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Michel L, Jehn S, Dykun I, Anker MS, Ferdinandy P, Dobrev D, Rassaf T, Mahabadi AA, Totzeck M. Detectable troponin below the 99 th percentile predicts survival in patients undergoing coronary angiography. IJC HEART & VASCULATURE 2024; 52:101419. [PMID: 38725439 PMCID: PMC11079461 DOI: 10.1016/j.ijcha.2024.101419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/26/2024] [Accepted: 04/30/2024] [Indexed: 05/12/2024]
Abstract
Background Cardiac troponin I (cTnI) above the 99th percentile is associated with an increased risk of major adverse events. Patients with detectable cTnI below the 99th percentile are a heterogeneous group with a less well-defined risk profile. The purpose of this study is to investigate the prognostic relevance of detectable cTnI below the 99th percentile in patients undergoing coronary angiography. Methods The study included 14,776 consecutive patients (mean age of 65.4 ± 12.7 years, 71.3 % male) from the Essen Coronary Artery Disease (ECAD) registry. Patients with cTnI levels above the 99th percentile and patients with ST-segment elevation acute myocardial infarction were excluded. All-cause mortality was defined as the primary endpoint. Results Detectable cTnI below the 99th percentile was present in 2811 (19.0 %) patients, while 11,965 (81.0 %) patients were below detection limit of the employed assay. The mean follow-up was 4.25 ± 3.76 years. All-cause mortality was 20.8 % for patients with detectable cTnI below the 99th percentile and 15.0 % for those without detectable cTnI. In a multivariable Cox regression analysis, detectable cTnI was independently associated with all-cause mortality with a hazard ratio of 1.60 (95 % CI 1.45-1.76; p < 0.001). There was a stepwise relationship with increasing all-cause mortality and tertiles of detectable cTnI levels with hazard ratios of 1.63 (95 % CI 1.39-1.90) for the first tertile to 2.02 (95 % CI 1.74-2.35) for the third tertile. Conclusions Detectable cTnI below the 99th percentile is an independent predictor of mortality in patients undergoing coronary angiography with the risk of death growing progressively with increasing troponin levels.
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Affiliation(s)
- Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany
| | - Stefanie Jehn
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany
| | - Iryna Dykun
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany
| | - Markus S. Anker
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
- Berlin Institute of Health (BIH) at Charité Berlin, Universitätsmedizin Berlin, Germany
- Deutsches Herzzentrum der Charité CBF, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Peter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Hospital Essen, Germany
- Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, Montréal, QC, Canada
- Department of Integrative Physiology, Baylor College of Medicine, Houston, TX, USA
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany
| | - Amir A. Mahabadi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany
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Ak K, Dericioğlu O, Midi A, Kararmaz A, Er Z, Doğusan Z, Arsan S. Comparison of Bretschneider HTK and Blood Cardioplegia (4:1): A Prospective Randomized Study. Thorac Cardiovasc Surg 2024; 72:11-20. [PMID: 36638809 DOI: 10.1055/s-0042-1759710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND We compared the effect of intermittent blood and histidine-tryptophan-ketoglutarate (HTK) solution of Bretschneider on myocardial histopathology and perioperative outcome. METHODS Forty adult cardiac surgery patients were grouped into two (n = 20 for each): (1) Intermittent blood cardioplegia (IBC): had repeated cold 4:1 blood cardioplegia and (2) HTK: had a single dose of cold HTK for cardioprotection. Creatine kinase (CK)-MB, Troponin-I (cTn-I), pH, and lactate were studied in coronary sinus blood before and after aortic cross-clamping (AXC) and systemic blood at postoperative 6th, 24th, and 48th hours. Myocardial biopsy was performed before and after AXC for light microscopy. Vacuolation, inflammation, edema, and glycogen were graded semiquantitatively (from 0 to 3). The myocardial apoptotic index was evaluated via the terminal deoxynucleotidyl transferase dUTP nick end labeling. RESULTS There were no differences in perioperative clinical outcomes between the groups. The coronary sinus samples after AXC were more acidotic (7.15 ± 0.14 vs. 7.32 ± 0.07, p = 0.001) and revealed higher CK-MB (21.0 ± 12.81 vs. 12.60 ± 11.80, p = 0.008) in HTK compared with IBC. The HTK had significantly a higher amount of erythrocyte suspension intraoperatively compared with IBC (0.21 ± 0.53 vs. 1.68 ± 0.93 U, p = 0.001). Microscopically, myocardial edema was more pronounced in HTK compared with IBC after AXC (2.25 ± 0.91 vs. 1.50 ± 0.04, p = 0.013). While a significant increase in the apoptotic index was seen after AXC in both groups (p = 0.001), no difference was detected between the groups (p = 0.417). CONCLUSION IBC and HTK have a similar clinical outcome and protective effect, except for more pronounced myocardial edema and increased need for intraoperative transfusion with HTK.
