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Gaudino M, Flather M, Capodanno D, Milojevic M, Bhatt DL, Biondi Zoccai G, Boden WE, Devereaux PJ, Doenst T, Farkouh M, Freemantle N, Fremes S, Puskas J, Landoni G, Lawton J, Myers PO, Redfors B, Sandner S. European Association of Cardio-Thoracic Surgery (EACTS) expert consensus statement on perioperative myocardial infarction after cardiac surgery. Eur J Cardiothorac Surg 2024; 65:ezad415. [PMID: 38420786 DOI: 10.1093/ejcts/ezad415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/14/2023] [Accepted: 12/12/2023] [Indexed: 03/02/2024] Open
Abstract
Cardiac surgery may lead to myocardial damage and release of cardiac biomarkers through various mechanisms such as cardiac manipulation, systemic inflammation, myocardial hypoxia, cardioplegic arrest and ischaemia caused by coronary or graft occlusion. Defining perioperative myocardial infarction (PMI) after cardiac surgery presents challenges, and the association between the current PMI definitions and postoperative outcomes remains uncertain. To address these challenges, the European Association of Cardio-Thoracic Surgery (EACTS) facilitated collaboration among a multidisciplinary group to evaluate the existing evidence on the mechanisms, diagnosis and prognostic implications of PMI after cardiac surgery. The review found that the postoperative troponin value thresholds associated with an increased risk of mortality are markedly higher than those proposed by all the current definitions of PMI. Additionally, it was found that large postoperative increases in cardiac biomarkers are prognostically relevant even in absence of additional supportive signs of ischaemia. A new algorithm for PMI detection after cardiac surgery was also proposed, and a consensus was reached within the group that establishing a prognostically relevant definition of PMI is critically needed in the cardiovascular field and that PMI should be included in the primary composite outcome of coronary intervention trials.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Biondi Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - William E Boden
- VA New England Healthcare System, Boston University School of Medicine, Boston, MA, USA
| | - P J Devereaux
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Michael Farkouh
- Academic Affairs, Cedars-Sinai Health System, Los Angeles, CA, USA
| | - Nicholas Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Stephen Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - John Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY, USA
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Jennifer Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Patrick O Myers
- Department of Cardiac Surgery, CHUV-Center Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Björn Redfors
- Cardiovascular Research Foundation, New York, NY, USA
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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2
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Robinson NB, Sef D, Gaudino M, Taggart DP. Postcardiac surgery myocardial ischemia: Why, when, and how to intervene. J Thorac Cardiovasc Surg 2023; 165:687-695. [PMID: 34556355 DOI: 10.1016/j.jtcvs.2021.05.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/21/2021] [Accepted: 05/30/2021] [Indexed: 01/18/2023]
Affiliation(s)
- N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Davorin Sef
- Department of Cardiac Surgery, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - David P Taggart
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.
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Zangrillo A, Lomivorotov VV, Pasyuga VV, Belletti A, Gazivoda G, Monaco F, Nigro Neto C, Likhvantsev VV, Bradic N, Lozovskiy A, Lei C, Bukamal NAR, Silva FS, Bautin AE, Ma J, Yong CY, Carollo C, Kunstyr J, Wang CY, Grigoryev EV, Riha H, Wang C, El-Tahan MR, Scandroglio AM, Mansor M, Lembo R, Ponomarev DN, Bezerra FJL, Ruggeri L, Chernyavskiy AM, Xu J, Tarasov DG, Navalesi P, Yavorovskiy A, Bove T, Kuzovlev A, Hajjar LA, Landoni G. Effect of Volatile Anesthetics on Myocardial Infarction After Coronary Artery Surgery: A Post Hoc Analysis of a Randomized Trial. J Cardiothorac Vasc Anesth 2022; 36:2454-2462. [PMID: 35168907 DOI: 10.1053/j.jvca.2022.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/08/2021] [Accepted: 01/02/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the effect of volatile anesthetics on the rates of postoperative myocardial infarction (MI) and cardiac death after coronary artery bypass graft (CABG). DESIGN A post hoc analysis of a randomized trial. SETTING Cardiac surgical operating rooms. PARTICIPANTS Patients undergoing elective, isolated CABG. INTERVENTIONS Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or total intravenous anesthesia (TIVA). The primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48 hours from surgery. The secondary outcome was 1-year death due to cardiac causes. MEASUREMENTS AND MAIN RESULTS A total of 5,400 patients were enrolled between April 2014 and September 2017 (2,709 patients randomized to the volatile anesthetics group and 2,691 to TIVA). The mean age was 62 ± 8.4 years, and the median baseline ejection fraction was 57% (50-67), without differences between the 2 groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14 of 2,530 [0.6%] v 27 of 2,501 [1.1%] in the TIVA group; p = 0.038) and as-treated analyses (16 of 2,708 [0.6%] v 29 of 2,617 [1.1%] in the TIVA group; p = 0.039), but not in the intention-to-treat analysis (17 of 2,663 [0.6%] v 28 of 2,667 [1.0%] in the TIVA group; p = 0.10). Overall, deaths due to cardiac causes were lower in the volatile group (23 of 2,685 [0.9%] v 40 of 2,668 [1.5%] than in the TIVA group; p = 0.03). CONCLUSIONS An anesthetic regimen, including volatile agents, may be associated with a lower rate of postoperative MI with hemodynamic complication in patients undergoing CABG. Furthermore, it may reduce long-term cardiac mortality.
