Effect of remote ischemic conditioning on atrial fibrillation and outcome after coronary artery bypass grafting (RICO-trial)

Background: Pre- and postconditioning describe mechanisms whereby short ischemic periods protect an organ against a longer period of ischemia. Interestingly, short ischemic periods of a limb, in itself harmless, may increase the ischemia tolerance of remote organs, e.g. the heart (remote conditioning, RC). Although several studies have shown reduced biomarker release by RC, a reduction of complications and improvement of patient outcome still has to be demonstrated. Atrial fibrillation (AF) is one of the most common complications after coronary artery bypass graft surgery (CABG), affecting 27-46% of patients. It is associated with increased mortality, adverse cardiovascular events, and prolonged in-hospital stay. We hypothesize that remote ischemic pre- and/or post-conditioning reduce the incidence of AF following CABG, and improve patient outcome.Methods/design: This study is a randomized, controlled, patient and investigator blinded multicenter trial. Elective CABG patients are randomized to one of the following four groups: 1) control, 2) remote ischemic preconditioning, 3) remote ischemic postconditioning, or 4) remote ischemic pre- and postconditioning. Remote conditio

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Validation of a new standardized method to measure proximal aneurysm neck angulation

Purpose: This study presented and validated a new standardized method for the measurement of the aortic angulation in patients with abdominal aortic aneurysms (AAA) and quantified the observer variability. Methods: A standardized method to quantify aortic angulation was introduced. To measure aortic angulation, a center lumen line (CLL) of the aorta was made, and a three-dimensional (3D) aortic reconstruction was obtained. The 3D reconstruction was turned 360 perpendicular to the CLL in the middle of the flexure. The sharpest angle of the CLL was considered the true angle of the aortic axis. The computed tomography angiography data sets of 20 patients scheduled for endovascular aneurysm repair (EVAR) were obtained. The angles between the suprarenal aorta and the aneurysm neck (alpha) and between the aneurysm neck and sac (beta) were measured. Two observers independently measured the angles. Differences of each pair of measurements were plotted against their mean and intraobserver and interobserver variabilities were calculated according to Bland and Altman. Results: The intraobserver mean difference for angle a was 0.2 (-0.5%), with a repeatability coefficient (RC) of 6.4 degrees (20.2%), and 0.6 degrees (1.4%) for angle beta, with a RC of 6.2 degrees (13.4%). The interobserver mean difference for angle a was 1.5 degrees (-4.5%), with a RC of 6.9 degrees (22.0%), and 0.2 degrees (-0.4%) for angle beta, with a RC of 7.4 degrees (16.0%). No significant differences were observed between the observers. Conclusion: The presented technique to objectively quantify the angulation of the aneurysm neck is easy to perform and reliable. This method showed good intraobserver and interobserver variability and should therefore be the standard when measuring and reporting aortic angulation. (J Vase Surg 2010;51:821-8.

Number of Entry Tears Is Associated With Aortic Growth in Type B Dissections

Background. Aortic growth rate in acute type B aortic dissection (ABAD) is a significant predictor for aortic complications and death. To improve the overall outcome, radiologic predictors might stratify patients who benefit from successful medical management vs those who require intervention. This study investigated whether the number of identifiable entry tears in ABAD patients is associated with aortic growth. Methods. ABAD patients with uncomplicated clinical conditions and therefore treated with medical therapy were evaluated. Those with a computed tomography angiography (CTA) obtained at clinical presentation and a subsequent CTA obtained at least 90 days after medical treatment were included (2005 to 2010). The CTAs were investigated for the number of entry tears between the true and false lumen. Diameters of the dissected aortas were measured at five levels on the baseline and on the last available follow-up CTA, and annual aortic growth rates were calculated. The number of entry tears in these patients and the location in the aorta were compared with the aortic growth rate. Results. Included were 60 patients who presented with 243 dissected segments. Mean growth rates during follow-up (median, 23.2; range, 3 to 132 months) were significantly higher in patients with 1 entry tear (5.6 +/- 8.9 mm) than in those with 2 (2.1 +/- 1.7 mm; p = 0.001) and 3 entry tears (mean 2.2 +/- 4.1; p = 0.010). The distance of the primary entry tear from the left subclavian artery did not have an effect on the aortic growth rate (median, 38; interquartile range, 24 to 137 mm; p = 0.434). Conclusions. The number of entry tears in ABAD patients detected on the first CTA after clinical presentation is a significant predictor for aortic growth. Patients with 1 entry tear at presentation show a higher growth rate than other patients and might benefit from more strict surveillance or early prophylactic intervention. (C) 2013 by The Society of Thoracic Surgeon

