[Show abstract][Hide abstract] ABSTRACT: We investigated whether oxidative stress and the arginine/nitric oxide pathway differ in control subjects and in adult patients who are candidates for the three most common cardiac surgical operations: coronary bypass surgery, aortic valve replacement for calcific non-rheumatic aortic stenosis or mitral valve repair for degenerative mitral insufficiency.
In this prospective observational study, we studied 165 consecutive patients undergoing surgery from January to June 2011 (coronary bypass surgery, n = 63; aortic valve replacement for calcific non-rheumatic aortic stenosis, n = 51; mitral valve repair for degenerative mitral insufficiency, n = 51). Thirty-three healthy subjects with cardiovascular risk factors similar to surgery patients were also studied (Controls). Oxidative stress (the ratio of reduced and oxidized glutathione and urinary isoprostane), antioxidants (alpha- and gamma tocopherol) and factors involved in nitric oxide synthesis (arginine, symmetric and asymmetric dimethylarginine) were measured before surgery. Analysis of variance general linear models and principal component analysis were used for statistical analysis.
Surgical patients had increased levels of oxidative stress and decreased levels of antioxidants. Increased levels of nitric oxide inhibitor asymmetric dimethylarginine were detected in surgical candidates, suggesting arginine/nitric oxide pathway impairment. Concerning the differences among surgical procedures, higher oxidative stress and a major imbalance of the ratio between substrate and inhibitors of nitric oxide synthesis were evidenced in patients who were candidates for mitral valve repair with respect to coronary bypass surgery patients and patients with calcific non-rheumatic aortic stenosis.
Patients undergoing cardiac surgery have increased oxidative stress and a trend towards an impaired arginine/nitric oxide pathway with respect to Controls. Patients affected by mitral valve regurgitation show more pronounced perturbations in these pathways. The clinical implications of these findings need to be investigated.
Full-text · Article · Sep 2013 · Interactive Cardiovascular and Thoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: Background:
Statins interact with multiple pathways involved in infection. Therefore, we examined the association between preoperative statin therapy and infections after cardiac operations and assessed whether statin therapy was associated with lower infection-related mortality.
From January 2005 to January 2011, 12,741 patients underwent cardiac operations. Endpoints were (1) postoperative infections and (2) mortality after an infectious complication. A propensity score was developed on the probability of patients receiving statin therapy; patients were matched in part on this score. A multivariable logistic model was developed to examine mortality. Survival of infected patients was estimated using Kaplan-Meier and multiphase hazard function methodology.
A total of 6,113 patients (48%) were receiving statins and 6,628 (52%) were not. Five hundred fifteen patients had postoperative infections-260 (4.3%) in the statin group and 255 (3.8%) in the no-statin group. However, patients receiving statins were older with more comorbidities and less favorable operative characteristics. Among propensity-matched groups, postoperative infections were significantly lower in patients receiving statins (n = 102 [3.1%]) than in those who were not (n = 147 [4.5%]; p = 0.004). Among patients in whom infections developed, there was no significant difference in hospital mortality between the statin and no-statin groups either before or after propensity-score matching (odds ratio, 1.38; confidence limit [CL], 0.59, 3.22; p = 0.5).
We observed a protective effect of statin therapy against the development of infections after cardiac operations, but not on mortality from these infections. Prospective investigations are needed to determine optimal dose and duration of statin therapy and their relationship to infectious complications.
No preview · Article · Feb 2013 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: Introduction. To evaluate the role of hyperthermic isolated limb perfusion (HILP) in arterial thrombosis following melanoma-soft tissue sarcoma chemotherapy. Report. Here is presented one case of iliac-common femoral artery subacute thrombosis and a review of the appropriate literature performed using a MEDLINE search. Acute/subacute arterial occlusion is one of the most feared vascular complications of HILP, located nearly always in the external iliac-femoral artery axis, being those vessels cannulated for perfusion. Conclusions. The small number of reported cases indicates either the rarity of this complication or unawareness of its existence. The true incidence of this complication is probably underreported.
Preview · Article · Jul 2011 · International journal of vascular medicine
[Show abstract][Hide abstract] ABSTRACT: Chest ultrasonography is a useful tool to assess extravascular lung water at bedside. In presence of interstitial-alveolar imbibition, vertical artifacts arising from the pleura are detected; these are called B-lines. Although a positive linear correlation between B-lines and extravascular lung water has been shown in symptomatic heart failure patients, the subclinical phase of pulmonary imbibition and the clearance of B-lines after rapid body fluid removal have been less investigated. The aim of this study was to assess if chest ultrasound could detect lung water imbibition and its variations induced by dialysis, an experimental model of controlled rapid fluid loss. Forty-one patients undergoing hemodialysis were studied. Total number of B-lines from ultrasound chest scanning and vena cava diameters were measured before and after treatment. Before dialysis, most of the patients presented ultrasound signs of pulmonary imbibition despite the absence of dyspnea; the number of B-lines was associated with the accumulated weight before treatment (p < 0.05) as well as with the residual weight after dialysis (p < 0.01); B-lines and end-inspiratory and end-expiratory vena cava diameters were also significantly reduced after dialysis. Moreover, B-lines reduction was significantly related to weight loss. Ultrasound performed at the bedside can detect lung water and intravascular overload and their reduction after dialysis in yet asymptomatic patients. These observations add further evidence regarding the use of lung ultrasound and inferior vena cava measurement in estimating volume overload and monitoring the response to therapy both in hemodialysis and congestive heart failure patients.