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Affiliation(s)
- Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Department of Anesthesiology and Intensive Care, Novosibirsk State University, Novosibirsk, Russia
| | - Vadim V Pasyuga
- Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan, Russia
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gordana Gazivoda
- Department of Anaesthesia and Intensive Care, Cardiovascular Institute Dedinje, Belgrade, Serbia
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Caetano Nigro Neto
- Anesthesia Section, Department of Cardiovascular Surgery, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Valery V Likhvantsev
- Department of Anesthesiology and Intensive Care, First Moscow State Medical University, Moscow, Russia; V. Negovsky Reanimatology Research Institute, Moscow, Russia
| | - Nikola Bradic
- Department of Cardiovascular Anesthesiology and Intensive Care Medicine, Clinical Department of Anesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia; Department of Biomedical Sciences, University North, Varazdin, Croatia
| | - Andrey Lozovskiy
- Department of Anesthesia and Intensive Care, Ural Institute of Cardiology, Ekaterinburg, Russia
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xi'an, Shaanxi, China
| | - Nazar A R Bukamal
- Cardiothoracic ICU and Anesthesia Department, Mohammed Bin Khalifa Cardiac Center, Riffa, Bahrain
| | | | - Andrey E Bautin
- Laboratory for Anesthesiology and Intensive Care, Almazov National Medical Research Center, Saint Petersburg, Russia
| | - Jun Ma
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chow Yen Yong
- Department of Anaesthesiology and Intensive Care, Hospital Pulau Pinang, Pulau Pinang, Malaysia
| | - Cristiana Carollo
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Jan Kunstyr
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine Charles University and General University Hospital, Prague, Czech Republic
| | - Chew Yin Wang
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Evgeny V Grigoryev
- Intensive Care Unit, Scientific Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - Hynek Riha
- Cardiothoracic Anesthesiology and Intensive Care Medicine, Department of Anesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Chengbin Wang
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Mohamed R El-Tahan
- Department of Anesthesiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marzida Mansor
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dmitry N Ponomarev
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Francisco José Lucena Bezerra
- Anesthesia Section, Department of Cardiovascular Surgery, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Laura Ruggeri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alexander M Chernyavskiy
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Junmei Xu
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Dmitry G Tarasov
- Department of Cardiac Surgery, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan, Russian Federation
| | - Paolo Navalesi
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy; Department of Medicine, University of Padua, Padua, Italy
| | - Andrey Yavorovskiy
- Federal Research and Clinical Center of Resuscitation and Rehabilitation, Moscow, Russia
| | - Tiziana Bove
- Department of Medicine (DAME), University of Udine, Udine, Italy; Department of Anesthesia and Intensive Care Medicine, ASUFC University-Hospital of Central Friuli, Udine, Italy
| | - Artem Kuzovlev
- V. Negovsky Reanimatology Research Institute, Moscow, Russia
| | - Ludhmila A Hajjar
- Department of Cardiopneumology, Instituto do Coração, Universidade de São Paulo, São Paulo, Brazil; Intensive Care Unit, Hospital SirioLibanes, São Paulo, Brazil
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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Chiong XH, Wong ZZ, Lim SM, Ng TY, Ng KT. The use of cerebral oximetry in cardiac surgery: A systematic review and meta-analysis of randomized controlled trials. Ann Card Anaesth 2022; 25:384-398. [PMID: 36254901 PMCID: PMC9732949 DOI: 10.4103/aca.aca_149_21] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
High prevalence of cerebral desaturation is associated with postoperative neurological complications in cardiac surgery. However, the evidence use of cerebral oximetry by correcting cerebral desaturation in the reduction of postoperative complications remains uncertain in the literature. This systematic review and meta-analysis aimed to examine the effect of cerebral oximetry on the incidence of postoperative cognitive dysfunction in cardiac surgery. Databases of MEDLINE, EMBASE, and CENTRAL were searched from their inception until April 2021. All randomized controlled trials comparing cerebral oximetry and blinded/no cerebral oximetry in adult patients undergoing cardiac surgery were included. Observational studies, case series, and case reports were excluded. A total of 14 trials (n = 2,033) were included in this review. Our pooled data demonstrated that patients with cerebral oximetry were associated with a lower incidence of postoperative cognitive dysfunction than the control group (studies = 4, n = 609, odds ratio [OR]: 0.15, 95% confidence interval [CI]: 0.04 to 0.54, P = 0.003, I2 = 88%; certainty of evidence = very low). In terms of postoperative delirium (OR: 0.75, 95%CI: 0.50-1.14, P = 0.18, I2 = 0%; certainty of evidence = low) and postoperative stroke (OR: 0.81 95%CI: 0.37-1.80, P = 0.61, I2 = 0%; certainty of evidence = high), no significant differences (P > 0.05) were reported between the cerebral oximetry and control groups. In this meta-analysis, the use of cerebral oximetry monitoring in cardiac surgery demonstrated a lower incidence of postoperative cognitive dysfunction. However, this finding must be interpreted with caution due to the low level of evidence, high degree of heterogeneity, lack of standardized cognitive assessments, and cerebral desaturation interventions.