The differences and similarities between intramural hematoma of the descending aorta and acute type B dissection.

Abstract INTRODUCTION: Aortic intramural hematoma type B (IMHB) is a variant of acute aortic syndrome, which presents with symptoms similar to classic type B aortic dissection (ABAD). However, the natural history of IMHB is not well understood. The purpose of this study was to better characterize IMHB, comparing its clinical characteristics, treatment, and in-hospital and long-term outcomes to those with classic ABAD. METHODS: A total of 107 IMHB and 790 ABAD patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between January 1996 and June 2012 were analyzed. Accordingly, differences in presentation, diagnostics, therapeutic management, and outcomes were assessed. RESULTS: As compared with the ABAD, IMHB presented predominantly in males (62% vs 33%; P < .001) at older age (69 \ub1 12 vs 63 \ub1 14; P < .001). IMHB patients more often had chest pain (80% vs 69%; P = .020) and periaortic hematoma (22% vs 13%; P = .020) and were more often treated medically (88% vs 62%; P < .001), with surgical/endovascular interventions being reserved for more complicated patients. Overall in-hospital mortality was 10% (IMHB, 7% vs ABAD, 11%; P = NS). Six out of seven IMHB deaths occurred during medical treatment, two due to aortic rupture. During follow-up in IMHB, patient mortality was 7%, and no adverse events, including progression to an aortic dissection or aortic rupture, were observed. Imaging showed significantly more aortic enlargement at the level of the descending aorta in ABAD patients (39% vs 61%; P = .034). CONCLUSIONS: Most IMHB patients can be treated medically, and aortic enlargement is less common during follow-up, which may suggest that IMHB may have a slightly more benign course compared with classic ABAD in the acute setting

Spinal cord ischemia after simultaneous and sequential treatment of multilevel aortic disease.

OBJECTIVES: The aim of the present study is to report a risk analysis for spinal cord injury in a recent cohort of patients with simultaneous and sequential treatment of multilevel aortic disease. METHODS: We performed a multicenter study with a retrospective data analysis. Simultaneous treatment refers to descending thoracic and infrarenal aortic lesions treated during the same operation, and sequential treatment refers to separate operations. All descending replacements were managed with endovascular repair. RESULTS: Of 4320 patients, multilevel aortic disease was detected in 77 (1.8%). Simultaneous repair was performed in 32 patients (41.5%), and a sequential repair was performed in 45 patients (58.4%). Postoperative spinal cord injury developed in 6 patients (7.8%). At multivariable analysis, the distance of the distal aortic neck from the celiac trunk was the only independent predictor of postoperative spinal cord injury (odds ratio, 0.75; 95% confidence interval, 0.56-0.99; P=.046); open surgical repair of the abdominal aortic disease was associated with a higher risk of spinal cord injury but did not reach statistical significance (odds ratio, 0.16; 95% confidence interval, 0.02-1.06; P=.057). Actuarial survival estimates at 1, 2, and 5 years after the procedure were 80%±5%, 68%±6%, and 63%±7%, respectively. Spinal cord injury did not impair survival (P=.885). CONCLUSIONS: In our experience, the risk of spinal cord injury is still substantial at 8% in patients with multilevel aortic disease. The distance of the distal landing zone from the celiac trunk is a significant predictor of spinal cord ischemia