1079-102 Correlation between norepinephrine and epinephrine myocardial spillover and tumor necrosis factor-alpha in conventional versus off-pump coronary artery bypass surgery

Background: Complete revascularization obtained by coronary artery bypass surgery does not prevent long term left ventricular remodeling and heart failure development. Periprocedural events linked to different surgical techniques, such as cardiopulmonary bypass with cardioplegic arrest (CABG) versus off-pump procedures may trigger an irreversible microvascular dysfunction or myocytes necrosis and apoptosis. Methods: To test this hypothesis we measured norepinephrine and epinephrine coronary sinus and aortic spillover before and after surgery, simultaneously with Tumor Necrosis Factor-alpha (TNF-alpha) measurements in 30 patients randomized to CABG (n=15), or off-pump (n=15) coronary surgery. Plasma catecholamines were assessed by high performance liquid chromatography and TNF-alpha by ELISA. Results: Norepinephrine and epinephrine spillover was similar in the two groups before surgery, being 1.38\ub10.62 and 1.08\ub10.45, respectively. After surgery norepinephrine spillover was 1.43\ub10.56, 0.72\ub10.49 in CABG and off-pump, respectively (P<0.05 CABG versus off-pump, means \ub1SD ). Epinephrine spillover was 1.27\ub10.16 and 0.65\ub10.15 respectively (P<0.05, CABG versus off-pump). TNF-alpha significantly increased only in CABG patients being 22.17\ub16.79 and 35.4\ub15.98, pg/mL, before and after surgery (P<0.05), respectively. After surgery norepinephrine spillover correlated with TNF-alpha levels (P=0.01, R=0.553). Conclusions: Patients undergoing off-pump interventions showed significantly lower catecholamines spillover as compared to CABG, suggesting that the off-pump technique may result less invasive, not only for a lower local and whole body inflammatory response but also for a lower sympathetic drive. For the first time in humans we have detected an increase in epinephrine-spillover after cardiac surgery. Further studies are necessary to evaluate if the short-term advantages observed after off-pump coronary surgery translate into a long-term attenuation of left ventricular remodeling and in the prevention of heart failure progression

The frail patient undergoing cardiac surgery: lessons learned and future perspectives

Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome

Reverse left ventricular remodeling after undersized annuloplasty for ischemic mitral regurgitation

Background: Coronary artery bypass grafting (CABG) results in improved left ventricular (LV) performance and reduced ischemic mitral regurgitation (IMR). However, MR often does not resolve and correlates with a poor prognosis. Benefits of repair have been reported also in mild‐to‐moderate IMR, but optimal surgical treatment for intermediate‐degree IMR remains widely debated. Methods: CABG combined with implantation of an undersized autologous pericardial band, or of a flexible or semirigid complete prosthetic ring was performed in 75 patients with 2+ or 3+ IMR. Longest follow‐up was 10 years. Results: Preoperative LV end‐systolic volume index was the strongest predictor of early postoperative outcome at multivariable logistic regression analysis, and showed a correlation with end‐systolic volume index (p<0.001, R2=0.65) and ejection fraction (p<0.001, R2=0.43) early after repair. However, a more compromised ejection fraction and end‐systolic volume index at baseline predicted a comparatively greater early functional improvement, but, in parallel, a higher residual postoperative end‐systolic volume index (p<0.01). Wall motion score index was identified as the best baseline predictor of late death and heart failure, whereas regional infero‐posterior wall motion resulted the strongest predictor of recurrent IMR at Cox multivariable analysis (p<0.01). More rigid annuloplasty determined a higher probability of ejection fraction and wall motion improvement, and of the occurrence and earlier timing of LV reverse remodeling, expressed as different degrees of end‐systolic volume index reduction (p<0.001, hazard ratio >5). Conclusions: Undersized mitral annuloplasty combined to CABG unloads the LV in patients with intermediate‐degree IMR. Global and regional wall motion predict late outcome, whereas a stiffer mitral annular stabilization promotes functional recovery and predicts higher probability and earlier timing of LV reverse remodelling