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Affiliation(s)
- Xin Hui Chiong
- School of Medicine, University of Aberdeen, United Kingdom
| | - Zhen Zhe Wong
- School of Medicine, International Medical University, Kuala Lumpur, Malaysia
| | - Siu Min Lim
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Tyng Yan Ng
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ka Ting Ng
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia,Address for correspondence: Dr. Ka Ting Ng, Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur - 50603, Malaysia. E-mail:
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5
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Bishawi M, Milano CA. Treatment of Perioperative Ischemia, Infarction, and Ventricular Failure in Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00013-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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6
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OUP accepted manuscript. Eur Heart J 2022; 43:2407-2417. [DOI: 10.1093/eurheartj/ehac054] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/01/2022] [Accepted: 01/24/2022] [Indexed: 11/14/2022] Open
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7
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Weidenmann V, Robinson NB, Rong LQ, Hameed I, Naik A, Morsi M, Grieshaber P, Böning A, Girardi LN, Gaudino M. Diagnostic dilemma of perioperative myocardial infarction after coronary artery bypass grafting: A review. Int J Surg 2020; 79:76-83. [PMID: 32442689 DOI: 10.1016/j.ijsu.2020.05.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/22/2023]
Abstract
Coronary artery bypass grafting (CABG) is one of the most commonly performed cardiac procedures in the United States (US) and Europe. In the US, perioperative morbidity and mortality related to CABG are below 5%. One of the most significant complications following CABG, however, is perioperative myocardial infarction (PMI). Cardiac biomarkers, intra- and post-operative echocardiography, and electrocardiography are routinely used to monitor for evidence of PMI. In this review, we seek to summarize how each of these modalities is used in the clinical setting to differentiate PMI from expected procedure-related changes, and how these findings impact patients' outcomes. We conclude that while no perfect diagnostic test for the detection of clinically meaningful PMI exists, using a combination of existing modalities with knowledge of expected post-procedure changes allows for early and reliable detection. Future development is needed to create more sensitive and specific modalities for the detection of PMI in patients undergoing CABG.
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Affiliation(s)
- Viola Weidenmann
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, 10065, USA
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA, 10065
| | - Irbaz Hameed
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Ajita Naik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Mahmoud Morsi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Philippe Grieshaber
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Andreas Böning
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, 10065, USA.
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8
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Nguyen TT, Espinoza AW, Hyler S, Remme EW, D'hooge J, Hoff L. Estimating Regional Myocardial Contraction Using Miniature Transducers on the Epicardium. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:2958-2969. [PMID: 31447239 DOI: 10.1016/j.ultrasmedbio.2019.07.416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 07/15/2019] [Accepted: 07/21/2019] [Indexed: 06/10/2023]
Abstract
This paper describes an ultrasound system to monitor cardiac motion using miniature transducers attached directly to the epicardial surface. Our aim was to develop both a research tool for detailed studies of cardiac mechanics and a continuous, real time system for peri-operative evaluation of heart function. The system was tested on a porcine model. Two 3 mm diameter, 10 MHz ultrasound transducers were sutured to the epicardial surface. As the epicardial surface was the reference for the velocity and strain estimations, this procedure compensated for the motion of the heart. The short distance allowed for the use of high frequencies and pulse repetition rates. The system was driven in pulse-echo mode, using electronics developed for the application, and radio frequency (RF) lines were recorded at a pulse repetition rate of 2500 s-1. The endocardial border was detected using an algorithm based on fuzzy logic with filtration to reduce noise and remove outliers, and the myocardium was divided into four layers. Inside the myocardium, radial tissue velocity as a function of depth was calculated from the recorded RF signals, and the velocity estimates were used to estimate radial strain rate and strain and to track the motion of the myocardial layers. The scope of this paper is technical, giving a detailed description of system design, hardware electronics and algorithms, with examples of processed velocity patterns and myocardial strain curves. The results from this study on a porcine model demonstrate the system's ability to estimate myocardial velocity and strain patterns and to track the motion of the myocardial layers, thereby obtaining detailed information of the regional function of the myocardium.
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Affiliation(s)
- Thuy Thu Nguyen
- Department of Microsystems, University of South-Eastern Norway, Horten, Norway.
| | - Andreas W Espinoza
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Anaesthesiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Stefan Hyler
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Espen W Remme
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Jan D'hooge
- Laboratory on Cardiovascular Imaging & Dynamics, Department of Cardiovascular Diseases, Catholic University of Leuven, Leuven, Belgium
| | - Lars Hoff
- Department of Microsystems, University of South-Eastern Norway, Horten, Norway
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9
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Perioperative myocardial infarction diagnosis after coronary artery bypass grafting surgery using coupled electrocardiographic changes and cardiac troponin I. Indian J Thorac Cardiovasc Surg 2019; 35:25-30. [PMID: 33060965 DOI: 10.1007/s12055-018-0713-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/02/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022] Open
Abstract
Purpose Perioperative myocardial infarction (PMI) is one of the most common causes of prolonged intensive care unit (ICU) and hospital stay after coronary artery bypass grafting (CABG) and is associated with poor prognosis and increases postoperative mortality due to the lack of accurate diagnostic methods. This study examines the association between electrocardiography (ECG) ischemic changes and cardiac troponin I concentration. Methods In this cross-sectional study, the ECG of 100 patients was recorded before and 24 h after the surgery. The cardiac troponin I concentration was measured 24 h after the termination of the surgery. Results The average concentration of troponin I was 6.79 μg/L in the no-ECG-changes group, 11.69 μg/L in the ST depression group, 11.26 μg/L in the ST elevation group, and 27.54 μg/L in the new Q wave group. The mean troponin concentration was significantly higher in the ECG-changes group compared to no-ECG-changes group. Comparing the ECG-changes together showed significant differences between the new Q wave and the other changes. ST elevation and ST depression were not statistically significant. Conclusion The three ECG-changes groups had a higher risk of PMI after their CABG. The risk of PMI was at its highest value in the new Q wave group and at its lowest in the no-ECG-changes group.
