Control angiography for perioperative myocardial Ischemia after coronary surgery: Meta-analysis

Background: Perioperative myocardial ischemia (PMI) in patients undergoing coronary artery bypass grafting (CABG) is associated with poor outcome. The aim of this study was to pool the available data on the outcome after control angiography and repeat revascularization in patients with perioperative myocardial ischemia (PMI) after coronary artery bypass grafting (CABG).Methods: A literature review was performed through PubMed, Scopus, ScienceDirect and Google Scholar to identify studies published since 1990 evaluating the outcome of PMI after CABG.Results: Nine studies included 1104 patients with PMI after CABG and 1056 of them underwent control angiography early after CABG. Pooled early mortality after reoperation for PMI without control angiography was 43.6% (95%CI 29.7-57.6%) and 79.8% of them (95%CI 64.4-95.2%) had an acute graft failure detected at reoperation. Among patients who underwent control angiography for PMI, 31.7% had a negative finding at angiography (95%CI 25.6-37.8%) and 62.1% had an acute graft failure (95%CI 56.6-67.6%). Repeat revascularization was performed after early control angiography in 46.3% of patients (95%CI 39.9-52.6%; 54.2% underwent repeat surgical revascularization; 45.8% underwent percutaneous coronary intervention). Pooled early mortality after control angiography with or without repeat revascularization was 8.9% (95%CI 6.7-11.1%). Three studies reported on early mortality rates which did not differ between repeat surgical revascularization and PCI (11.7% vs. 9.2%, respectively; risk ratio 1.45, 95%CI 0.67-3.11). In these three series, early mortality after conservative treatment was 5.9% (95%CI 3.6-8.2%).Conclusions: Control angiography seems to be a valid life-saving strategy to guide repeat revascularization in hemodynamically stable patients suffering PMI after CABG.</p

Outcome after Surgery for Iatrogenic Acute Type A Aortic Dissection

(1) Background: Acute Stanford type A aortic dissection (TAAD) may complicate the outcome of cardiovascular procedures. Data on the outcome after surgery for iatrogenic acute TAAD is scarce. (2) Methods: The European Registry of Type A Aortic Dissection (ERTAAD) is a multicenter, retrospective study including patients who underwent surgery for acute TAAD at 18 hospitals from eight European countries. The primary outcomes were in-hospital mortality and 5-year mortality. Twenty-seven secondary outcomes were evaluated. (3) Results: Out of 3902 consecutive patients who underwent surgery for acute TAAD, 103 (2.6%) had iatrogenic TAAD. Cardiac surgery (37.8%) and percutaneous coronary intervention (36.9%) were the most frequent causes leading to iatrogenic TAAD, followed by diagnostic coronary angiography (13.6%), transcatheter aortic valve replacement (10.7%) and peripheral endovascular procedure (1.0%). In hospital mortality was 20.5% after cardiac surgery, 31.6% after percutaneous coronary intervention, 42.9% after diagnostic coronary angiography, 45.5% after transcatheter aortic valve replacement and nihil after peripheral endovascular procedure (p = 0.092), with similar 5-year mortality between different subgroups of iatrogenic TAAD (p = 0.710). Among 102 propensity score matched pairs, in-hospital mortality was significantly higher among patients with iatrogenic TAAD (30.4% vs. 15.7%, p = 0.013) compared to those with spontaneous TAAD. This finding was likely related to higher risk of postoperative heart failure (35.3% vs. 10.8%, p < 0.0001) among iatrogenic TAAD patients. Five-year mortality was comparable between patients with iatrogenic and spontaneous TAAD (46.2% vs. 39.4%, p = 0.163). (4) Conclusions: Iatrogenic origin of acute TAAD is quite uncommon but carries a significantly increased risk of in-hospital mortality compared to spontaneous TAAD

Prognostic Significance of Arterial Lactate Levels at Weaning from Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation

