[Show abstract][Hide abstract] ABSTRACT: Background:The first few months after admission are the most vulnerable period in patients with acute decompensated heart failure (ADHF).Methods and Results:We assessed the association of the updated ADHF/N-terminal pro-B-type natriuretic peptide (NT-proBNP) risk score with 90-day and in-hospital mortality in 701 patients admitted with advanced ADHF, defined as severe symptoms of worsening HF, severely depressed left ventricular ejection fraction, and the need for i.v. diuretic and/or inotropic drugs. A total of 15.7% of the patients died within 90 days of admission and 5.2% underwent ventricular assist device (VAD) implantation or urgent heart transplantation (UHT). The C-statistic of the ADHF/NT-proBNP risk score for 90-day mortality was 0.810 (95% CI: 0.769-0.852). Predicted and observed mortality rates were in close agreement. When the composite outcome of death/VAD/UHT at 90 days was considered, the C-statistic decreased to 0.741. During hospitalization, 7.6% of the patients died. The C-statistic for in-hospital mortality was 0.815 (95% CI: 0.761-0.868) and Hosmer-Lemeshow χ(2)=3.71 (P=0.716). The updated ADHF/NT-proBNP risk score outperformed the Acute Decompensated Heart Failure National Registry, the Organized Program to Initiate Lifesaving Treatment in Patients Hospitalized for Heart Failure, and the American Heart Association Get with the Guidelines Program predictive models.Conclusions:Updated ADHF/NT-proBNP risk score is a valuable tool for predicting short-term mortality in severe ADHF, outperforming existing inpatient predictive models.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
The study objective was to evaluate the effects on early outcome and midterm survival of performing coronary artery bypass grafting with the off-pump technique in comparison with cardiopulmonary bypass (on-pump) in patients with preoperative anemia.
Consecutive adult anemic patients (preoperative hemoglobin <13.0 g/dL in men and <12.0 g/dL in women) resident in Puglia region who underwent isolated coronary artery bypass grafting between January 2011 and November 2013 were considered. Vital status was ascertained from the date of surgery to December 31, 2013. Odds ratio and hazard ratio (HR) were estimated. Propensity score methods were used to control for confounders.
Of 939 anemic patients (234 female, aged 71 ± 9 years), 361 underwent operation with the off-pump technique and 578 underwent operation with the on-pump technique. Patients undergoing off-pump coronary artery bypass had a shorter intensive care unit length of stay, lower blood transfusion rate, and postoperative reduction in creatinine clearance. During a median follow-up of 18 months, 126 patients died: 46 in hospital (35 on-pump) and 80 after discharge (33 on-pump). In comparison with the off-pump technique, the on-pump technique had greater hospital mortality (odds ratio, 2.57; P = .028) and 30-day incidence of fatal events (HR, 2.67; P = .026). After a period without risk differences between groups (1-6 months; HR, 0.79; P = .618), a lower mortality in those undergoing the on-pump technique was detected (after 6 months HR, 0.35; P = .014). All results were confirmed in the 157 pairs of patients matched for propensity score, anemia grade, and surgery center.
In patients with low levels of preoperative hemoglobin, off-pump coronary artery bypass was associated with lower early morbidity and mortality but a greater risk of mortality during follow-up compared with on-pump coronary artery bypass.
Journal of Thoracic and Cardiovascular Surgery 12/2014; 149(4). DOI:10.1016/j.jtcvs.2014.12.049 · 4.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background. Antithrombotic prophylaxis is invariably prescribed in patients undergoing mitral valve repair to prevent thrombus formation and systemic embolization at short term. However whether oral anticoagulation should be preferred to antiplatelet therapy is still debated. No study has specifically addressed this issue and current guidelines are discordant. The aim of the present study was to verify the rate of thromboembolic and hemorrhagic complications during the first 6 months after mitral valve repair for degenerative mitral regurgitation and whether the type of antithrombotic therapy influenced the clinical outcome.