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10
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Sellke N, Gordon C, Lawandy I, Gorvitovskaia AY, Scrimgeour LA, Fingleton JG, Sellke FW, Feng J. Impaired coronary contraction to phenylephrine after cardioplegic arrest in diabetic patients. J Surg Res 2018; 230:80-86. [PMID: 30100044 PMCID: PMC6310168 DOI: 10.1016/j.jss.2018.04.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 03/21/2018] [Accepted: 04/17/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND We have previously found that hyperkalemic cardioplegic arrest in the setting of cardiopulmonary bypass (CP/CPB) is associated with impairment of the coronary arteriolar response to phenylephrine in nondiabetic (ND) patients. We hypothesized that diabetes may alter coronary arteriolar response to alpha-1 adrenergic agonist in the setting of CP/CPB. In this study, we further investigated the effects of diabetes on the altered coronary arteriolar response to phenylephrine in patients undergoing cardiac surgery. METHODS Coronary arterioles (90-150 μm in diameter) were harvested pre- and post-CP/CPB from the ND and diabetic mellitus (DM) patients (n = 8/group) undergoing cardiac surgery. In-vitro microvascular reactivity was examined in response to phenylephrine. The protein expression/localization of the alpha-1 adrenergic receptors in the atrial myocardium was measured by Western blotting and immunohistochemistry. RESULTS Phenylephrine (10-9 to 10-4 M) induced a dose-dependent contractile response in both ND and DM vessels pre- and post-CP/CPB. There was no significant difference in the pre-CP/CPB contractile responses to phenylephrine between ND and DM groups. The post-CP/CPB contractile response was significantly diminished in both ND and DM groups compared with the respective pre-CP/CPB response (P < 0.05 versus pre-CP/CPB). This diminished contractile response was more pronounced in vessels from DM patients compared with vessels from ND patients (P < 0.05 versus ND). There were no significant differences in the protein expression of alpha-1A and alpha-1B receptors in the atrial myocardium between the ND and DM groups or tissue harvested pre- or post-CP/CPB. CONCLUSIONS Diabetes is associated with a decreased contractile response of coronary arterioles to phenylephrine in the setting of CP/CPB versus that observed in ND patients. This alteration may contribute to the vasomotor dysfunction of coronary microcirculation seen early after CP/CPB in patients with diabetes.
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Affiliation(s)
- Nicholas Sellke
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Caroline Gordon
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Isabella Lawandy
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Anastassia Y Gorvitovskaia
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Laura A Scrimgeour
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - James G Fingleton
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Frank W Sellke
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jun Feng
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island.
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11
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Significance of new Q waves and their location in postoperative ECGs after elective on-pump cardiac surgery. Eur J Anaesthesiol 2017; 34:271-279. [DOI: 10.1097/eja.0000000000000605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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12
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Becker M, Roehl AB, Siekmann U, Koch A, de la Fuente M, Roissant R, Radermacher K, Marx N, Hein M. Simplified detection of myocardial ischemia by seismocardiography. Differentiation between causes of altered myocardial function. Herz 2013; 39:586-92. [PMID: 23793836 DOI: 10.1007/s00059-013-3851-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 04/17/2013] [Accepted: 05/10/2013] [Indexed: 10/26/2022]
Abstract
Seismocardiography (SCG) is a noninvasive technique for recording cardiac vibrations. Changes in these waves have been correlated with chronic and acute alterations in myocardial function. This analysis is complex and clinical integration limited. The current study aimed to simplify the utilization of SCG by fast Fourier transformation for a reliable discrimination between different intra- and postoperative causes of hypotension (i.e., myocardial ischemia or hypovolemia). We operated on nine pigs and recorded SCG at baseline, at hypovolemia (occlusion of the inferior vena cava), and at ischemia (occlusion of the right coronary artery). In conclusion, SCG enables detection and differentiation of ischemia and hypovolemia as important causes of altered myocardial function during and after surgery. Thus, this simple and noninvasive diagnostic tool may be used intra- and postoperatively to identify patients at risk.