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Affiliation(s)
- Koray Ak
- Department of Cardiovascular Surgery, Marmara University School of Medicine, Marmara Uninersitesi Hastanesi Mimar Sinan Cad. Fevzi Cakmak Mah. Ust Kaynarca Kalp ve Damar Cerrahisi Bolumu Pendik, Istanbul, Turkey
| | - Okan Dericioğlu
- Department of Cardiovascular Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Ahmet Midi
- Department of Pathology, Bahcesehir University, School of Medicine, Istanbul, Turkey
| | - Alper Kararmaz
- Department of Anesthesiology and Reanimation, Marmara University School of Medicine, Istanbul, Turkey
| | - Zafer Er
- Department of Cardiovascular Surgery, Bozok University Faculty of Medicine Ringgold Standard Institution, Yozgat, Yozgat, Turkey
| | - Zeynep Doğusan
- Department of Pathology, Bone Marrow Transplantation Unite, Yeni Yüzyıl University School of Medicine, Istanbul, Turkey
| | - Sinan Arsan
- Department of Cardiovascular Surgery, Marmara University School of Medicine, Istanbul, Turkey
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Norman AV, Kron IL. Reply: The importance of early intervention for ischemia after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00994-7. [PMID: 38032561 DOI: 10.1016/j.jtcvs.2023.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Anthony V Norman
- Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, Va
| | - Irving L Kron
- Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, Va
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4
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Zhang C, He C, Chen Z, Chen X, Qin J, Xu Y, Ma J. The effects of volatile anesthetics and propofol in patients undergoing off-pump coronary artery bypass grafting: a systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1271557. [PMID: 38034375 PMCID: PMC10684663 DOI: 10.3389/fcvm.2023.1271557] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/02/2023] [Indexed: 12/02/2023] Open
Abstract
Background Studies investigating the cardioprotective effect of volatile anesthetics on cardiac troponins in off-pump coronary artery bypass grafting (OPCAB) surgery remain controversial. This current study was conducted to systematically evaluate the impact of volatile anesthetics and propofol on patients undergoing OPCAB surgery. Methods A computerized search of electronic databases was conducted up to July 21, 2023, to identify relevant studies using appropriate search terms. The primary outcomes of interest were the levels of myocardial injury biomarkers (e.g., cTnI, cTnT), while secondary outcomes included extubation time, length of ICU stay, 30-day mortality, transfusion and thrombosis, and postoperative recovery, which were compared between two anesthesia techniques. Results A search of databases produced 14 relevant studies with a combined total of 703 patients. Among them, 355 were allocated to the volatile anesthetics group and 348 to the propofol group. Our study reveals a statistically significant reduction in myocardial injury biomarkers among patients who received volatile anesthetics compared to those who received propofol (P < .001). Subgroup analysis showed that patients using sevoflurane had lower postoperative cardiac troponins levels compared to propofol (P = .01). However, desflurane and isoflurane currently have no significant advantage over propofol (all P > 0.05). There was no significant difference in postoperative mechanical ventilation time, length of ICU stay, and mortality between the two groups (all P > 0.05). Conclusions This study suggested that volatile anesthetics, specifically sevoflurane, in adult OPCAB surgery provide a better cardioprotective effect than propofol. Systematic Review Registration PROSPERO (CRD42023444277).
