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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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Hosseini S, Salari S, Banar S, Rezaei Y, Tajik A, Zahedmehr A, Emkanjoo Z. Hypothermia-induced accelerated idioventricular rhythm after cardiac surgery; a case report. BMC Cardiovasc Disord 2023; 23:142. [PMID: 36941559 PMCID: PMC10026505 DOI: 10.1186/s12872-023-03178-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 03/09/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Accelerated idioventricular rhythm (AIVR) is a slow ventricular arrhythmia, commonly due to myocardial ischemia in coronary artery disease. It is a transitory rhythm that rarely causes hemodynamic instability or necessitates any specific therapy. Besides, the common predisposing factors for ventricular arrhythmias after open-heart surgery are hemodynamic instability, electrolyte imbalances, hypoxia, hypovolemia, myocardial ischemia and infarction, acute graft closure, reperfusion injury, and administration of inotropes and antiarrhythmic drugs. Here we report a case of AIVR after cardiac surgery, mostly due to hypothermia that to our knowledge, it is the first report. CASE PRESENTATION We describe a 76-year-old man presenting with typical chest pain. Following routine investigations, the patient underwent coronary artery bypass grafting. Postoperatively, he was transferred to the intensive care unit with good hemodynamic status. However, about 3 h later, he developed rhythm disturbances, leading to hemodynamic instability without response to volume replacement or inotropic support. His rhythm was AIVR, although, at first glance, it resembled the left bundle branch block. Given his unstable hemodynamic status, he was emergently transferred to the operating room. Cardiopulmonary bypass (CPB) was resumed for hemodynamic support. After the patient was rewarmed to about 35 ºC, AIVR returned to normal. He was weaned from CPB successfully and with an uneventful hospital course. CONCLUSIONS Hypothermia is a potential cause of rhythm disturbance. Preventing the causes of arrhythmias, including hypothermia, is the best strategy.
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Affiliation(s)
- Saeid Hosseini
- Heart Valve Diseases Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, 1995614331, Iran
| | - Soheila Salari
- Heart Valve Diseases Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, 1995614331, Iran.
| | - Sepideh Banar
- Heart Valve Diseases Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, 1995614331, Iran
| | - Yousef Rezaei
- Heart Valve Diseases Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, 1995614331, Iran
| | - Atieh Tajik
- Heart Valve Diseases Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, 1995614331, Iran
| | - Ali Zahedmehr
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, 1995614331, Iran
| | - Zahra Emkanjoo
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, 1995614331, Iran
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3
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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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4
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Piantá RM, Ferrari ADL, Heck AA, Ferreira DK, Piccoli JDCE, Albuquerque LC, Guaragna JCVDC, Petracco JB. Atrioventricular block in coronary artery bypass surgery: perioperative predictors and impact on mortality. Braz J Cardiovasc Surg 2015; 30:164-72. [PMID: 26107447 PMCID: PMC4462961 DOI: 10.5935/1678-9741.20140086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 06/29/2014] [Indexed: 11/20/2022] Open
Abstract
Introduction Disturbances of the cardiac conduction system are frequent in the
postoperative period of coronary artery bypass surgery. They are mostly
reversible and associated with some injury of the conduction tissue, caused
by the ischemic heart disease itself or by perioperative factors. Objective Primary: investigate the association between perioperative factors and the
emergence of atrioventricular block in the postoperative period of coronary
artery bypass surgery. Secondary: determine the need for temporary pacing
and of a permanent pacemaker in the postoperative period of coronary artery
bypass surgery and the impact on hospital stay and hospital mortality. Methods Analysis of a retrospective cohort of patients submitted to coronary artery
bypass surgery from the database of the Postoperative Heart Surgery Unit of
the Sao Lucas Hospital of the Pontifical Catholic University of Rio Grande
do Sul, using the logistic regression method. Results In the period from January 1996 to December 2012, 3532 coronary artery bypass
surgery were carried out. Two hundred and eighty-eight (8.15% of the total
sample) patients had atrioventricular block during the postoperative period
of coronary artery bypass surgery, requiring temporary pacing. Eight of
those who had atrioventricular block progressed to implantation of a
permanent pacemaker (0.23% of the total sample). Multivariate analysis
revealed a significant association of atrioventricular block with age above
60 years (OR=2.34; CI 95% 1.75-3.12; P<0.0001), female gender (OR=1.37;
CI 95% 1.06-1.77; P=0.015), chronic kidney disease (OR=2.05; CI 95%
1.49-2.81; P<0.0001), atrial fibrillation (OR=2.06; CI 95% 1.16-3.66;
P=0.014), functional class III and IV of the New York Heart Association
(OR=1.43; CI 95% 1.03-1.98; P=0.031), perioperative acute myocardial
infarction (OR=1.70; CI 95% 1.26-2.29; P<0.0001) and with the use of the
intra-aortic balloon in the postoperative period of coronary artery bypass
surgery (OR=1.92; CI 95% 1.21-3.05; P=0.006). The presence of
atrioventricular block resulted in a significant increase in mortality
(17.9% vs. 7.3% in those who did not develop atrioventricular block)
(OR=2.09; CI 95% 1.46-2.99; P<0.0001) and a longer hospital stay (12.75
days x 10.53 days for those who didn't develop atrioventricular block)
(OR=1.01; CI 95% 1.00-1.02; P=0.01). Conclusions In most cases, atrioventricular block in the postoperative period of coronary
artery bypass surgery is transient and associated with several perioperative
factors: age above 60 years, female sex, chronic kidney disease, atrial
fibrillation, New York Heart Association functional class III or IV,
perioperative acute myocardial infarction and use of an intra-aortic
balloon. Its occurrence prolongs hospitalization and, above all, doubles the
risk of mortality.