Methods. Data related to patients submitted to mitral valve repair were retrospectively collected from 16 centers. Inclusion criteria were any type of isolated mitral valve repair and ring implantation, whether exclusion criteria were history of ongoing or past atrial fibrillation (AF) and any other intra- operative associated surgical procedures. Primary outcome (efficacy) was the incidence of arterial thrombo-embolic events (cerebrovascular accidents, transient ischemic attack, limb or mesenteric ischemia) within 6 months from valve repair. Primary outcome (safety) was the incidence of major bleeding until 3 months after mitral valve repair or the stop of warfarin-based anticoagulation + 1 day, whichever comes first. Univariate logistic regression analyses were used to assess the association with the primary outcomes. The baseline characteristics associated with treatment on univariate analyses with p<0.05 were included in the adjusted model.
Results. Study cohort consisted of 1698 patients (61 ± 15 years; 34.7% females), and included 1511 treated with anticoagulant and 187 with antiplatelet drug, respectively. No differences were detected in terms of arterial embolic complications between the 2 groups (overall 1.4%, 1.4% vs 1.6% in the anticoagulant and antiplatelet groups respectively, p=0.74). Patients treated with antiplatelet drugs had a lower incidence of bleeding complications (overall 3.1%, 3.4% vs 0.5% in the anticoagulant and antiplatelet groups, respectively, p=0.02). Postoperative mortality at 6- months was not different between anticoagulant and antiplatelet-treated patients. The association between drug and post-operative outcome was estimated by an OR 1.16 (0.34-3.92; p=0.815) for arterial embolic complications and an OR 0.15 (0.02-1.09; p=0.062) for bleeding complications (antiplatelet vs anticoagulant). At multivariate analysis adjusted for variables significantly different between the two groups, the OR was 2.15 (0.48-9.76; p=0.323) for arterial embolic complications and 0.36 (0.05-2.68; p=0.318) for bleeding complications.
Conclusions. Antiplatelet therapy is apparently not inferior to oral anticoagulation in antithrombotic prophylaxis after mitral valve repair. Our data suggest that oral anticoagulation carries a higher bleeding risk compared to antiplatelet therapy although these results should be confirmed in a large randomized controlled trial.
27° Congresso Nazionale della Società Italiana di Chirurgia Cardiaca - SICCH, Roma; 11/2014
[Show abstract][Hide abstract] ABSTRACT: Background
Anemia is a risk factor for adverse events after cardiac operations. We evaluated the incremental value of preoperative anemia over the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II to predict hospital death after cardiac operations.
Data for 4,594 consecutive adults (1,548 women [33.7%]), aged 67 ± 11 years, who underwent cardiac operations from January 2011 to July 2013 were extracted from the Regional Cardiac Surgery Registry of Puglia. The last preoperative hemoglobin value was used, according to World Health Organization criteria, to classify anemia as mild (hemoglobin 11.0 to 12.9 g/dL in men and 11.0 to 11.9 g/dL in women) in 1,021 patients (22.2%) and as moderate to severe (hemoglobin <11.0 g/dL) in 593 patients (12.9%). The EuroSCORE II was used to evaluate predicted hospital death after operations. Logistic regression analysis for in-hospital death was performed including EuroSCORE II risk factors and anemia, with model discrimination quantified by C statistic and risk classification by the use of net reclassification improvement (NRI).
Overall expected and observed mortality rates were 4.4% and 5.9%. Anemia was significantly associated with a mortality rate of 3.4% in patients without anemia, 7.7% in mild anemia, and 15.7% in moderate to severe anemia (p < 0.001) and also at multivariate analysis correcting for EuroSCORE II (p < 0.001). When anemia was analyzed with EuroSCORE II, the model improved in discrimination (C statistic = 0.852 vs 0.860; p = 0.007) and reclassification (category free-NRI, 0.592; p < 0.001), preserving the calibration with good concordance between predicted probabilities and outcome.
Preoperative anemia has strong association with operative death in cardiac surgical patients. Anemia provides significant incremental value over the EuroSCORE II and should be considered for assessment of cardiac surgical risk.