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Affiliation(s)
- Chenghong Zhang
- School of Medicine, Hangzhou Normal University, Hangzhou, China
| | - Changlin He
- Department of Anesthesiology, Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Zhengwei Chen
- Department of Anesthesiology, Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Xin Chen
- Department of Anesthesiology, Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Junjun Qin
- Department of Anesthesiology, Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Yuhui Xu
- Department of Anesthesiology, Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Jiasen Ma
- Department of Anesthesiology, Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
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Heuts S, Vriesendorp PA. The incidence and consequent relevance of unplanned invasive coronary angiography following coronary artery bypass grafting. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00896-6. [PMID: 37897451 DOI: 10.1016/j.jtcvs.2023.09.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/30/2023]
Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Pieter A Vriesendorp
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
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6
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Crea F. Acute coronary syndromes: new guidelines and new light shed on biomarkers and mechanisms of plaque instability. Eur Heart J 2023; 44:3707-3711. [PMID: 37822014 DOI: 10.1093/eurheartj/ehad656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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7
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Pölzl L, Engler C, Sterzinger P, Lohmann R, Nägele F, Hirsch J, Graber M, Eder J, Reinstadler S, Sappler N, Kilo J, Tancevski I, Bachmann S, Abfalterer H, Ruttmann-Ulmer E, Ulmer H, Griesmacher A, Heuts S, Thielmann M, Bauer A, Grimm M, Bonaros N, Holfeld J, Gollmann-Tepeköylü C. Association of High-Sensitivity Cardiac Troponin T With 30-Day and 5-Year Mortality After Cardiac Surgery. J Am Coll Cardiol 2023; 82:1301-1312. [PMID: 37730286 DOI: 10.1016/j.jacc.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/29/2023] [Accepted: 07/05/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND The relevance of perioperative myocardial injury (PMI) after cardiac surgery for 30-day mortality and long-term survival remains to be determined. OBJECTIVES This study assessed the association of PMI after cardiac surgery, reflected by postoperative troponin release, with 30-day mortality and long-term survival after: 1) coronary artery bypass grafting (CABG); 2) isolated aortic valve replacement (AVR) surgery; and 3) all other cardiac surgeries. METHODS A consecutive cohort of 8,292 patients undergoing cardiac surgery with serial perioperative high-sensitivity cardiac troponin T (hs-cTnT) measurements was retrospectively analyzed. The relationship between postoperative hs-cTnT release and 30-day mortality or 5-year mortality was analyzed after adjustment with EuroSCORE II using a Cox proportional hazards model. hs-cTnT thresholds for 30-day and 5-year mortality were determined for isolated CABG (32.3%), AVR (14%), and other cardiac surgery (53.8%). RESULTS High postoperative hs-cTnT levels were associated with higher 30-day mortality but not 5-year mortality. In CABG, median peak concentration of postoperative hs-cTnT was 1,044 ng/L, in AVR it was 502 ng/L, and in other cardiac surgery it was 1,110 ng/L. hs-cTnT thresholds defining mortality-associated PMI were as follows: for CABG, 2,385 ng/L (170× the upper reference limit of normal in a seemingly healthy population [URL]); for AVR, 568 ng/L (41× URL); and for other cardiac procedures, 1,873 ng/L (134× URL). hs-cTnT levels above the cutoffs resulted in an HR for 30-day mortality for CABG of 12.56 (P < 0.001), for AVR of 4.44 (P = 0.004), and for other cardiac surgery of 3.97 (P < 0.001). CONCLUSIONS PMI reflected by perioperative hs-cTnT release is associated with the expected 30-day mortality but not 5-year mortality. Postoperative hs-cTnT cutoffs to identify survival-relevant PMI are higher than suggested in current definitions.