Background: The outcome after weaning from postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) is poor. In this study, we investigated the prognostic impact of arterial lactate levels at the time of weaning from postcardiotomy VA. Methods: This analysis included 338 patients from the multicenter PC-ECMO registry with available data on arterial lactate levels at weaning from VA-ECMO. Results: Arterial lactate levels at weaning from VA-ECMO (adjusted OR 1.426, 95%CI 1.157-1.758) was an independent predictor of hospital mortality, and its best cutoff values was 1.6 mmol/L (= 1.6 mmol/L, 45.0%; adjusted OR 2.489, 95%CI 1.374-4.505). When 261 patients with arterial lactate at VA-ECMO weaning = 1.4 mmol/L, 38.5%, p = 0.014). Among 87 propensity score-matched pairs, hospital mortality was significantly higher in patients with arterial lactate >= 1.4 mmol/L (39.1% vs. 23.0%, p = 0.029) compared to those with lower arterial lactate. Conclusions: Increased arterial lactate levels at the time of weaning from postcardiotomy VA-ECMO increases significantly the risk of hospital mortality. Arterial lactate may be useful in guiding optimal timing of VA-ECMO weaning

&quot;Delirium Day&quot;: A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

Cianosis después del cierre quirúrgico de una comunicación interauricular

The closure at the right time of the atrial septal defect (ASD) type fossa ovalis, or ostium secundum, guarantees a normal life and the surgical risk tends to be zero. But there is a variety of these congenital malformations that can lead to surgical errors that, although rare, continue to be repeated since the beginning of cardiac surgery. These are large ASD with incomplete limbus that extend to the entrance of the inferior vena cava and coincide with a large Eustachian valve. In these cases, an inadvertent deviation of the inferior vena cava towards the left atrium can be produced by erroneously suturing the edges of the limbus to the Eustachian valve. The case is presented of 7 year-old boy, operated 2 years before due to an ASD, who had cyanosis and dyspnoea on exertion, as well as a description of the surgical treatment performed for correction. To prevent this complication, it is important to pay attention to the anatomy and begin the closure of the ASDs from its inferior margin.El cierre en el momento oportuno de las comunicaciones interauriculares (CIA) del tipo defecto de fosa oval, ostium secundum en la nomenclatura anglosajona, garantiza una vida normal y el riesgo quirúrgico tiende a cero. Pero existe una variedad de estas malformaciones congénitas que induce a errores quirúrgicos que, aunque raros, se siguen repitiendo desde el inicio de la cirugía cardíaca. Se trata de las CIA con limbo incompleto situadas en la parte inferior del septo, que se extienden hasta la desembocadura de la vena cava inferior y coinciden con una válvula de Eustaquio grande. En estos casos se puede producir una desviación inadvertida de la vena cava inferior hacia la aurícula izquierda al suturar erróneamente los bordes del limbo a la válvula de Eustaquio. Informamos de un niño de 7 años, operado 2 años antes de una CIA, que presentaba cianosis y disnea de esfuerzo, y del tratamiento quirúrgico seguido para su corrección. Para prevenir esta complicación es importante prestar atención a la anatomía y comenzar el cierre de las CIA por su extremo inferior

Control angiography for perioperative myocardial Ischemia after coronary surgery:meta-analysis

Abstract Background: Perioperative myocardial ischemia (PMI) in patients undergoing coronary artery bypass grafting (CABG) is associated with poor outcome. The aim of this study was to pool the available data on the outcome after control angiography and repeat revascularization in patients with perioperative myocardial ischemia (PMI) after coronary artery bypass grafting (CABG). Methods: A literature review was performed through PubMed, Scopus, ScienceDirect and Google Scholar to identify studies published since 1990 evaluating the outcome of PMI after CABG. Results: Nine studies included 1104 patients with PMI after CABG and 1056 of them underwent control angiography early after CABG. Pooled early mortality after reoperation for PMI without control angiography was 43.6% (95%CI 29.7–57.6%) and 79.8% of them (95%CI 64.4–95.2%) had an acute graft failure detected at reoperation. Among patients who underwent control angiography for PMI, 31.7% had a negative finding at angiography (95%CI 25.6–37.8%) and 62.1% had an acute graft failure (95%CI 56.6–67.6%). Repeat revascularization was performed after early control angiography in 46.3% of patients (95%CI 39.9–52.6%; 54.2% underwent repeat surgical revascularization; 45.8% underwent percutaneous coronary intervention). Pooled early mortality after control angiography with or without repeat revascularization was 8.9% (95%CI 6.7–11.1%). Three studies reported on early mortality rates which did not differ between repeat surgical revascularization and PCI (11.7% vs. 9.2%, respectively; risk ratio 1.45, 95%CI 0.67–3.11). In these three series, early mortality after conservative treatment was 5.9% (95%CI 3.6–8.2%). Conclusions: Control angiography seems to be a valid life-saving strategy to guide repeat revascularization in hemodynamically stable patients suffering PMI after CABG