The Annals of Thoracic Surgery 09/2014; 98(3). DOI:10.1016/j.athoracsur.2014.04.124 · 3.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Renal dysfunction may confound the clinical interpretation of N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentration. This study investigated whether renal dysfunction influences the prognostic accuracy of NT-proBNP in acute decompensated heart failure (ADHF).
Methods and results:
We studied 908 ADHF patients. The primary outcome was 12-month mortality. Interaction between estimated glomerular filtration rate (eGFR) and NT-proBNP in predicting mortality was tested with the likelihood ratio test. The patients were classified into 3 eGFR strata: ≥60, 30-59, and <30 ml·min(-1)·1.73 m(-2). Cox models were used to calculate the adjusted hazard ratios (HR) for NT-proBNP, modeled as a dichotomous or categorized variable, within each level of eGFR. NT-proBNP was categorized using optimal cut-offs defined in ROC analysis for each eGFR level. A total of 234 patients (25.8%) died. Testing for interaction was not significant (χ(2)=0.29; P=0.5928). The adjusted HR for NT-proBNP >5,180 pg/ml was 2.09 (P<0.001) in the highest, 1.7 (P<0.001) in the intermediate, and 3.33 (P=0.010) in the lowest eGFR level. The adjusted HR for NT-proBNP above the optimal cut-offs defined on ROC analysis were 1.5 (P=0.239), 2.2 (P<0.001), and 3.24 (P=0.002), respectively. The models incorporating NT-proBNP as a dichotomous or categorized variable had equivalent C-statistics.
There was no evidence of interaction between eGFR and NT-proBNP in predicting mortality. The NT-proBNP cut-off of 5,180 ng/L provided independent prognostic information, irrespective of the level of residual renal function.
[Show abstract][Hide abstract] ABSTRACT: Background:
Acute Kidney Injury (AKI) after cardiac surgery is a complication influencing postoperative outcome. Preoperative hemoglobin is a predictor of postoperative AKI. We aimed to identify preoperative predictors of Renal Replacement Therapy (RRT) and to develop a new risk-scoring system including hemoglobin to better stratify the risk of events.
We evaluated 3288 consecutive patients of the Regional Cardiac Surgery Registry of Puglia operated in 2011-2012. Chronic dialysis and renal transplantation patients were excluded. Primary outcome was post-operative RRT incidence.
The study sample was divided in two cohorts: 1642 patients (70 RRT) operated during the year 2011 as derivation cohort and 1646 patients (69 RRT) of the year 2012 as validation. In a multivariable logistic regression model using a stepwise method, six preoperative risk factors were associated with RRT in the derivation cohort: creatinine clearance, preoperative hemoglobin, neurological dysfunction, left ventricular ejection fraction, urgency and combined procedures (discrimination c-index 0.844 and 0.818 in the validation cohort). Scoring system included risk factors obtained from derivation cohort adjusting their relative weight with updated rounded coefficients in the validation cohort: creatinine clearance<50ml/min (1 point), hemoglobin≤12.5g/dl (1 point), left ventricular ejection fraction≤30% (1 point), urgent operation (1 point), emergency-salvage surgery (2 points), and combined procedures (1 point). In both cohorts, outcomes were strongly correlated with score points.
Our simple bedside prognostic score demonstrates good performance in predicting RRT. Hemoglobin plays an important role and future studies will clarify if preoperative anemia correction will lead to decreased RRT risk.
International Journal of Cardiology 08/2014; 176(3). DOI:10.1016/j.ijcard.2014.08.003 · 4.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives:
A systematic review of the European System for Cardiac Operative Risk Evaluation (euroSCORE) II performance for prediction of operative mortality after cardiac surgery has not been performed. We conducted a meta-analysis of studies based on the predictive accuracy of the euroSCORE II.
We searched the Embase and PubMed databases for all English-only articles reporting performance characteristics of the euroSCORE II. The area under the receiver operating characteristic curve, the observed/expected mortality ratio, and observed-expected mortality difference with their 95% confidence intervals were analyzed.