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Affiliation(s)
- Leo Pölzl
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Clemens Engler
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Philipp Sterzinger
- Department of Statistics, University of Warwick, Coventry, United Kingdom
| | - Ronja Lohmann
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Felix Nägele
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Hirsch
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Graber
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Jonas Eder
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sebastian Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolay Sappler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Juliane Kilo
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ivan Tancevski
- Department of Internal Medicine I, Innsbruck Medical University, Innsbruck, Austria
| | - Sebastian Bachmann
- Central Institute of Clinical Chemistry and Laboratory Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Hannes Abfalterer
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Hanno Ulmer
- Department for Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Andrea Griesmacher
- Central Institute of Clinical Chemistry and Laboratory Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Samuel Heuts
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
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8
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Crea F. Cardiovascular and dementia prevention: role of scores, diet, and rehabilitation. Eur Heart J 2023; 44:2501-2505. [PMID: 37477627 DOI: 10.1093/eurheartj/ehad449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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9
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Kavsak PA, Belley-Cote EP, Whitlock RP, Lamy A. Cardiac troponin testing in cardiac surgery. Expert Rev Cardiovasc Ther 2023; 21:729-731. [PMID: 37947177 DOI: 10.1080/14779072.2023.2283123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/09/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - André Lamy
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
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10
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Sharma V, Zheng H, Candilio L, Nicholas JM, Clayton T, Yellon DM, Bulluck H, Hausenloy DJ. Defining Peri-Operative Myocardial Injury during Cardiac Surgery Using High-Sensitivity Troponin T. J Clin Med 2023; 12:4291. [PMID: 37445326 PMCID: PMC10342425 DOI: 10.3390/jcm12134291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/11/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE Cut-offs for high-sensitivity troponin (hs-Tn) elevations to define prognostically significant peri-operative myocardial injury (PMI) in cardiac surgery is not well-established. We evaluated the associations between peri-operative high-sensitivity troponin T (hs-TnT) elevations and 1-year all-cause mortality in patients undergoing cardiac surgery. METHODS The prognostic significance of baseline hs-TnT and various thresholds for post-operative hs-TnT elevation at different time-points on 1-year all-cause mortality following cardiac surgery were assessed after adjusting for baseline hs-TnT and EuroSCORE in a post-hoc analysis of the ERICCA trial. RESULTS 1206 patients met the inclusion criteria. Baseline elevation in hs-TnT >x1 99th percentile upper reference limit (URL) was significantly associated with 1-year all-cause mortality (adjusted hazard ratio 1.90, 95% confidence interval 1.15-3.13). In the subgroup with normal baseline hs-TnT (n = 517), elevation in hs-TnT at all post-operative time points was associated with higher 1-year mortality, reaching statistical significance for elevations above: ≥100 × URL at 6 h; ≥50 × URL at 12 and 24 h; ≥35 × URL at 48 h; and ≥30 × URL at 72 h post-surgery. Elevation in hs-TnT at 24 h ≥ 50 × URL had the optimal sensitivity and specificity (73% and 75% respectively). When the whole cohort of patients was analysed, including those with abnormal baseline hs-TnT (up to 10 × URL), the same threshold had optimal sensitivity and specificity (66% and 70%). CONCLUSIONS Both baseline and post-operative hs-TnT elevations are independently associated with 1-year all-cause mortality in patients undergoing cardiac surgery. The optimal threshold to define a prognostically significant PMI in our study was ≥50 × URL elevation in hs-TnT at 24 h.
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Affiliation(s)
- Vikram Sharma
- Department of Cardiovascular Medicine, University of Iowa, Iowa City, IA 52242, USA;
| | - Huili Zheng
- National Registry of Diseases, Health Promotion Board, Singapore 168937, Singapore;
| | - Luciano Candilio
- Department of Cardiology, Royal Free Hospital, London NW3 2QG, UK;
| | - Jennifer M. Nicholas
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (J.M.N.); (T.C.)
| | - Tim Clayton
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK; (J.M.N.); (T.C.)