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Affiliation(s)
- M Becker
- Department of Cardiology, Medizinische Klinik I, RWTH Aachen University Hospital, Pauwelsstr. 30, 52057, Aachen, Germany,
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13
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Royse CF, Andrews DT, Newman SN, Stygall J, Williams Z, Pang J, Royse AG. The influence of propofol or desflurane on postoperative cognitive dysfunction in patients undergoing coronary artery bypass surgery*. Anaesthesia 2011; 66:455-64. [DOI: 10.1111/j.1365-2044.2011.06704.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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12-Month Outcome After Cardiac Surgery: Prediction by Troponin T in Combination With the European System for Cardiac Operative Risk Evaluation. Ann Thorac Surg 2009; 88:1806-12. [DOI: 10.1016/j.athoracsur.2009.07.080] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 07/30/2009] [Accepted: 07/31/2009] [Indexed: 11/20/2022]
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15
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Hjortshøj S, Otterstad JE, Lindahl B, Danielsen R, Pulkki K, Ravkilde J. Biochemical diagnosis of myocardial infarction evolves towards ESC/ACC consensus: Experiences from the Nordic countries. SCAND CARDIOVASC J 2009; 39:159-66. [PMID: 16146978 DOI: 10.1080/14017430510009140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To investigate the diagnostic approach in Nordic hospitals receiving patients suspected of acute myocardial infarction (MI), especially focusing on implementation of the recently proposed criteria by the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) for the definition of MI. DESIGN A survey with questionnaires of the diagnostic approach was conducted among all relevant departments (220) in the Nordic countries. RESULTS Seventy-six percent (167) of hospitals responded. Troponins I and T (TnI and TnT) and creatinine kinase monobasic fraction (mass concentration) (CKMB(mass)) covered 93 and 65% of hospitals, respectively. Of troponin users, 34% indicated use of TnI vs 66% using TnT. Sporadic use of AST, CK, LD and myoglobin was reported. There was a tendency to lower cut-off levels in Sweden and Finland. Among troponin assays, there was considerable heterogeneity regarding cut-off levels. CONCLUSIONS The Nordic countries are approaching ESC/ACC consensus on cardiac markers. Compared with previous national surveys (1995-1999), there is a shift towards the use of troponins. However, differences in cut-off levels of troponin emphasize the need for harmonization of assays.
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Affiliation(s)
- Søren Hjortshøj
- Cardiovascular Research Center and Department of Cardiology, Aalborg Hospital, Denmark
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16
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Halvorsen PS, Fleischer LA, Espinoza A, Elle OJ, Hoff L, Skulstad H, Edvardsen T, Fosse E. Detection of myocardial ischaemia by epicardial accelerometers in the pig. Br J Anaesth 2008; 102:29-37. [PMID: 19022793 DOI: 10.1093/bja/aen331] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We describe a novel technique for continuous real-time assessment of myocardial ischaemia using a three-axis accelerometer. METHODS In 14 anaesthetized open-chest pigs, two accelerometers were sutured on the left ventricle (LV) surface in the perfusion areas of the left anterior descending (LAD) and circumflex (CX) arteries. Acceleration was measured in the longitudinal, circumferential, and radial directions, and the corresponding epicardial velocities were calculated. Regional LV dysfunction was induced by LAD occlusion for 60 s. Global LV function was altered by nitroprusside, epinephrine, esmolol, and fluid loading. Epicardial velocities were compared with strain by echocardiography during LAD occlusion and with aortic flow and LV dP/dt(max) during interventions on global LV function. RESULTS LAD occlusion induced ischaemia, shown by lengthening in systolic strain in the LV apical anterior region (P<0.01) and concurrent changes in LAD accelerometer circumferential velocities during systole (P<0.01) and during the isovolumic relaxation phase (P<0.01). The changes in accelerometer circumferential velocities during LAD occlusion were greater compared with the changes during the interventions on global function (P<0.01). For the LAD accelerometer circumferential velocities, sensitivity was 94-100% and specificity was 92-94% in detecting ischaemia. CONCLUSIONS Myocardial ischaemia can be detected with epicardial three-axis accelerometers. The accelerometer had the ability to distinguish ischaemia from interventions altering global myocardial function. This novel technique may be used for continuous real-time monitoring of myocardial ischaemia during and after cardiac surgery.
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Affiliation(s)
- P S Halvorsen
- The Interventional Centre, Rikshospitalet University Hospital, N-0027 Oslo, Norway.
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17
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Simon C, Capuano F, Roscitano A, Benedetto U, Comito C, Sinatra R. Cardiac troponin I vs EuroSCORE: myocardial infarction and hospital mortality. Asian Cardiovasc Thorac Ann 2008; 16:97-102. [PMID: 18381864 DOI: 10.1177/021849230801600203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Perioperative myocardial infarction is the most common cause of morbidity and mortality in cardiac surgery. It occurs in 8% to 35% of patients. The primary aim of this prospective study was to determine the level of cardiac troponin I that indicates perioperative myocardial infarction in patients undergoing coronary artery bypass. A secondary goal was to establish the best independent predictor of hospital death. There were 180 consecutive patients undergoing isolated coronary artery bypass surgery enrolled in this study. Values of cardiac troponin I > 12.9 ng.mL(-1) at 8 hours postoperatively predicted perioperative myocardial infarction with a sensitivity of 100% and a specificity of 93.2%. Compared to patients who survived, those who suffered hospital death were significantly older (74 +/- 7 vs 63 +/- 10 years), had significantly higher levels of cardiac troponin I at 24 hours (9 +/- 17 vs 27.3 +/- 16 ng.mL(-1)) and 48 hours (6.9 +/- 19 vs 30.3 +/- 24 ng.mL(-1)) postoperatively, and a significantly higher EuroSCORE (9 +/- 2 vs 4 +/- 3). At 8 hours postoperatively, cardiac troponin I led to an earlier diagnosis of perioperative myocardial infarction, while EuroSCORE was the strongest independent predictor of hospital death.