Full-text · Article · May 2011 · Internal and Emergency Medicine
[Show abstract][Hide abstract] ABSTRACT: It is not known whether statin treatment improves clinical outcomes and reduces aortic stenosis progression in non-rheumatic calcific aortic stenosis.
A meta-analysis of studies was performed comparing statin therapy with placebo or no treatment on outcomes and on aortic stenosis progression echocardiographic parameters.
The authors searched Medline and Pubmed up to January 2010.
Two independent reviewers independently abstracted information on study design (prospective vs retrospective or randomised vs non-randomised), study and participant characteristics. Fixed and random effects models were used. A-priori subanalyses assessed the effect of statins on low-quality (retrospective or non-randomised) and on high-quality (prospective or randomised) studies separately.
Meta-analysis identified 10 studies with a total of 3822 participants (2214 non-statin-treated and 1608 statin-treated); five studies were classified as prospective and five as retrospective; concerning randomisation, three trials were randomised whereas seven were not. No significant differences were found in all-cause mortality, cardiovascular mortality or in the need for aortic valve surgery. Lower-quality (retrospective or non-randomised) studies showed that, in statin-treated patients, the annual increase in peak aortic jet velocity and the annual decrease in aortic valve area were lower, but this was not confirmed by the analysis in high-quality (prospective or randomised) studies. Statins did not significantly affect the progression over time of peak and mean aortic gradient.
Currently available data do not support the use of statins to improve outcomes and to reduce disease progression in non-rheumatic calcific aortic valve stenosis.
[Show abstract][Hide abstract] ABSTRACT: Mitral valve prolapse (MVP) represents a common degenerative disease, often requiring surgery. If untreated, MVP with considerable valve incompetence can lead to cardiovascular and systemic complications causing substantial morbidity and mortality. In contrast with the wide knowledge concerning clinical and physiological features, currently available data regarding its molecular bases are very limited. We review current knowledge concerning MVP biological mechanisms, focusing on specific aspects of haemostasis, platelet function, oxidative stress, extracellular matrix remodeling and genomics. In particular, available evidence supports the role played by tissue remodeling processes in determining MVP onset and progression. Moreover, even if a consistent although controversial perturbation of haemostatic system and alterations of the oxidative stress equilibrium have been proposed to influence disease development, it is unknown whether these changes precede or follow MVP occurrence. Consequently, the complete knowledge of all the biochemical pathways involved are far from complete. In addition, changes in the regulation pattern of adrenergic and renin-angiotensin-aldosterone systems have been described in MVP syndrome, a condition characterized by the association of MVP with other peculiar neurological and general symptoms, but it is unknown whether these abnormalities are shared by "traditional" MVP. In conclusion, MVP is probably a multi-factorial process, and many aspects still need to be clarified. As surgery can only correct the damaged valve but not the underlying mechanisms, a more complete knowledge of the involved molecular pathways is necessary, as it may allow the discovery of targeted therapeutic strategies aimed at modifying or slackening MVP natural course in the early phases.
No preview · Article · Dec 2010 · International journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) was developed to predict immediate outcomes after adult cardiac operations, but less than 30% of the cases used to develop this score were valve procedures. We studied EuroSCORE performance in valve procedures.
We performed a meta-analysis of published studies reporting the assessment of discriminatory power of the EuroSCORE by receiver operating characteristics (ROC) curve analysis in adult valve operations. A comparison of observed and predicted mortality rates was also performed.
A literature search identified 37 potentially eligible studies, and 12 were selected for meta-analysis comprising 26,621 patients with 1250 events (mortality rate, 4.7%). Meta-analysis of these studies provided an average area under the curve (AUC) value of 0.730 (95% confidence interval [CI], 0.717 to 0.743). The same results were obtained when meta-analyses were performed separately in studies categorized on reliability of uncertainty estimation: in the seven studies reporting reliable uncertainty estimation (8175 patients with 358 events; mortality rate, 4.4%), the ROC curve provided an average AUC value of 0.724 (95% CI, 0.699 to 0.749). The five studies not reporting reliable uncertainty estimation (18,446 patients with 892 events; mortality rate, 4.8%) had an average AUC of 0.732 (95% CI, 0.717 to 0.747). We documented a constant trend to overpredict mortality by EuroSCORE, both in the additive and especially in the logistic form.
