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Laugesen S, Krasniqi L, Benhassen LL, Mortensen PE, Pallesen PA, Bak S, Kjelsen BJ, Riber LP. How to harvest the left internal mammary artery-a randomized controlled trial. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae102. [PMID: 38775645 PMCID: PMC11139514 DOI: 10.1093/icvts/ivae102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/01/2024] [Accepted: 05/17/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVES It is uncertain whether Thunderbeat has a place in harvesting the left internal mammary artery (LIMA) and whether skeletonization is superior to pedicle-harvested LIMA. Some investigations have shown improved flowrates in the skeletonized graft. The aim of this study was to compare 3 groups of harvesting techniques: Pedicled, surgical skeletonized and skeletonized with Thunderbeat in terms of flow rates in the LIMA and postoperative in-hospital outcomes. METHODS Patients undergoing coronary artery bypass grafting with the LIMA to the anterior descending artery were randomized to pedicled (n = 56), surgical skeletonized (n = 55) and skeletonized with Thunderbeat (n = 54). Main outcomes were blood flow and pulsatility index in the graft. RESULTS No statistical difference between groups regarding flow in LIMA or pulsatility index. Similarly, no difference in postoperative bleeding or days of hospitalization. The duration of harvesting was faster for the pedicled technique compared with surgical skeletonized and skeletonized with Thunderbeat [mean total min: pedicled 20.2 min standard deviation (SD) ± 5.4; surgical skeletonized 28.6 min SD ± 8.7; skeletonized with Thunderbeat 28.3 min SD ± 9.11, P < 0.001]. No grafts discarded due to faulty harvesting and there was no graft failure within hospital stay. CONCLUSIONS We found no difference between the harvesting methods except for a significantly faster harvesting time with the pedicled technique. However, non-touch skeletonized LIMA harvesting with Thunderbeat seems to be an effective alternative to traditional surgical skeletonized LIMA. The future will reveal whether patency is harvesting dependent. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05562908.
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Affiliation(s)
- Sofie Laugesen
- Department of Cardio, Vascular and Thoracic Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Medicine, Faculty of Health, Odense University, Odense, Denmark
| | - Lytfi Krasniqi
- Department of Cardio, Vascular and Thoracic Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Medicine, Faculty of Health, Odense University, Odense, Denmark
| | - Leila Louise Benhassen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Poul Erik Mortensen
- Department of Cardio, Vascular and Thoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Peter Appel Pallesen
- Department of Cardio, Vascular and Thoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Søren Bak
- Department of Cardio, Vascular and Thoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Bo Juel Kjelsen
- Department of Cardio, Vascular and Thoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Lars Peter Riber
- Department of Cardio, Vascular and Thoracic Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Medicine, Faculty of Health, Odense University, Odense, Denmark
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2
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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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Chen W, Ni M, Huang H, Cong H, Fu X, Gao W, Yang Y, Yu M, Song X, Liu M, Yuan Z, Zhang B, Wang Z, Wang Y, Chen Y, Zhang C, Zhang Y. Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition). MedComm (Beijing) 2023; 4:e438. [PMID: 38116064 PMCID: PMC10729292 DOI: 10.1002/mco2.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Since the four working groups of the Chinese Society of Cardiology issued first expert consensus on coronary microvascular diseases (CMVD) in 2017, international consensus documents on CMVD have increased rapidly. Although some of these documents made preliminary recommendations for the diagnosis and treatment of CMVD, they did not provide classification of recommendations and levels of evidence. In order to summarize recent progress in the field of CMVD, standardize the methods and procedures of diagnosis and treatment, and identify the scientific questions for future research, the four working groups of the Chinese Society of Cardiology updated the 2017 version of the Chinese expert consensus on CMVD and adopted a series of measures to ensure the quality of this document. The current consensus has raised a new classification of CMVD, summarized new epidemiological findings for different types of CMVD, analyzed key pathological and molecular mechanisms, evaluated classical and novel diagnostic technologies, recommended diagnostic pathways and criteria, and therapeutic strategies and medications, for patients with CMVD. In view of the current progress and knowledge gaps of CMVD, future directions were proposed. It is hoped that this expert consensus will further expedite the research progress of CMVD in both basic and clinical scenarios.