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Affiliation(s)
- Ricardo Medeiros Piantá
- Sao Lucas Hospital, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | | | | | | | | | - João Batista Petracco
- Department of Cardiovascular Surgery, São Lucas Hospital, PUCRS, Porto Alegre, RS, Brazil
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Abstract
The creation and development of nonnatural peptidomimetics has become an area of increasing significance in bioorganic and chemical biology. A wide range of new peptide mimics with novel structures and functions are urgently needed to be explored in order to identify potential drug candidates and targeted probes, and to study protein functions. AApeptides are a new class of peptide mimics based on chiral PNA backbone. They are resistant to proteolytic degradation and have limitless potential for diversification. They have been found to have a wide variety of biological applications including cellular translocation, disruption of protein-protein interactions, formation of nanostructures, antimicrobial activity, etc. The synthesis of AApeptides is modular and straightforward. In this chapter, methods for the synthesis of AApeptides (including different subclasses) are described.
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Affiliation(s)
- Youhong Niu
- Department of Chemistry, University of South Florida, Tampa, FL, USA
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Hu Y, Li X, Sebti SM, Chen J, Cai J. Design and synthesis of AApeptides: a new class of peptide mimics. Bioorg Med Chem Lett 2011; 21:1469-71. [PMID: 21292484 DOI: 10.1016/j.bmcl.2011.01.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 12/24/2010] [Accepted: 01/03/2011] [Indexed: 10/18/2022]
Abstract
A new family of peptide mimics termed 'AApeptides', which are oligomers of N-acylated-N-aminoethyl amino acids, was proposed. The design and efficient synthesis of AApeptides are described. As proof-of-the-concept, we show that AApeptides can inhibit p53/MDM2 protein-protein interaction with significant activity (IC(50)=38 μM) and specificity. Preliminary data also demonstrates that AApeptides are resistant to enzymatic hydrolysis. With the ease of synthesis and diversification, potent bioactivity, and resistance to proteolysis, the development of sequence-specific AApeptides may expand the potential biomedical applications of peptidomimetics.
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Affiliation(s)
- Yaogang Hu
- Department of Chemistry, University of South Florida, Tampa, FL 33620, USA
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Arribas Leal JM, Pascual-Figal DA, Ahumada Vidal M, Marín Ortuño F, Gutiérrez García F, García-Puente del Corral J, Ruipérez Abizanda JA, Torres Martínez G, Valdés Chávarri M, Arcas Meca R. QRS duration and early hemodynamic instability after coronary revascularization surgery. Rev Esp Cardiol 2009; 62:652-9. [PMID: 19480761 DOI: 10.1016/s1885-5857(09)72229-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND OBJECTIVES The duration of the QRS interval measured by ECG is a marker of ventricular dysfunction and indicates a poor prognosis. Its value in patients undergoing coronary revascularization surgery has not been established. METHODS The study involved 203 consecutive patients (age 64+/-9 years, 74% male) scheduled for elective coronary surgery. The maximum QRS duration measured on a preoperative 12-lead ECG was recorded. Hemodynamic instability was defined as the occurrence of cardiac death, heart failure, or a need for intravenous inotropic drugs or intra-aortic balloon counterpulsation during the postoperative period. RESULTS The occurrence of hemodynamic instability (n=94, 46%) was associated with a longer preoperative QRS duration (97.5+/-21.14 ms vs 88.5+/-16.9 ms; P=.001). The QRS duration was also longer in patients who developed heart failure (n=23; 104.3+/-22.9 ms vs. 91.1+/-18.5 ms; P=.002), needed inotropic drugs (n=77; 96.5+/-20.5 ms vs. 90.1+/-18.2 ms; P=.007) or developed postoperative atrial fibrillation (n=58; 98.2+/-23.8 ms vs. 90.4+/-17.0 ms; P=.018). Bundle branch block was associated with a greater need for intra-aortic balloon counterpulsation (29% vs 12%; P=.012) or inotropic drugs (58% vs 35%; P=.014) and a higher incidence of hemodynamic instability (69% vs 42%; P=.006). Multivariate analysis identified the following independent predictors of hemodynamic instability: QRS duration (adjusted odds ratio [OR] per 10 ms=1.49; 95% confidence interval [CI], 1.11-2; P=.007), the lack of an arterial graft (OR=3.6; 95% CI, 1.14-11.6; P=.029) and extracorporeal circulation time (OR per min=1.013; 95% CI, 1.003-1.023; P=.013). CONCLUSIONS The intraventricular conduction delay, or QRS duration, was associated with a higher risk of postoperative hemodynamic instability following coronary surgery.
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Affiliation(s)
- José M Arribas Leal
- Servicio de Cirugía Cardiovascular, Hospital Universitario Virgen de la Arrixaca, Murcia, España.
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Arribas Leal JM, Pascual-Figal DA, Ahumada Vidal M, Marín Ortuño F, Gutiérrez García F, García-Puente del Corral J, Ruipérez Abizanda JA, Torres Martínez G, Valdés Chávarri M, Arcas Meca R. Duración del QRS y deterioro hemodinámico precoz tras cirugía de revascularización coronaria. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)71332-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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