The EuroSCORE has low discrimination ability for valve surgery, and it sensibly overpredicts risk. Alternative risk scoring algorithms should be seriously considered.
Full-text · Article · Mar 2010 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: Intravenous administration of saline and non-ionic isosmolar contrast media significantly reduces the incidence of contrast-induced nephropathy, one of the most common causes of acute renal failure. Results with oral N-acetylcysteine are conflicting. The aim of our study was to evaluate the prophylactic role of N-acetylcysteine in patients with stable chronic renal failure undergoing coronary and/or peripheral angiography and/or angioplasty.
We randomized 200 elective, consecutive patients (mean age 74.9 +/- 7.3 years; 65% male, 25% diabetics) with basal creatinine clearance <or=55 ml/min to receive oral N-acetylcysteine (600 mg bid the day before and the day of the procedure plus saline i.v. 0.9% 1 ml/kg/h 12-24 h before and 24 h after the procedure, n = 99) or placebo and saline at the same time intervals, n = 101. The contrast medium was non-ionic isosmolar (Iodixanol, Visipaque Amersham Health). Contrast-induced nephropathy was defined as an increase in serum creatinine >0.5 mg/dl or >25% within 3 days after the procedure. Serum creatinine was measured at baseline, 24, 48 and 72 h after the procedure.
Contrast-induced nephropathy was 8/99 (8.1%) in the N-acetylcysteine group versus 6/101 (5.9%) in the placebo group, P = 0.6. No difference was noted in high-risk subgroups such as diabetics (4/25 versus 2/25 P = 0.4) and those with serum creatinine clearance <42.3 ml/min (5/54 versus 4/48; P = 0.9).
In our experience, N-acetylcysteine did not prevent contrast-induced nephropathy in patients receiving isosmolar (iodixanol) contrast media and adequate hydration.
No preview · Article · Jun 2009 · Nephrology Dialysis Transplantation
[Show abstract][Hide abstract] ABSTRACT: To assess EuroSCORE performance in predicting in-hospital mortality in on-pump coronary artery bypass grafting (CABG) and off-pump coronary artery bypass grafting (OPCAB).
Additive and logistic EuroSCORE were computed for consecutive patients undergoing CABG (n = 3440, 75%) or OPCAB (n = 1140, 25%) at our hospital from 1999 to September 2007. The areas under the receiver operating characteristic (ROC) curves (AUCs) were used to describe performance and accuracy. No difference in performance between CABG and OPCAB and between additive and logistic EuroSCORE (additive EuroSCORE AUCs of 0.808 and 0.779 for CABG and OPCAB, respectively; logistic EuroSCORE AUCs of 0.813 and of 0.773 for CABG and OPCAB, respectively) was found, although a marked tendency to overpredict mortality by both models was evident. A meta-analysis of previously published data was done, and a total of eight studies representing 19 212 and 5461 patients undergoing CABG and OPCAB, respectively, met inclusion criteria. Meta-analysis confirmed similar performance of EuroSCORE in CABG and OPCAB: estimated AUCs were 0.767 and 0.766 for CABG and OPCAB, respectively, with an estimated difference of 0.001 (95% CI -0.061 to 0.063).
Additive and logistic EuroSCORE algorithms performed similarly, and cumulative evidence suggests comparable performance in CABG and OPCAB procedures; both risk models, however, significantly overestimated mortality.
Full-text · Article · Feb 2009 · European Heart Journal
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine whether, in recent years, sex differences in the type of care during coronary artery bypass graft surgery procedures occurred.
Between 1995 and 2004, 5,935 consecutive patients (4,867 men and 1,068 women) underwent isolated coronary artery bypass graft surgery; propensity score matching was used to investigate whether sex adversely impacts standard care and early outcomes of coronary revascularization.
Of the 1,068 women undergoing isolated coronary artery bypass graft surgery, only 280 (26.2%) were matched on propensity scores with men. Distribution of preoperative variables among matched pairs was, on average, equal. Propensity-matched women received similar number of distal anastomoses as men (2.70 +/- 0.89 versus 2.82 +/- 0.97; p = 0.13), had similar rates of complete revascularization (82.5% versus 81.6%; p = 0.78), and of off-pump procedures (24.3% versus 27.5%; p = 0.39); also, the rate of utilization of arterial grafts (left internal mammary artery 98.5% versus 98.2%; p = 0.73; right internal mammary artery 3.2% versus 3.2%; p > 0.99; radial artery 8.2% versus 9.6%; p = 0.55), as well as the number of distal anastomoses performed with arterial grafts (1.11 +/- 0.36 versus 1.13 +/- 0.39; p = 0.47), were similar in women and men. No differences were detected in major complications (in-hospital mortality, perioperative myocardial infarction, and stroke) in propensity-matched pairs, whereas women had lower reexploration for bleeding and blood transfusion rates.