| | - Derek M. Yellon
- The Hatter Cardiovascular Institute, University College London, London WC1E 6HX, UK;
| | - Heerajnarain Bulluck
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK;
- Department of Cardiology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK
| | - Derek J. Hausenloy
- The Hatter Cardiovascular Institute, University College London, London WC1E 6HX, UK;
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore 169857, Singapore
- National Heart Research Institute Singapore, National Heart Centre, Singapore 169609, Singapore
- Yong Loo Lin School of Medicine, National University Singapore, Singapore 117597, Singapore
- Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, Taichung 41354, Taiwan
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11
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Kim KM, Kim SY, Jung JC, Chang HW, Lee JH, Kim DJ, Kim JS, Lim C, Park KH. Elevated troponin I is associated with a worse long-term prognosis in patients undergoing beating-heart coronary surgery. Eur J Cardiothorac Surg 2023; 63:ezad087. [PMID: 36946289 DOI: 10.1093/ejcts/ezad087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/22/2023] [Accepted: 03/20/2023] [Indexed: 03/23/2023] Open
Abstract
OBJECTIVES The impacts of elevated troponin I levels after coronary artery bypass grafting (CABG) on long-term outcomes were investigated. METHODS A total of 996 patients who underwent elective isolated CABG for stable or unstable angina were enrolled. Patients were divided into higher and lower groups based on 80th percentile postoperative peak troponin I (ppTnI) levels. The relationship between ppTnI and long-term clinical outcomes was analysed. RESULTS The median ppTnI was 1.55 (2.74) ng/ml and was significantly higher in the conventional CABG subgroup than in the beating-heart CABG subgroup: 4.04 (4.71) vs 1.24 (1.99) ng/ml, P < 0.001. The 80th percentile of ppTnI was 3.3 ng/ml in the beating-heart CABG subgroup and 8.9 ng/ml in the conventional CABG subgroup. In the conventional CABG subgroup (n = 150), 10-year overall survival showed no significant difference between the higher (≥8.9 ng/ml) and lower (<8.9 ng/ml) ppTnI groups: 71% (10%) vs 76% (5%), P = 0.316. However, the beating-heart CABG subgroup (n = 846) showed significantly worse 10-year overall survival in the higher ppTnI group (≥3.3 ng/ml) than in the lower ppTnI group (<3.3 ng/ml): 64% (6%) vs 73% (3%), P = 0.010. In the beating-heart CABG subgroup, multivariable analysis showed that ppTnI exceeding the 80th percentile was a risk factor for overall death (hazard ratio: 1.505, 95% confidence interval: 1.019-2.225, P = 0.040). CONCLUSIONS Higher ppTnI over the 80th percentile was associated with worse long-term survival in beating-heart CABG, but not in conventional CABG.
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Affiliation(s)
- Kang Min Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Sang Yoon Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Joon Chul Jung
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Hyoung Woo Chang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Jae Hang Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Dong Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Jun Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Cheong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Kay-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
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12
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Vendramini SPDA, Strunz CMC, Hueb WA, Mansur ADP. Cardiac Troponin I in Patients Undergoing Percutaneous and Surgical Myocardial Revascularization: Comparison of Analytical Methods. Diagnostics (Basel) 2023; 13:diagnostics13071316. [PMID: 37046534 PMCID: PMC10093140 DOI: 10.3390/diagnostics13071316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/10/2023] [Accepted: 03/16/2023] [Indexed: 04/05/2023] Open
Abstract
The myocardial infarction (MI) types 4a and 5 guidelines recommend cardiac troponin (cTn) diagnostic decision limits of 5 and 10 times the 99th percentile, respectively. Different cTn kits elicit different responses, so the MI diagnosis is still challenging. The study aimed to establish the cutoff values and the accuracy of three different cTnI kits in the diagnosis of post-procedural MI. We analyzed 115 patients with multivessel stable chronic coronary artery disease; 26 underwent percutaneous coronary intervention, and 89 underwent coronary artery bypass graft. Delayed-enhancement magnetic resonance imaging was performed before and after each intervention for definitive MI diagnoses. Two contemporary and one high-sensitivity cTnI immunoassays were used. ROC curves determined the accuracy of each assay. Low accuracy was observed after applying the current guidelines recommendations. The three cTnI assays accuracies improved when adjusted by the new ROC cutoffs, reaching 82% for MI type 5 for all assays, and 78%, 88%, and 87% for MI type 4 for Siemens, Beckman, and Abbott, respectively. The ultrasensitive and contemporary tests’ accuracy for MI types 4a and 5 diagnoses are equivalent when adjusted for these new cutoffs. The hs-cTnI assays had lower accuracy than contemporary tests for MI types 4a and 5 diagnoses.