Twenty-two articles were selected, including 145,592 procedures. Operative mortality occurred in 4293 (2.95%), whereas the expected events according to euroSCORE II were 4802 (3.30%). Meta-analysis of these studies provided an area under the receiver operating characteristic curve of 0.792 (95% confidence interval, 0.773-0.811), an estimated observed/expected ratio of 1.019 (95% confidence interval, 0.899-1.139), and observed-expected difference of 0.125 (95% confidence interval, -0.269 to 0.519). Statistical heterogeneity was detected among retrospective studies including less recent procedures. Subgroups analysis confirmed the robustness of combined estimates for isolated valve procedures and those combined with revascularization surgery. A significant overestimation of the euroSCORE II with an observed/expected ratio of 0.829 (95% confidence interval, 0.677-0.982) was observed in isolated coronary artery bypass grafting and a slight underestimation of predictions in high-risk patients (observed/expected ratio 1.253 and observed-expected difference 1.859).
Despite the heterogeneity, the results from this meta-analysis show a good overall performance of the euroSCORE II in terms of discrimination and accuracy of model predictions for operative mortality. Validation of the euroSCORE II in prospective populations needs to be further studied for a continuous improvement of patients' risk stratification before cardiac surgery.
Journal of Thoracic and Cardiovascular Surgery 07/2014; 148(6). DOI:10.1016/j.jtcvs.2014.07.039 · 4.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims:
To conduct a comparative study of cardiac troponin I (cTnI) and MB isoenzyme of serum creatine kinase (CK-MB) after different cardiac surgeries.
Consecutive cardiac operations under cardiopulmonary bypass (200 adults, 144 men, 68 ± 11 years): 67 coronary artery bypass graft (CABG), 27 aortic valve surgery, 21 mitral valve surgery, 11 thoracic aorta surgery, and 74 combined surgery. Postoperative cTnI and CK-MB were measured on admission to the ICU and at fixed time until the fifth postoperative day.
Peak values of cTnI (median 5.8 ng/ml; interquartile range 3.6-11.9) and CK-MB (29.0 ng/ml; 15.6-60.4) were reached mainly within 18 h after the end of surgery (85% of cTnI and 95% of CK-MB highest determinations) without differences among groups. Cardiopulmonary bypass and cross-clamp time significantly correlated with markers' peak values. At multivariate analysis, mitral valve surgery showed greater cTnI, CK-MB, and their cumulative area under the curve than other isolated procedures. Thoracic aorta surgery showed lower cumulative area under the curve for both markers than CABG and combined surgery. Mitral valve surgery had significant later reduction of both markers in comparison with other procedures. No patient in mitral valve surgery group reached cTnI values in the normal laboratory range within 5 postoperative days.
Release pattern of cTnI and CK-MB after heart surgery depends on the type of procedure. Mitral valve surgery was characterized by highest and longest elevation of postoperative markers' concentration. Determinants of differences in myocardial injury biomarkers and their prognostic value after valve surgery should be accurately assessed.
Journal of Cardiovascular Medicine 07/2014; 16(6). DOI:10.2459/JCM.0000000000000044 · 1.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims:
To evaluate the feasibility of a cardiac surgery registry and to describe patients' characteristics, type of procedures performed, incidence of postoperative complications with short and middle-term mortality.
A database with clinical information and details on cardiac surgical operations was implemented by Puglia Health Regional Agency to collect data of each cardiac surgery procedure performed in the seven adult cardiac surgery centres of the region. Health regional agency personnel guaranteed data accuracy and quality control procedures. Mortality after the discharge was evaluated for residents in Puglia by linking clinical data to the Health Information System.