The preoperative profiles of women and men were markedly different, as only one fourth of women could be matched. In the current era, after adjustment for preoperative variables, female patients received the same standard of care as men, with improved results in some minor early outcomes.
Full-text · Article · Mar 2008 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: The aim of this prospective study is to evaluate the role in the onset of surgical site infections of bilateral internal thoracic arteries harvesting in patients with decompensated preoperative glycemia.
81 consecutive patients with uncontrolled diabetes mellitus underwent elective CABG harvesting single or double internal thoracic arteries. Single left ITA was harvested in 41 patients (Group 1, 50.6%), BITAs were harvested in 40 (Group 2, 49.4%). The major clinical end points analyzed in this study were infection rate, type of infection, duration of infection, infection relapse rate and total hospital length of stay.
Five patients developed sternal SSI in the perioperative period, 2 in group 1 and 3 in group 2 without significant difference. All sternal SSIs were superficial with no sternal dehiscence. The development of infection from the time of surgery took 18.5 +/- 2.1 and 7.3 +/- 3.0 days for Groups 1 and 2 respectively. The infections were treated with wound irrigation and debridement, and with VAC therapy as well as with antibiotics. The VAC system was removed after a mean of 12.8 +/- 5.1 days, when sterilization was achieved. The overall survival estimate at 1 year was 98.7%. Only BMI was a significant predictor of SSI using multivariate stepwise logistic regression analysis (Odds Ratio: 1.34; 95%Conficdence Interval: 1.02-1.83; p value: 0.04). In the model, the use of BITA was not an independent predictor of SSI.
CABG with bilateral pedicled ITAs grafting could be performed safely even in diabetics with poor preoperative glycaemic control.
Full-text · Article · Feb 2008 · Journal of Cardiothoracic Surgery
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study is to assess the effects of linear and geometric left ventricular aneurysm reconstruction on early postoperative outcomes.
A search of computerized databases supplemented with manual bibliographic review was performed for all peer-reviewed English language publications concerning randomized and nonrandomized studies reporting the results of left ventricular reconstruction after both linear and geometric reconstruction techniques. Meta-analyses of several short-term outcomes were performed.
No randomized trial was identified. Eighteen nonrandomized trials were found with a total of 1,814 and 803 patients who underwent linear and geometric reconstruction, respectively. Meta-analysis of all studies (n = 18) revealed an increased risk of in-hospital death for patients undergoing linear reconstruction (relative risk = 1.59, 95% confidence interval: 1.12 to 2.26, p = 0.01). The subanalysis of studies in which linear reconstruction was adopted mainly in the first period of time, and geometric reconstruction was adopted in a later phase, still showed a significant advantage in terms of in-hospital mortality for patients undergoing geometric reconstruction (n = 11 studies, relative risk = 1.89, 95% confidence interval: 1.22 to 2.93, p = 0.004). By contrast, when the two surgical approaches were carried out in the same time lag, there was no difference between linear and geometric reconstruction techniques (n = 7 studies, relative risk = 1.04, 95% confidence interval: 0.57 to 1.92, p = 0.89). No differences in the other outcomes of interest were observed.
The advantage for geometric reconstruction techniques in terms of in-hospital mortality shown in some studies can be an effect of learning curve or of improvement over time in management of these difficult patients. Further studies are required to clarify this issue.
Preview · Article · Jul 2007 · The Annals of thoracic surgery
[Show abstract][Hide abstract] ABSTRACT: This study was undertaken to evaluate predictors and outcomes of octogenarians who underwent abdominal aortic aneurysm repair.
A prospective observational study.
Between January 1st, 1997 and April 15th, 2005, 31 octogenarians were admitted to our Department with the diagnosis of abdominal aortic aneurysm. Mean follow-up time was 53.7+/-27.2 months. All patients were in good clinical condition and represented a selected healthy group of octogenarians.
The overall perioperative (30-days) mortality rate was 3.1%. The total in-hospital morbidity rate was 22.6%. Overall survival estimates at 48 and 96 months were 81+/-8% and 46+/-21%, respectively. The actuarial freedom from aneurysm-related death at 48 and 96 months was 96+/-4% and 96+/-4%, respectively. The actuarial freedom from aneurysm-unrelated death at 48 and 96 months was 84+/-7% and 48+/-21%. Only coronary artery disease was a significant predictor of survival using multivariate stepwise logistic regression analysis.
In this series, AAA surgery was carried out in selected octogenarians without affecting long-term survival.
Full-text · Article · Jun 2006 · European Journal of Vascular and Endovascular Surgery