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Affiliation(s)
- Sabrina Pacheco do Amaral Vendramini
- Laboratorio de Analises Clinicas, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil
| | - Célia Maria Cássaro Strunz
- Laboratorio de Analises Clinicas, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil
| | - Whady Armindo Hueb
- Unidade Clinica de Aterosclerose, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil
| | - Antonio de Padua Mansur
- Serviço de Prevencao, Cardiopatia na Mulher e Reabilitação Cardiovascular, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-900, SP, Brazil
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Panholzer B, Walter V, Jakobi C, Stöck M, Bein B. [Intensive Care in Heart Surgery - is All Now Different?]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:164-181. [PMID: 36958313 DOI: 10.1055/a-1861-0225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
With approximately 100000 operations performed in Germany per year, cardiac surgery is among the surgical specialties that require intensive care tratment most frequently. Although all therapeutic aspects of ICU treatment are of high importance among cardiac surgery patients, there is a focus on hemodynamics with the overarching goal of sufficient oxygen delivery. Patients undergoing cardiac surgery are particularily prone to hemodynamic instability and low cardiac output syndrome, potentially culminating into cardiogenic shock. This article presents an overview of essential elements of intensive care medicine in cardiac surgery, paying special attention to hemodynamic monitoring, low cardiac output syndrome, inotropy, cardiac arrhyhmia, perioperative myocardial infarction, and patient blood management.
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14
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Heuts S, Gollmann-Tepeköylü C, Denessen EJS, Olsthoorn JR, Romeo JLR, Maessen JG, van ‘t Hof AWJ, Bekers O, Hammarsten O, Pölzl L, Holfeld J, Bonaros N, van der Horst ICC, Davidson SM, Thielmann M, Mingels AMA. Cardiac troponin release following coronary artery bypass grafting: mechanisms and clinical implications. Eur Heart J 2023; 44:100-112. [PMID: 36337034 PMCID: PMC9897191 DOI: 10.1093/eurheartj/ehac604] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 09/13/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
The use of biomarkers is undisputed in the diagnosis of primary myocardial infarction (MI), but their value for identifying MI is less well studied in the postoperative phase following coronary artery bypass grafting (CABG). To identify patients with periprocedural MI (PMI), several conflicting definitions of PMI have been proposed, relying either on cardiac troponin (cTn) or the MB isoenzyme of creatine kinase, with or without supporting evidence of ischaemia. However, CABG inherently induces the release of cardiac biomarkers, as reflected by significant cTn concentrations in patients with uncomplicated postoperative courses. Still, the underlying (patho)physiological release mechanisms of cTn are incompletely understood, complicating adequate interpretation of postoperative increases in cTn concentrations. Therefore, the aim of the current review is to present these potential underlying mechanisms of cTn release in general, and following CABG in particular (Graphical Abstract). Based on these mechanisms, dissimilarities in the release of cTnI and cTnT are discussed, with potentially important implications for clinical practice. Consequently, currently proposed cTn biomarker cut-offs by the prevailing definitions of PMI might warrant re-assessment, with differentiation in cut-offs for the separate available assays and surgical strategies. To resolve these issues, future prospective studies are warranted to determine the prognostic influence of biomarker release in general and PMI in particular.