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Affiliation(s)
- Caterina Simon
- Department of Cardiac Surgery, St. Andrea Hoursospital, University of Rome "La Sapienza", Rome, Italy.
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18
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Paparella D, Cappabianca G, Malvindi P, Paramythiotis A, Galeone A, Veneziani N, Fondacone C, de Luca Tupputi Schinosa L. Myocardial injury after off-pump coronary artery bypass grafting operation. Eur J Cardiothorac Surg 2007; 32:481-7. [PMID: 17643993 DOI: 10.1016/j.ejcts.2007.06.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Revised: 05/29/2007] [Accepted: 06/14/2007] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Perioperative myocardial ischemia is less pronounced in off-pump coronary artery bypass (OPCAB) compared to on-pump coronary artery bypass; however, the threshold over which the postoperative release of cardiac troponin I (cTnI) release and creatine kinase-MB (CK-MB) after OPCAB should be considered clinically relevant is unknown. The study was designated to evaluate if perioperative myocardial damage, measured by means of postoperative release of cTnI and CK-MB, has an influence on short- and mid-term outcome after OPCAB operations. METHODS Two hundred and sixty-one unselected patients undergoing OPCAB had cTnI and CK-MB measured preoperatively and nine times postoperatively. Postoperative peak values were evaluated and the 80th percentiles were used to segregate the population into two groups for each marker. The following cut-offs were used: 7.1 ng/dl for cTnI peak and 36.3 ng/dl for CK-MB peak. RESULTS Patients with cTnI>7.1 ng/ml (n=51) and CK-MB>36.3 ng/ml (n=48) had a longer mechanical ventilation and ICU length of stay. Nevertheless, hospital mortality did not differ between groups. Survival after 3 years was 92.8+/-2.3% and 81.8+/-6.2 for patients with postoperative cTnI peak<or=7.1 ng/ml and >7.1 ng/ml, respectively (p=0.003). It was 93+/-2.2% and 80+/-6.8% for patients with CK-MB<or=36.3 ng/ml and >36.3 ng/ml, respectively (p=0.005). Adjusted hazard ratios for mid-term mortality were HR 2.7 (CI 1-7.6), p=0.05 for cTnI>7.1 ng/dl and HR 3.1 (CI 1-9.1), p=0.04 for CK-MB>36.3 ng/ml. CONCLUSION Perioperative myocardial damage should not be considered an innocuous event following OPCAB operations since the survival rate over 3 years is significantly worse in patients with the highest postoperative peak release of cTnI and CK-MB.
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Affiliation(s)
- Domenico Paparella
- Division of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari, Italy.
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19
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Abdulmalik A, Arabi A, Alroaini A, Rosman H, Lalonde T. Feasibility of percutaneous coronary interventions in early postcoronary artery bypass graft occlusion or stenosis. J Interv Cardiol 2007; 20:204-8. [PMID: 17524112 DOI: 10.1111/j.1540-8183.2007.00258.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND With continuing technical advances in percutaneous coronary interventions (PCI) for coronary artery disease (CAD), patients undergoing coronary artery bypass surgery (CABG) often have complex coronary anatomy that is not ideal for PCI. Because of the complex anatomy, these patients have a higher risk of early graft occlusion. The feasibility of PCI in the treatment of early graft occlusion is not well established. METHODS A retrospective chart review was performed of patients presenting with recurrent ischemia within three months post-CABG and at one-year follow-up. RESULTS Forty-six patients with 156 grafts were identified. Three presented with STEMI, 21 with NSTEMI, 21 with unstable angina, and one with congestive heart failure. Sixty-three grafts were occluded or stenosed (>70%). Twenty-seven grafts (43%) in 17 patients were not amenable to PCI. The other 34 grafts (54%) in 23 patients underwent successful PCI. PCI was performed upon native vessels and occluded grafts with equal frequency. Six patients had patent grafts. At one-year follow-up, six of 23 patients in the PCI group were readmitted with ischemia; five vessels (14%) in four patients had restenosed. There were no deaths. In the group with no PCI, 11 of 23 patients were readmitted with ischemia with one death. CONCLUSION PCI for early post-CABG occlusion was safely performed in slightly more than half of target vessels. PCI was performed upon native vessels and occluded grafts with equal frequency. After initial PCI success, the clinical target vessel restenosis rate was 14% at one-year follow-up.
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Affiliation(s)
- Ameen Abdulmalik
- Department of Cardiology, St. John Hospital & Medical Center, Detroit, Michigan 48236, USA.