From January 2011 to December 2012, 6429 operations were performed. All operations were included in the registry with very high completeness of collected data (95.3% per patient). The majority of the operations performed were coronary artery bypass graft alone (41.1%), valve surgery alone (26.2%), coronary artery bypass graft and valve surgery (11.4%), or valve with other surgery (11.8%). During a median follow-up of 12 months (interquartile range 6-18 months), 211 deaths were detected after the discharge. Overall, cumulative mortality from the operation was 8.2% at 6 months and 9.5% at 12 months.
Implementation of a regional clinical registry of cardiac surgery is feasible with a great level of accuracy and the evaluation of mid-term mortality overcomes the limited value of hospital mortality. An accurate cardiac surgery registry elicits epidemiologic evaluations, comparisons between expected and observed mortality, incidence of postoperative complications and encourages a reliable public reporting.
Journal of Cardiovascular Medicine 06/2014; 15(11). DOI:10.2459/JCM.0000000000000115 · 1.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the effects of prophylactic perioperative corticosteroid administration, compared with placebo, on postoperative mortality and clinical outcomes (renal dysfunction, duration of mechanical ventilation, and ICU length of stay) in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass.
MEDLINE and Cochrane Library were screened through August 2013 for randomized controlled trials in which perioperative steroid treatment was adopted.
Included were randomized controlled trials conducted on pediatric population that reported clinical outcomes about mortality and morbidity.
Eighty citations (PubMed, 48 citations; Cochrane, 32 citations) were identified, of which 14 articles were analyzed in depth and six articles fulfilled eligibility criteria and reported mortality data (232 patients), two studies reported ICU length of stay and mechanical ventilation duration (60 patients), and two studies reported renal dysfunction (49 patients).
A nonsignificant trend of reduced mortality was observed in steroid-treated patients (11 [4.7%] vs 4 [1.7%] patients; odds ratio, 0.41; 95% CI, 0.14-1.15; p = 0.089). Steroids had no effects on mechanical ventilation time (117.4 ± 95.9 hr vs 137.3 ± 102.4 hr; p = 0.43) and ICU length of stay (9.6 ± 4.6 d vs 9.9 ± 5.9 d; p = 0.8). Perioperative steroid administration reduced the prevalence of renal dysfunction (13 [54.2%] vs 2 [8%] patients; odds ratio, 0.07; 95% CI, 0.01-0.38; p = 0.002).
Despite a demonstrated attenuation of cardiopulmonary bypass-induced inflammatory response by steroid administration, a systematic review of randomized controlled trials performed so far reveals that steroid administration has potential clinical advantages (lower mortality and significant reduction of renal function deterioration). A larger prospective randomized study is needed to verify clearly the effects of steroid prophylaxis in pediatric patients.
Pediatric Critical Care Medicine 04/2014; 15(5). DOI:10.1097/PCC.0000000000000128 · 2.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Antithrombin (AT) concentrations are reduced after cardiac surgery with cardiopulmonary bypass compared with the preoperative levels. Low postoperative AT is associated with worse short- and mid-term clinical outcomes. The aim of the study is to evaluate the effects of AT administration on activation of the coagulation and fibrinolytic systems, platelet function, and the inflammatory response in patients with low postoperative AT levels.
Sixty patients with postoperative AT levels of less than 65% were randomly assigned to receive purified AT (5000 IU in three administrations) or placebo in the postoperative intensive care unit. Thirty patients with postoperative AT levels greater than 65% were observed as controls. Interleukin 6 (a marker of inflammation), prothrombin fragment 1-2 (a marker of thrombin generation), plasmin-antiplasmin complex (a marker of fibrinolysis), and platelet factor 4 (a marker of platelet activation) were measured at six different times.
Compared with the no AT group and control patients, patients receiving AT showed significantly higher AT values until 48 hours after the last administration. Analysis of variance for repeated measures showed a significant effect of study treatment in reducing prothrombin fragment 1-2 (p = 0.009; interaction with time sample, p = 0.006) and plasmin-antiplasmin complex (p < 0.001; interaction with time sample, p < 0.001) values but not interleukin 6 (p = 0.877; interaction with time sample, p = 0.521) and platelet factor 4 (p = 0.913; interaction with time sample, p = 0.543). No difference in chest tube drainage, reopening for bleeding, and blood transfusion was observed.