Survival results of postoperative coronary angiogram for treatment of perioperative myocardial ischaemia following coronary artery bypass grafting:a single-centre experience

Abstract OBJECTIVES: Although perioperative myocardial ischaemia (PMI) is a well-known complication following coronary artery bypass grafting (CABG), standard strategies for its diagnosis and treatment are so far not defined. In this study, we sought to evaluate the impact on survival of postoperative coronary angiogram for management of patients with PMI after CABG. em>METHODS: Overall, 4028 patients underwent isolated CABG in a single-centre institution between January 2006 and September 2013. A total of 168 (4.2%) patients received postoperative coronary angiogram because of diagnosis of PMI. These patients were matched on the basis of gender, age at surgery and date of surgery, with 336 (1:2 ratio) CABG patients without PMI to determine the impact of the PMI management. RESULTS: A total of 476 grafts were examined (263 venous grafts, 196 internal mammary artery grafts and 17 radial artery grafts). Almost three-quarters of the 168 PMI (74.4%) patients underwent postoperative coronary angiogram within 24 h of surgery. Normal postoperative coronary angiogram, graft failure and new native vessels occlusion were observed in 23.2%, 52.4% and 24.4% of patients, respectively. A total of 30 (17.9%) patients underwent surgical revision of grafts, whereas 60 (35.7%) patients were treated with percutaneous coronary intervention. Eighteen (10.7%) PMI patients died during the hospital stay compared with 6 (1.8%) patients in the non-PMI group. Survival rates at 7 years were 62.5% in the PMI group and 81.1% in non-PMI group (P 24 h after surgery) was an independent predictor of poorer mid-term survival (P = 0.008; hazard ratio 3.62, 95% confidence interval 1.41–9.33). CONCLUSIONS: PMI after CABG is associated with a significantly poorer survival. A prompt postoperative management must always be considered. Further prospective studies are required to confirm our results

Meta-analysis of the outcome after postcardiotomy venoarterial extracorporeal membrane oxygenation in adult patients

Abstract Objective: This study was planned to pool existing data on outcome and to evaluate the efficacy of postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adult patients. Design: Systematic review of the literature and meta-analysis. Setting: Multi-institutional study. Participants: Adult patients with acute heart failure immediately after cardiac surgery. Interventions: VA-ECMO after cardiac surgery. Studies evaluating only heart transplant patients were excluded from this analysis. Measurements and Main Results: A literature search was performed to identify studies published since 2000. Thirty-one studies reported on 2,986 patients (mean age, 58.1 years) who required postcardiotomy VA-ECMO. The weaning rate from VA-ECMO was 59.5% and hospital survival was 36.1% (95% CI 31.5–40.8). The pooled rate of reoperation for bleeding was 42.9%, major neurological event 11.3%, lower limb ischemia 10.8%, deep sternal wound infection/mediastinitis 14.7%, and renal replacement therapy 47.1%. The pooled mean number of transfused red blood cell units was 17.7 (95% CI 13.3–22.1). The mean stay in the intensive care unit was 13.3 days (95% CI 10.2–16.4). Survivors were significantly younger (mean, 55.7 v 63.6 years, p = 0.015) and their blood lactate level before starting VA-ECMO was lower (mean, 7.7 v 10.7 mmol/L, p = 0.028) than patients who died. One-year survival rate was 30.9% (95% CI 24.3–37.5). Conclusions: Pooled data showed that VA-ECMO may salvage one-third of patients unresponsive to any other resuscitative treatment after adult cardiac surgery