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Affiliation(s)
- Wenqiang Chen
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Mei Ni
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - He Huang
- Department of CardiologySir Run Run Shaw Hospital affiliated with Zhejiang University School of MedicineHangzhouChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest Hospital, Tianjin UniversityTianjinChina
| | - Xianghua Fu
- Department of CardiologyThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wei Gao
- Department of CardiologyPeking University Third HospitalBeijingChina
| | - Yuejin Yang
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Mengyue Yu
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiantao Song
- Department of CardiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Meilin Liu
- Department of GeriatricsPeking University First HospitalBeijingChina
| | - Zuyi Yuan
- Department of CardiologyThe First Affiliated Hospital of Xian Jiaotong UniversityXianChina
| | - Bo Zhang
- Department of CardiologyFirst Affiliated Hospital, Dalian Medical UniversityDalianLiaoningChina
| | - Zhaohui Wang
- Department of CardiologyUnion Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yan Wang
- Department of CardiologyXiamen Cardiovascular Hospital, Xiamen UniversityXiamenChina
| | - Yundai Chen
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China; for the Basic Research Group, Atherosclerosis and Coronary Heart Disease Group, Interventional Cardiology Group, and Women's Heart Health Group of the Chinese Society of Cardiology
| | - Cheng Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Yun Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
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Koköfer A, Cozowicz C, Wernly B, Rodemund N. Timing and threshold of high sensitive troponin T measurement for the prediction of mortality after cardiac surgery: a retrospective cohort analysis. Intensive Care Med Exp 2023; 11:58. [PMID: 37656268 PMCID: PMC10473995 DOI: 10.1186/s40635-023-00545-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/29/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND High sensitive cardiac troponin T (hsTnT) is a widely used biomarker of myocardial injury. Along with other high sensitive troponins, HsTnT can predict mortality in both cardiac and non-cardiac surgery. The aim of this study was to determine the association between hsTnT serum elevations in the immediate postoperative period until 120 h after cardiac surgery and the occurrence of in-hospital mortality compared to the Simplified Acute Physiology Score 3 (SAPS3). Additionally, we identified an ideal hsTnT serum threshold to predict in-hospital mortality. METHODS We performed a retrospective single-institutional cohort analysis of 2179 patients undergoing cardiac surgery with cardiopulmonary bypass from 2013 to 2021. Logistic regression analysis was used to investigate an association of hsTnT at various time points and in-hospital mortality. The model was adjusted for relevant covariates including SAPS3, lactate and administered norepinephrine dosage. ROC analysis was performed to estimate the accuracy to predict mortality by serum hsTnT concentrations. This prediction was compared to the SAPS3 score. An ideal cutoff of hsTnT concentration was calculated by means of Youden index. RESULTS In total 7576 troponins were measured at the predefined timepoints. 100 (4.59%) patients died during the hospital stay. The fourth hsTnT on d3 (at 96-120 h postoperatively) showed the highest association with in-hospital death (OR 1.56; 95% CI (1.39-1.76); p < 0.001). This finding persisted after multivariable adjustment (aOR 1.34; 95% CI (1.18-1.53); p < 0.001). In contrast, the third hsTnT on d2 (at 48-72 h postoperatively) showed the best discrimination for in-hospital mortality (AUC 82.75%; 95% CI (0.77-0.89). The prediction by the third hsTnT was comparable to the in-hospital mortality prediction by SAPS3 (AUC 79.36%; 95% CI (0.73-0.85); p = 0.056). The optimal cutoff for the third hsTnT was calculated to be 1264 ng/L (Sensitivity 0.62; Specificity 0.88). CONCLUSION Elevated hsTnT after cardiac surgery was associated with an increased risk of in-hospital mortality. HsTnT measured on postoperative day 2 and 3 were most accurate to predict in-hospital mortality. The prediction of in-hospital mortality using hsTNT is comparable to mortality prediction using the SAPS3 score. HsTnT serum levels currently recommended to establish clinically important periprocedural myocardial injury are lower than thresholds identified in this study.