Antithrombin administration in patients with low AT activity after surgery with cardiopulmonary bypass reduces postoperative thrombin generation and fibrinolysis with no effects on platelet activation and inflammatory response.
The Annals of thoracic surgery 02/2014; 97(4). DOI:10.1016/j.athoracsur.2013.11.040 · 3.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate performance of the European System for Cardiac Operation Risk Evaluation (EuroSCORE II), to assess the influence of model updating and to derive a hierarchical tree for modelling the relationship between EuroSCORE II risk factors and hospital mortality after cardiac surgery in a large prospective contemporary cohort of consecutive adult patients.
Data on consecutive patients, who underwent on-pump cardiac surgery or off-pump coronary artery bypass graft intervention, were retrieved from Puglia Adult Cardiac Surgery Registry. Discrimination, calibration, re-estimation of EuroSCORE II coefficients and hierarchical tree analysis of risk factors were assessed.
Out 6293 procedures, 6191 (98.4%) had complete data for EuroSCORE II assessment with a hospital mortality rate of 4.85% and EuroSCORE II of 4.40 ± 7.04%. The area under the receiver operator characteristic curve (0.830) showed good discriminative ability of EuroSCORE II in distinguishing patients who died and those who survived. Calibration of EuroSCORE II was preserved with lower predicted than observed risk in the highest EuroSCORE II deciles. At logistic regression analysis, the complete revision of the model had most of re-estimated regression coefficients not statistically different from those in the original EuroSCORE II model. When missing values were replaced with the mean EuroSCORE II value according to urgency and weight of intervention, the risk score confirmed discrimination and calibration obtained over the entire sample. A recursive tree-building algorithm of EuroSCORE II variables identified three large groups (55.1, 17.1 and 18.1% of procedures) with low-to-moderate risk (observed mortality of 1.5, 3.2 and 6.4%) and two groups (3.8 and 5.9% of procedures) at high risk (mortality of 14.6 and 32.2%). Patients with low-to-moderate risk had good agreement between observed events and predicted frequencies by EuroSCORE II, whereas those at greater risk showed an underestimation of expected mortality.
This study demonstrates that EuroSCORE II is a good predictor of hospital mortality after cardiac surgery in an external validation cohort of contemporary patients from a multicentre prospective regional registry. The EuroSCORE II predicts hospital mortality with a slight underestimation in high-risk patients that should be further and better evaluated. The EuroSCORE II variables as a risk tree provides clinicians and surgeons a practical bedside tool for mortality risk stratification of patients at low, intermediate and high risk for hospital mortality after cardiac surgery.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 01/2014; 46(5). DOI:10.1093/ejcts/ezt657 · 3.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Myocardial damage occurs after valve surgery, but its prognostic implication has not been evaluated. The aim of the present study was to assess the influence of myocardial damage on mortality and morbidity in patients undergoing aortic surgery (AVS) and mitral valve surgery (MVS).
In a prospective multicenter study from the cardiac surgery registry of the Puglia region, cardiac troponin I (cTnI) was measured immediately after and the morning after the intervention in consecutive patients undergoing AVS or MVS. The percentile ranks of the cTnI peak values within each center were analyzed.
Of 965 patients (age, 67 ± 12 years; 45.5% women), 579 had undergone AVS and 386 MVS. cTnI release was significantly greater in the MVS group than in the AVS group and in the nonsurvivors than in the survivors in both groups. The cTnI cutoff with the greatest sensitivity and specificity (60th percentile for AVS and 91st for MVS) in predicting hospital mortality (2.6%) was also associated with a greater rate of postoperative complications and mortality within 3 months postoperatively (multivariate hazard ratio, 3.38; P = .005). Compared with the reference model, which included the multivariate predictors of hospital mortality (active endocarditis, New York Heart Association class III-IV, left ventricular ejection fraction ≤ 30%, and cardiopulmonary bypass duration), the addition of cTnI greater than the cutoffs showed significant improvement in model performance (likelihood ratio test, P = .009; net reclassification improvement, 0.751; P < .001; integrated discrimination improvement, 0.048; P = .002; c-index 0.832 vs 0.838).
