staining in large number of cells (C) (original magnification 400×). TIMP2, tissue inhibitor of metalloproteinase.</p

Kaplan-Meier estimates of (A) primary endpoints (B) cardiovascular death (C) admission for heart failure between different TIMP2 expression populations.

<p>(p = 0.004, 0.042 and 0.021, respectively). TIMP2, tissue inhibitor of metalloproteinase.</p

Comparison of Baseline Characteristics and Medication between Patients with and without Primary Endpoint Events.

<p>LAD, left atrial diameter; LVESD, left ventricular end-systolic dimension; LVEDD, left ventricularend-diastolic dimension; RAS, renin-angiotensin system; ACEI, angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor blockers; CCB, calcium channel blocker.</p

Multivariate Cox regression analysis of independent predictors of primary endpoints.

<p>TIMP2, tissue inhibitor of metalloproteinase; LVESD, left ventricular end-systolic dimension.</p