Midwall Fibrosis Is an Independent Predictor of Mortality in Patients With Aortic Stenosis

ObjectivesThe goal of this study was to assess the prognostic significance of midwall and infarct patterns of late gadolinium enhancement (LGE) in aortic stenosis.BackgroundMyocardial fibrosis occurs in aortic stenosis as part of the hypertrophic response. It can be detected by LGE, which is associated with an adverse prognosis in a range of other cardiac conditions.MethodsBetween January 2003 and October 2008, consecutive patients with moderate or severe aortic stenosis undergoing cardiovascular magnetic resonance with administration of gadolinium contrast were enrolled into a registry. Patients were categorized into absent, midwall, or infarct patterns of LGE by blinded independent observers. Patient follow-up was completed using patient questionnaires, source record data, and the National Strategic Tracing Service.ResultsA total of 143 patients (age 68 ± 14 years; 97 male) were followed up for 2.0 ± 1.4 years. Seventy-two underwent aortic valve replacement, and 27 died (24 cardiac, 3 sudden cardiac deaths). Compared with those with no LGE (n = 49), univariate analysis revealed that patients with midwall fibrosis (n = 54) had an 8-fold increase in all-cause mortality despite similar aortic stenosis severity and coronary artery disease burden. Patients with an infarct pattern (n = 40) had a 6-fold increase. Midwall fibrosis (hazard ratio: 5.35; 95% confidence interval: 1.16 to 24.56; p = 0.03) and ejection fraction (hazard ratio: 0.96; 95% confidence interval: 0.94 to 0.99; p = 0.01) were independent predictors of all-cause mortality by multivariate analysis.ConclusionsMidwall fibrosis was an independent predictor of mortality in patients with moderate and severe aortic stenosis. It has incremental prognostic value to ejection fraction and may provide a useful method of risk stratification. (The Prognostic Significance of Fibrosis Detection in Cardiomyopathy; NCT00930735

Radial artery versus saphenous vein graft patency: Meta-analysis of randomized controlled trials

[No abstract available

Is minimized extracorporeal circulation effective to reduce the need for red blood cells transfusion in coronary artery bypass grafting? Meta-analysis of randomized controlled trials

Perioperative red blood cell (RBC) transfusion is the single factor most consistently associated with an increased risk of postoperative morbid events after isolated coronary artery bypass grafting (CABG), and each unit of RBC transfused is associated with incrementally increased risk for adverse outcome.1 Miniaturized extracorporeal circulation (mini-ECC) has been proposed to limit perioperative blood product use. Mini-ECC consists of a closed ECC system with no cardiotomy suction or venous reservoir. The rationale is to avoid air–blood contact and minimize priming volume, thus reducing hemostasis alteration and intraoperative hemodilution. However, there is still controversy on whether such a strategy effectively reduces postoperative RBC transfusion, with some reports showing no evident benefit. We conducted a meta-analysis on available randomized controlled trials (RCTs) to evaluate whether mini-ECC decreases the risk of postoperative RBC transfusion compared with conventional ECC in patients undergoing CABG

Prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery

Objective: Progression of functional tricuspid regurgitation is not uncommon after mitral valve surgery and is associated with poor outcomes. We tested the hypothesis that concomitant tricuspid valve annuloplasty in patients with tricuspid annulus dilatation (>= 40 mm) prevents tricuspid regurgitation progression after mitral valve surgery. Methods: We enrolled 44 patients undergoing mitral valve surgery (both repair or replacement) showing less than moderate (= 40 mm) at preoperative echocardiography. They were randomized to receive (n = 22) or not receive (n = 22) concomitant tricuspid annuloplasty (Cosgrove-Edwards annuloplasty ring; Edwards Lifesciences, Irvine, Calif) at the time of mitral valve surgery. Clinical and echocardiographic follow-up was 100% completed at 12 months after surgery. Results: Preoperative clinical and echocardiographic characteristics were comparable in the 2 groups. Operative mortality was 4.4%(1 death in each group). At 12 months follow-up, tricuspid regurgitation was absent in 71% (n 15) versus 19%(n 4) of patients in the treatment and control groups, respectively (P = .001). Moderate to severe tricuspid regurgitation (>=+3) was present in 0% versus 28%(n = 6) of patients in the treatment and control groups, respectively (P = .02). Pulmonary artery systolic pressure significantly decreased from baseline in all cases (P < .001) and was comparable in the 2 groups (41 +/- 8 mmHg vs 40 +/- 5 mm Hg; P = .4). Right ventricular reverse remodeling was marked in the treatment group (right ventricular long axis: 71 +/- 7mmvs 65 +/- 8 mm; P = .01; short axis: 33 +/- 4 mm vs 27 +/- 5 mm; P = .001) but only minimal in the control group (right ventricular long axis: 72 +/- 6 mm vs 70 +/- 7 mm; P = .08; short axis: 34 +/- 5 mm vs 33 +/- 5 mm; P = .1). The 6-minute walk test improved from baseline in both groups (P < .001), but this improvement was greater in the treatment group (+115 +/- 23 m from baseline vs +75 +/- 35 m; P = .008). Conclusions: Prophylactic tricuspid valve annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery was associated with a reduced rate of tricuspid regurgitation progression, improved right ventricular remodeling, and better functional outcomes. (J Thorac Cardiovasc Surg 2012;143:632-8

Preoperative Angiotensin-converting enzyme inhibitors and acute kidney injury after coronary artery bypass grafting

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors confer renal protection in different clinical settings. No final conclusions are available on the renal benefits of ACE inhibitors after coronary artery bypass grafting (CABG). Because ACE inhibitors decrease glomerular perfusion pressure, they may exacerbate kidney injury during cardiopulmonary bypass (CPB)-related hypoperfusion. We evaluated the effect of preoperative ACE inhibitors on acute kidney injury (AKI) after CABG. METHODS: A propensity score-based analysis of 536 patients undergoing CABG on CPB was performed, among which 281 received ACE inhibitors preoperatively. Patients with preoperative end-stage renal failure requiring dialysis were excluded. Postoperative AKI was defined as 50% or more decrease in the glomerular filtration rate from preoperative or postoperative mechanical renal support. RESULTS: After CABG, AKI developed in 49 patients (9.1%), and 23 (4.2%) required dialysis. The incidence of AKI was 6.4% in patients who received preoperative ACE inhibitors and 12.2% in patients who did not (p = 0.02). The incidence of AKI requiring dialysis was 2.4% in the treatment group and 6.3% in controls (p = 0.03). After adjusting for propensity score and covariates, preoperative ACE inhibitors were found to reduce the incidence of postoperative AKI (odds ratio, 0.48; 95% confidence interval, 0.23 to 0.77; p = 0.04). Other independent predictors were age, preoperative glomerular filtration rate, left ventricular ejection fraction of less than 0.35, preoperative use of intraaortic balloon pump, emergency operation, and CPB time. CONCLUSIONS: Preoperative ACE inhibitors are associated with a reduced rate of AKI after on-pump CABG surgery