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20
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Licker M, Sierra J, Kalangos A, Panos A, Diaper J, Ellenberger C. Cardioprotective effects of acute normovolemic hemodilution in patients with severe aortic stenosis undergoing valve replacement. Transfusion 2007; 47:341-50. [PMID: 17302782 DOI: 10.1111/j.1537-2995.2007.01111.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND After acute normovolemic hemodilution (ANH), improvement of the rheologic conditions may contribute to optimize tissue oxygen delivery and attenuate ischemia-reperfusion injuries. It was hypothesized that ANH would confer additional cardioprotection in patients with ventricular hypertrophy undergoing open heart surgery. STUDY DESIGN AND METHODS This study was a randomized controlled trial. Forty patients scheduled for elective aortic valve replacement were randomly assigned to a control group (standard care) or an ANH group (target hematocrit level of 28%). All patients were managed with standard myocardial preservation techniques (cold blood cardioplegia, anesthetic preconditioning). The outcome measures included the release of myocardial enzymes, perioperative hemodynamic changes, the need for pharmacologic cardiovascular support, and cardiac complications. RESULTS In the ANH group, the postoperative release of troponin I (mean peak plasma concentrations, 1.7 ng/mL; 95% confidence interval, 1.4-2.1 ng/mL) and myocardial fraction of creatine kinase (22 U/L; range, 18-24 U/L) was significantly lower than in the control group (3.6 [range, 3.0-4.2] ng/mL and 45 [range, 39-51] U/L, respectively). In addition, requirement for inotropic support was significantly lower and fewer hemodiluted patients presented adverse cardiac events. After ANH, there was a significant decrease in heart rate (-11 +/- 6%) and rate-pressure product (-16 +/- 8%) until the aortic cross-clamping time and, at the end of surgery, the circulating levels of erythropoietin (EPO) were higher than in control patients (13.6 +/- 4.2 mUI/mL vs. 7.3 +/- 2.4 mUI/mL; p < 0.05). CONCLUSIONS Besides conventional cardiac preservation techniques, preoperative ANH further attenuates myocardial injuries. Optimization of preischemic myocardial oxygen delivery and/or consumption and the postconditioning effects of endogenous EPO are potential mechanisms for ANH-induced cardioprotection.
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Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology and Surgical Intensive Care, University Hospital of Geneva, Geneva, Switzerland.
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21
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Paparella D, Cappabianca G, Visicchio G, Galeone A, Marzovillo A, Gallo N, Memmola C, Schinosa LDLT. Cardiac troponin I release after coronary artery bypass grafting operation: effects on operative and midterm survival. Ann Thorac Surg 2006; 80:1758-64. [PMID: 16242452 DOI: 10.1016/j.athoracsur.2005.04.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2005] [Revised: 04/07/2005] [Accepted: 04/18/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Markers of myocardial necrosis are usually elevated in patients who have undergone a coronary bypass operation with cardiac arrest. The preferred marker in detecting acute myocardial ischemia is cardiac troponin I (cTnI). However, its ability to predict short-term and, particularly, midterm outcome after coronary bypass operations is uncertain. METHODS Two hundred thirty unselected patients undergoing surgical revascularization had cTnI measured preoperatively and 11 times postoperatively. Receiver operating characteristic curves were constructed using cTnI postoperative peak values in order to assess the prognostic sensitivity and specificity of the test. The cut-off value of 13 ng/mL was used to assess the prognostic significance of the peak cTnI postoperative release for short-term and midterm outcomes. RESULTS One hundred forty-six patients (63.5%) had postoperative cTnI peak values less than 13 ng/mL (mean peak value, 6.6 +/- 3.1 ng/mL) and 84 patients (36.5%) had postoperative cTnI peak values greater than 13 ng/mL (mean peak value, 45.5 +/- 59.9 ng/mL). Patients with peak cTnI greater than 13 ng/mL were older and had higher preoperative cTnI values. They required both longer cross-clamp time and CPB time. Moreover, hospital death in the cTnI greater than 13 ng/mL group (9.5% versus 0.7%, p = 0.0009) was significantly higher. Multivariate analysis showed that cTnI greater than 13 ng/mL was the only independent predictor of hospital death (odds ratio 10.33, p = 0.04) and hospital death from cardiac causes. A 2-year follow-up demonstrates that cTnI postoperative release had no influence on midterm mortality and hospitalization for due to cardiac illness. CONCLUSIONS Cardiac troponin I is a valuable marker for immediate myocardial damage after coronary bypass operations. Its postoperative release does not predict midterm outcome.
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Affiliation(s)
- Domenico Paparella
- Division of Cardiac Surgery, Dipartimento d'Emergenza e Trapianti d'Organo, Universitá di Bari, Bari, Italy.
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22
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Cosgrave J, Foley B, Ho E, Bennett K, McGovern E, Tolan M, Young V, Crean P. Troponin T elevation after coronary bypass surgery: clinical relevance and correlation with perioperative variables. J Cardiovasc Med (Hagerstown) 2006; 7:669-74. [PMID: 16932080 DOI: 10.2459/01.jcm.0000243000.82546.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Elevation in markers of myocardial necrosis is a common feature following coronary artery bypass surgery, but its relevance is unclear. The objective of this study was to evaluate the association between postoperative troponin T elevation, perioperative variables and clinical outcomes. METHODS We evaluated 100 low-risk patients undergoing first-time elective on-pump coronary artery bypass surgery. The mean age was 62 +/- 9.8 years and 83% were male; patients with diabetes mellitus, renal failure and impaired left ventricular function (ejection fraction < 40%) were excluded. Troponin levels were measured at baseline and 12 and 24 h following the onset of cardiopulmonary bypass. Predefined clinical endpoints included death, new Q waves on 12-lead electrocardiogram and inotropic requirement. RESULTS Postoperative troponin elevation occurred in 95%. Troponin T elevation was related to the duration of cardiopulmonary bypass (P = 0.0001) and aortic cross-clamp time (P = 0.0003). There was also an inverse relationship with perioperative core temperature (P = 0.0001). There was no association between postoperative troponin elevation and clinical outcomes. CONCLUSIONS Postoperative troponin T elevation occurs in the majority of patients undergoing elective on-pump coronary artery bypass surgery. In this low-risk cohort, troponin T elevation was associated with procedural duration but not with clinical outcome.