An elevated postoperative cTnI level was an independent risk factor for mortality and morbidity. Measurement of the cTnI level improved the risk reclassification of patients undergoing AVS or MVS.
The Journal of thoracic and cardiovascular surgery 11/2013; 148(5). DOI:10.1016/j.jtcvs.2013.10.061 · 4.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Acute kidney injury (AKI) after cardiac operations is a serious complication associated with postoperative mortality. Multiple factors contribute to AKI development, principally ischemia-reperfusion injury and inflammatory response. It is well proven that glucocorticoid administration, leukocyte filter application, and miniaturized extracorporeal circuits (MECC) modulate inflammatory response. We conducted a systematic review of randomized controlled trials (RCTs) in which one of these inflammatory system modulation strategies was used, with the aim to evaluate the effects on postoperative AKI. MEDLINE and Cochrane Library were screened through November 2011 for RCTs in which an inflammatory system modulation strategy was adopted. Included were trials that reported data about postoperative renal outcomes. Because AKI was defined by different criteria, including biochemical determinations, urine output, or dialysis requirement, we unified renal outcome as worsening renal function (WRF). We identified 14 trials for steroids administration (931 patients, WRF incidence [treatment vs. placebo]: 2.7% vs. 2.4%; OR: 1.13; 95% CI: 0.53-2.43; P = 0.79), 9 trials for MECC (947 patients, WRF incidence: 2.4% vs. 0.9%; OR: 0.47; 95% CI: 0.18-1.25; P = 0.13), 6 trials for leukocyte filters (374 patients, WRF incidence: 1.1% vs. 7.5%; OR: 0.18; 95% CI: 0.05-0.64; P = 0.008). Only leukocyte filters effectively reduced WRF incidence. Not all cardiopulmonary bypass-related anti-inflammatory strategies analyzed reduced renal damage after cardiac operations. In adult patients, probably other factors are predominant on inflammation in determining AKI, and only leukocyte filters were effective. Large multicenter RCTs are needed in order to better evaluate the role of inflammation in AKI development after cardiac operations.
[Show abstract][Hide abstract] ABSTRACT: Introduction No data on the prevalence of erectile dysfunction (ED) in subjects with newly diagnosed DM type 2 are currently available. Aim The aim of the present study was to estimate the prevalence of ED and its associated causes in a sample of male patients with recently diagnosed DM (<24 months) attending a diabetes care center. Methods The study comprised two phases: a cross-sectional analysis and a longitudinal reassessment of the data collected during the first phase. During the first phase 1503 subjects (mean age, 58.7±8.9 years) from 27 centers were interviewed: 666 (43.3%) reported experiencing ED, 499 of which (mean age, 58.8±8.8 years) agreed to participate in the study (final enrolment rate, 33.3%). Concurrent morbidities were hypertension (55.3%), dyslipidemia (39.5%), and coronary heart disease (7.8%); chronic complications were neuropathy (8.9%), nephropathy (12.6%) and retinopathy (7.6%) in about one third of the sample at enrolment. Results Overall, about 20% of the patients reported having used ED drugs, but more than 50% had abandoned therapy because of the drug's ineffectiveness or high cost. The prevalence of hypogonadism was 46.9% (total testosterone level, 3.5 ng/ml). Some 20% of patients reported symptoms suggestive of depression. Conclusion The present study provides data showing a high prevalence of ED, hypogonadism and depressive symptoms among male patients with newly diagnosed DM type 2. Further analysis of the data will elucidate the specific determinants of such conditions and their longitudinal significance.