Complexity of coronary artery disease and the release of cardiac biomarkers after CABG

Objective: In patients with complex coronary artery disease (CAD) undergoing cardiac surgery, myocardial protection might be impaired due to microvascular obstruction, resulting in myocardial injury and subsequent biomarker release. Therefore, this study investigated the correlation between the complexity of CAD, reflected by the SYNTAX Score, and the release of cardiac biomarkers after CABG. Methods: In a consecutive series of 919 patients undergoing isolated CABG SYNTAX scores I and II were calculated to assess the complexity of CAD. Levels of high sensitivity cardiac troponin T (hs-cTnT) and creatine kinase-myocardial band (CK-MB) were routinely measured once before and serially after surgery. Patients were divided into tertiles according to their SYNTAX Scores I and II. Spearman correlations and regression models were performed to measure the degree of association between the release of hs-cTnT and CK-MB and the SYNTAX Scores. Results: Patients with a higher SYNTAX Score I had more comorbidities reflected in a higher EuroSCORE II. Preoperatively, higher levels of cardiac biomarkers were found in patients with higher SYNTAX Score II. No correlation was observed between hs-cTnT, CK-MB and SYNTAX Score I or II. Regression models did not show any association between cardiac biomarkers and the complexity of CAD. Conclusion: The complexity of CAD is not associated with the release of cardiac biomarkers after CABG. Factors influencing postoperative biomarker release need to be elucidated in future trials to include postoperative biomarker release into risk stratification models predicting outcome after cardiac surgery

"Randomized comparison of HARVesting the left internal thoracic artery in a skeletonized versus pedicled technique: the HARVITA trial-study protocol".

Latest research has posed a potential adverse effect of skeletonizing left internal thoracic artery on graft patency rates and clinical outcomes. With this trial, we aim to provide a prospective, randomized, multicentre trial to compare skeletonized versus pedicled harvesting technique of left internal thoracic artery concerning graft patency rates and patient survival. 1350 patients will be randomized to either skeletonized or pedicled harvesting technique and undergo surgical revascularization. Follow-up will be performed at 30 days, 1 year, 2 years and 5 years after surgery. The primary outcome will be death or left internal thoracic artery graft occlusion in coronary computed tomography angiography or invasive angiography within 2 years (+/- 3 months) after surgery. The secondary outcome will be major adverse cardiac events (composite outcome of all-cause death, myocardial infarction and repeated revascularization) within 1 year, 2 years and 5 years after surgery. The primary end-point will be compared in the modified intention-to-treat population between the two treatment groups using Kaplan-Meier graphs, together with log-rank testing. Hereby, we present the study protocol of the first adequately powered prospective, randomized, multicentre trial, which compares skeletonized and pedicled harvesting technique of left internal thoracic artery regarding graft patency rates and patient survival

Prolonged extracorporeal membrane oxygenation-assisted support provides improved survival in hypothermic patients with cardiocirculatory arrest

ObjectiveExtracorporeal circulation is considered the gold standard in the treatment of hypothermic cardiocirculatory arrest; however, few centers use extracorporeal membrane oxygenation instead of standard extracorporeal circulation for this indication. The aim of this study was to evaluate whether extracorporeal membrane oxygenation-assisted resuscitation improves survival in patients with hypothermic cardiac arrest.MethodsA consecutive series of 59 patients with accidental hypothermia in cardiocirculatory arrest between 1987 and 2006 were included. Thirty-four patients (57.6%) were resuscitated by standard extracorporeal circulation, and 25 patients (42.4%) were resuscitated by extracorporeal membrane oxygenation. Accidental hypothermia was caused by avalanche in 22 patients (37.3%), drowning in 22 patients (37.3%), exposure to cold in 8 patients (13.5%), and falling into a crevasse in 7 patients (11.9%). Multivariate logistic regression analysis was used to compare extracorporeal membrane oxygenation with extracorporeal circulation resuscitation, with adjustment for relevant parameters.ResultsRestoration of spontaneous circulation was achieved in 32 patients (54.2%). A total of 12 patients (20.3%) survived hypothermia. In the extracorporeal circulation group, 64% of the nonsurviving patients who underwent restoration of spontaneous circulation died of severe pulmonary edema, but none died in the extracorporeal membrane oxygenation group. In multivariate analysis, extracorporeal membrane oxygenation-assisted resuscitation showed a 6.6-fold higher chance for survival (relative risk: 6.6, 95% confidence interval: 1.2–49.3, P = .042). Asphyxia-related hypothermia (avalanche or drowning) was the most predictive adverse factor for survival (relative risk: 0.09, 95% confidence interval: 0.01–0.60, P = .013). Potassium and pH failed to show statistical significance in the multivariate analysis.ConclusionsExtracorporeal rewarming with an extracorporeal membrane oxygenation system allows prolonged cardiorespiratory support after initial resuscitation. Our data indicate that prolonged extracorporeal membrane oxygenation support reduces the risk of intractable cardiorespiratory failure commonly observed after rewarming

Association of high-sensitivity cardiac troponin T with 30-day and 5-year mortality after cardiac surgery

Background The relevance of perioperative myocardial injury (PMI) after cardiac surgery for 30-day mortality and long-term survival remains to be determined. Objectives This study assessed the association of PMI after cardiac surgery, reflected by postoperative troponin release, with 30-day mortality and long-term survival after: 1) coronary artery bypass grafting (CABG); 2) isolated aortic valve replacement (AVR) surgery; and 3) all other cardiac surgeries. Methods A consecutive cohort of 8,292 patients undergoing cardiac surgery with serial perioperative high-sensitivity cardiac troponin T (hs-cTnT) measurements was retrospectively analyzed. The relationship between postoperative hs-cTnT release and 30-day mortality or 5-year mortality was analyzed after adjustment with EuroSCORE II using a Cox proportional hazards model. hs-cTnT thresholds for 30-day and 5-year mortality were determined for isolated CABG (32.3%), AVR (14%), and other cardiac surgery (53.8%). Results High postoperative hs-cTnT levels were associated with higher 30-day mortality but not 5-year mortality. In CABG, median peak concentration of postoperative hs-cTnT was 1,044 ng/L, in AVR it was 502 ng/L, and in other cardiac surgery it was 1,110 ng/L. hs-cTnT thresholds defining mortality-associated PMI were as follows: for CABG, 2,385 ng/L (170× the upper reference limit of normal in a seemingly healthy population [URL]); for AVR, 568 ng/L (41× URL); and for other cardiac procedures, 1,873 ng/L (134× URL). hs-cTnT levels above the cutoffs resulted in an HR for 30-day mortality for CABG of 12.56 (P < 0.001), for AVR of 4.44 (P = 0.004), and for other cardiac surgery of 3.97 (P < 0.001). Conclusions PMI reflected by perioperative hs-cTnT release is associated with the expected 30-day mortality but not 5-year mortality. Postoperative hs-cTnT cutoffs to identify survival-relevant PMI are higher than suggested in current definitions