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229HX Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | | | - Ellen J S Denessen
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jules R Olsthoorn
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229HX Maastricht, The Netherlands
- Department of Cardiothoracic Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Jamie L R Romeo
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229HX Maastricht, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, P. Debyelaan 25, 6229HX Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Arnoud W J van ‘t Hof
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Otto Bekers
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ola Hammarsten
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Leo Pölzl
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
- Institute of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Iwan C C van der Horst
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, London, UK
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Alma M A Mingels
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, The Netherlands
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Armillotta M, Foà A, Pizzi C. Cardiac troponin elevation after coronary artery bypass graft: improving risk stratification. Eur Heart J 2023; 44:162. [PMID: 36263771 DOI: 10.1093/eurheartj/ehac537] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Matteo Armillotta
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna
| | - Alberto Foà
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna
| | - Carmine Pizzi
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna
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16
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Affiliation(s)
- Hazem Omran
- Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545 Bad Oeynhausen, Germany
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Crea F. Hot topics in ischaemic heart disease: polygenic risk scores, coronary microvascular dysfunction, myocardial injury, and diagnostic role of imaging. Eur Heart J 2023; 44:73-76. [PMID: 36617251 DOI: 10.1093/eurheartj/ehac785] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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18
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Gerçek M, Omran H, Friedrichs KP, Bleiziffer S, Gummert J, Rudolph V, Deutsch MA, Rudolph TK. Right coronary artery deformation and injury following tricuspid valve surgery. Front Cardiovasc Med 2022; 9:987993. [DOI: 10.3389/fcvm.2022.987993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/12/2022] [Indexed: 11/11/2022] Open
Abstract
BackgroundDue to its close anatomical proximity to the annular plane of the tricuspid valve (TV), the right coronary artery (RCA) is at risk of injury and distortion during surgical and interventional repair. Recently, reversible, non-flow limiting, purse-string like deformations of the RCA following percutaneous TV annuloplasty have been described. In contrast, there are only anecdotal reports on RCA deformation following conventional TV surgery.Materials and methodsA retrospective analysis of all patients undergoing TV surgery in our hospital between 2009 and 2019 was performed including all patients who received a post-operative coronary angiography (POCA). Angiographic footage was reviewed for RCA affections.ResultsA total of 1,383 patients underwent TV surgery (replacement and repair) for tricuspid regurgitation in our center. TV repair was performed in 1,248 (90.2%) patients and 135 (9.8%) patients underwent isolated TV surgery. Sixty-five patients (4.7%) underwent POCA within 48 h after surgery due to suspected myocardial ischemia, representing the final study population. Mean age was 70.3 ± 11.3 years, 56.3% were female. Mean EuroSCORE II was 9.8 ± 11.6%. Patients with the need for POCA due to suspected myocardial injury suffered from a higher mortality compared to event-free patients over the long-term follow up period (median 2.9 years) regardless of the observed coronary status. RCA affections were observed in 24 (36.9%) patients. A new RCA deformation without flow-impairment or vascular damage was found in 16 (24.6%) of the cases and was managed conservatively. There was no significantly worse outcome observed as compared to patients without RCA affections. Six (9.2%) patients showed an RCA deformation accompanied by subtotal occlusion. A complete RCA-occlusion was observed in 2 (3.1%) patients. Revascularization by percutaneous coronary intervention could be successfully performed in these patients. RCA deformation occurred exclusively after TV repair while no cases were observed after TV replacement.ConclusionRight coronary artery deformation without flow-limitation following surgical TV repair is a specific/typical phenomenon which might not impair patients’ outcome and could be managed conservatively in most of the cases. RCA injury indicating further interventional therapy is a rare complication of TV surgery. However, the need for immediate POCA in general appears to be associated with a worsened intermediate-term outcome.
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Crea F. The challenge of risk stratification in aortic aneurysms, congenital heart disease, and coronary bypass surgery. Eur Heart J 2022; 43:2343-2346. [PMID: 35772806 DOI: 10.1093/eurheartj/ehac334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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20
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Giannitsis E, Frey N. Isolated early peak cardiac troponin for clinical decision-making after elective cardiac surgery: useless at best. Eur Heart J 2022; 43:2404-2406. [PMID: 35175335 DOI: 10.1093/eurheartj/ehab786] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Evangelos Giannitsis
- Medizinische Klinik III, Department of Cardiology, Angiology and Pulmology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Norbert Frey
- Medizinische Klinik III, Department of Cardiology, Angiology and Pulmology, University Hospital of Heidelberg, Heidelberg, Germany
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