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: To assess the incidence of incomplete heparin reversal and heparin rebound after cardiac surgery with cardiopulmonary bypass (CPB) and the ability of the activated coagulation time (ACT) and thromboelastography (TEG) to detect these phenomena. DESIGN: Prospective single-center study. SETTING: University hospital. PARTICIPANTS: Forty-one patients undergoing elective cardiac surgery with CPB and with normal preoperative TEG parameters. INTERVENTIONS: ACT, TEG, and plasma heparin levels were measured in all patients at 5 different times between 20 minutes and 3 hours after protamine administration. The variability of TEG reaction time (R) with and without heparinase (delta-R [DR]) was used to detect the presence of residual heparin. MEASUREMENTS AND MAIN RESULTS: Plasma heparin expressed as anti-FXa activity was detected in 180 (88%) samples. At univariate analysis, ACT, R-kaolin (R-k), and DR significantly correlated with plasma heparin concentration (respectively, p = 0.007, p = 0.006, and p = 0.002). At multivariate analysis, R-k and DR remained associated with plasma heparin concentration (respectively, p = 0.014 and p = 0.004). Greater quartiles of heparin were associated with higher values of R-k and DR. Combined procedures had significantly lower DR than isolated procedures (p = 0.017), and CPB time and heparinization time positively correlated with R-k (respectively, p = 0.044 and p = 0.022). No association was observed between heparin concentration, ACT, and TEG parameters with postoperative bleeding and need for blood and blood components transfusions. CONCLUSIONS: Heparin rebound and incomplete heparin reversal are very common phenomena after cardiac surgery with CPB; ACT is not able to detect residual heparin activity, whereas TEG analysis with and without heparinase allows the diagnosis of heparin rebound.
Journal of cardiothoracic and vascular anesthesia 04/2013; 27(5). DOI:10.1053/j.jvca.2012.10.020 · 1.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Insulin resistance is a metabolic condition characterized by a reduced insulin
sensitivity. It is associated to an increased cardiovascular risk. Many literature data outlined
endothelial damages due to insulin resistance condition, which in turn is a well-known early
atherosclerotic event. Cardiac rehabilitation and controlled physical activity during early
phase after the main event could influence insulin resistance condition and, therefore, limit
vascular damages progression. Flow-Mediated vasodilatation (FMD) at the level of brachial
artery is a validated non-invasive ultrasound tool able to study endothelial function.
Purpose. Study aim is to investigate the relationships between endothelial dysfunction and
insulin resistance condition in subjects undergone a cardiac rehabilitation cycle.
Materials and methods: 35 consecutive patients (27 men, mean age 65�13 years, range: 36-83
years) admitted to the Department of Preventive Cardiology and Rehabilitation, ‘‘Codivilla-
Putti" Institute, Cortina d’Ampezzo (BL), Italy for a cardiac rehabilitation period (mean
duration: 15�4 days) were enrolled from November to December 2011. Each patient under-
went FMD evaluation at the admission and before discharge. According to HOMA-IR we
divided our population in two groups: 1) insulin-resistant patients (IR) and 2) non insulin-
resistant patients (noIR).
Results: IR patients showed higher body mass index (27.1�3.5 vs 24.3�2.9 kg/m2; p=0.012),
higher triglycerides levels (152�73 vs 93�36 mg/dl; p=0.004) and there were more smokers
(35% vs 6%; p=0.028) than noIR. noIR FMD values at admission were higher than IR FMD
ones (5.4�2.5 vs 3.5�1.5; p=0.011), as well as FMD values before discharge (9.4�3.2 vs
5.6�2.3; p <0.001). After the cardiac rehabilitation period, both groups showed a clear
amelioration in endothelial function (�FMD: IR: 4�3.2 vs noIR: 2.1�2.2; p=0.044).
Conclusions: Cardiac rehabiliation in sub-acute phase induces a clear amelioration in endothe-
lial function, although the absolute increase is linked to insulin resistance: endothelial function
amelioration in IR patients is less pronounced than noIR one. FMD is a useful clinical tool
able to evaluate and monitor cardiac rehabilitation improvement.
Europrevent Congress 2013, Rome, April 18-20, 2013 -Abstract P555; 04/2013