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Affiliation(s)
- John Cosgrave
- Department of Cardiology, EMO Centro Cuore Columbus, Milan, Italy.
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23
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Chieffo A, Morici N, Maisano F, Bonizzoni E, Cosgrave J, Montorfano M, Airoldi F, Carlino M, Michev I, Melzi G, Sangiorgi G, Alfieri O, Colombo A. Percutaneous Treatment With Drug-Eluting Stent Implantation Versus Bypass Surgery for Unprotected Left Main Stenosis. Circulation 2006; 113:2542-7. [PMID: 16717151 DOI: 10.1161/circulationaha.105.595694] [Citation(s) in RCA: 256] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Improvements in results with percutaneous coronary intervention (PCI) with drug-eluting stents (DES) may extend their use in patients with left main coronary artery (LMCA) stenosis.
Methods and Results—
Two hundred forty-nine patients with LMCA stenosis were treated with PCI and DES implantation (n=107) or coronary artery bypass grafting (CABG) (n=142), in a single center, between March 2002 and July 2004. A propensity analysis was performed to adjust for baseline differences between the two cohorts. At 1 year, there was no statistical difference in the occurrence of death in PCI versus CABG both for the unadjusted (OR=0.291; 95% CI=0.054 to 1.085;
P
=0.0710) and adjusted analyses (OR=0.331; 95% CI=0.055 to 1.404;
P
=0.1673). PCI was correlated to a lower occurrence of the composite end points of death and myocardial infarction (unadjusted OR=0.235; 95% CI=0.048 to 0.580;
P
=0.0002; adjusted OR=0.260; 95% CI=0.078 to 0.597;
P
=0.0005) and death, myocardial infarction, and cerebrovascular events (unadjusted OR=0.300; 95% CI=0.102 to 0.617;
P
=0.0004; adjusted OR=0.385; 95% CI=0.180 to 0.819;
P
=0.01). No difference was detected in the occurrence of major adverse cardiac and cerebrovascular event at the unadjusted (OR=0.675; 95% CI=0.371 to 1.189;
P
=0.1891) and adjusted analyses (OR=0.568; 95% CI=0.229 to 1.344;
P
=0.2266).
Conclusions—
At 1 year, in this single-center, retrospective experience, there was no difference in the degree of protection against death, stroke, myocardial infarction, and revascularization between PCI with DES and CABG for LMCA disease. (Circulation. 2006;113:2542-2547.)
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Affiliation(s)
- Alaide Chieffo
- Interventional Cardiology, San Raffaele Scientific Institute, Milan, Italy
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24
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Zangrillo A, Crescenzi G, Landoni G, Benussi S, Crivellari M, Pappalardo F, Dorigo E, Pappone C, Alfieri O. The Effect of Concomitant Radiofrequency Ablation and Surgical Technique (Repair Versus Replacement) on Release of Cardiac Biomarkers During Mitral Valve Surgery. Anesth Analg 2005; 101:24-9, table of contents. [PMID: 15976200 DOI: 10.1213/01.ane.0000155959.42236.b8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
All patients undergoing heart surgery experience a certain amount of nonspecific myocardial injury documented by the release of cardiac biomarkers and associated with poor outcome. We investigated the role of unipolar radiofrequency ablation of atrial fibrillation on the release of cardiac biomarkers in 71 patients undergoing mitral valve surgery and concomitant left atrial ablation case-matched with 71 patients undergoing isolated mitral surgery. The study was powered to detect a 3 ng/mL difference. There was no difference between the 2 groups in terms of cardiac troponin I (10 +/- 5.3 versus 12 + 10.4 ng/mL; P = 0.7) or creatine kinase-MB (50 +/- 21.8 versus 57 +/- 62.0 ng/mL; P = 0.5) release. Postoperative peak cardiac troponin I levels had univariate associations with the duration of cardiopulmonary bypass (P = 0.002) and aortic cross-clamping (P = 0.001) and with the surgical technique (15 +/- 12 ng/mL for mitral valve replacement versus 9 +/- 4.8 for mitral valve repair; P = 0.0007) at univariate analysis. Mitral valve replacement was the only independent predictor of postoperative peak release of cardiac troponin I identified with multivariate analysis (P = 0.005). Radiofrequency ablation of atrial fibrillation does not significantly increase cardiac biomarker release compared with isolated mitral surgery; mitral valve repair is associated with less release of cardiac biomarkers compared with mitral valve replacement.
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Affiliation(s)
- Alberto Zangrillo
- Department of Cardiovascular Anesthesia, IRCCS San Raffaele Hospital, Milan, Italy, Via Olgettina 60, 20132 Milano Italy
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