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Affiliation(s)
- Andreas Koköfer
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria.
| | - Crispiana Cozowicz
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Bernhard Wernly
- Center for Public Health and Healthcare Research, Paracelsus Medical University of Salzburg, Salzburg, Austria
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Niklas Rodemund
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria
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5
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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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Nanni S, Garofalo M, Schinzari M, Nardi E, Semprini F, Battistini P, Barberini F, Foà A, Baiocchi M, Castelli A, Folesani G, Pacini D, Galiè N, Corsini A. Prognostic value of high-sensitivity cardiac troponin I early after coronary artery bypass graft surgery. J Cardiothorac Surg 2022; 17:280. [PMID: 36319986 PMCID: PMC9628166 DOI: 10.1186/s13019-022-02027-x] [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: 05/20/2022] [Accepted: 09/24/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The diagnosis of periprocedural myocardial infarction (PMI) after coronary artery bypass graft (CABG) is based on biochemical markers along with clinical and instrumental findings. However, there is not a clear cutoff value of high-sensitivity cardiac troponin (hs-cTn) to identify PMI. We hypothesized that isolated hs-cTn concentrations in the first 24 h following CABG could predict cardiac adverse events (in-hospital death and PMI) and/or left ventricular ejection fraction (LVEF) decrease. METHODS We retrospectively enrolled all consecutive adult patients undergoing CABG, alone or in association with other cardiac surgery procedures, over 1 year. Hs-cTn I concentrations (Access, Beckman Coulter) were serially measured in the post-operative period and analyzed according to post-operative outcomes. RESULTS 300 patients were enrolled; 71.3% underwent CABG alone, 33.7% for acute coronary syndrome. Most patients showed hs-cTn I values superior to the limit required by the latest guidelines for the diagnosis of PMI. Five patients (1.7%) died, 8% developed a PMI, 10.6% showed a LVEF decrease ≥ 10%. Hs-cTn I concentrations did not significantly differ with respect to death and/or PMI whereas they were associated with LVEF decrease ≥ 10% (p value < 0.005 at any time interval), in particular hs-cTn I values at 9-12 h post-operatively. A hs-cTn I cutoff of 5556 ng/L, a value 281 (for males) and 479 (for females) times higher than the URL, at 9-12 h post-operatively was identified, representing the best balance between sensitivity (55%) and specificity (79%) in predicting LVEF decrease ≥ 10%. CONCLUSIONS Hs-cTn I at 9-12 h post-CABG may be useful to early identify patients at risk for LVEF decrease and to guide early investigation and management of possible post-operative complications.
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Affiliation(s)
- Samuele Nanni
- grid.6292.f0000 0004 1757 1758Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mattia Garofalo
- grid.6292.f0000 0004 1757 1758Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy ,grid.6292.f0000 0004 1757 1758Department of Specialist, Diagnostic, and Experimental Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Matteo Schinzari
- grid.6292.f0000 0004 1757 1758Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy ,grid.6292.f0000 0004 1757 1758Department of Specialist, Diagnostic, and Experimental Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Elena Nardi
- grid.6292.f0000 0004 1757 1758Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy ,grid.6292.f0000 0004 1757 1758Department of Specialist, Diagnostic, and Experimental Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Franco Semprini
- grid.6292.f0000 0004 1757 1758Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paola Battistini
- grid.6292.f0000 0004 1757 1758Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Barberini
- grid.6292.f0000 0004 1757 1758Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alberto Foà
- grid.6292.f0000 0004 1757 1758Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy ,grid.6292.f0000 0004 1757 1758Department of Specialist, Diagnostic, and Experimental Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Massimo Baiocchi
- grid.6292.f0000 0004 1757 1758Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Castelli
- grid.6292.f0000 0004 1757 1758Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gianluca Folesani
- grid.6292.f0000 0004 1757 1758Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Davide Pacini
- grid.6292.f0000 0004 1757 1758Department of Specialist, Diagnostic, and Experimental Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy ,grid.6292.f0000 0004 1757 1758Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Nazzareno Galiè
- grid.6292.f0000 0004 1757 1758Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy ,grid.6292.f0000 0004 1757 1758Department of Specialist, Diagnostic, and Experimental Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Anna Corsini
- grid.6292.f0000 0004 1757 1758Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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7
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Omran H, Deutsch MA, Groezinger E, Zittermann A, Renner A, Neumann JT, Westermann D, Myles P, Ramosaj B, Pauly M, Scholtz W, Hakim-Meibodi K, Rudolph TK, Gummert J, Rudolph V. High-sensitivity cardiac troponin I after coronary artery bypass grafting for post-operative decision-making. Eur Heart J 2022; 43:2388-2403. [PMID: 35165695 PMCID: PMC9246661 DOI: 10.1093/eurheartj/ehab918] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 01/09/2023] Open
Abstract
AIMS Current troponin cut-offs suggested for the post-operative workup of patients following coronary artery bypass graft (CABG) surgery are based on studies using non-high-sensitive troponin assays or are arbitrarily chosen. We aimed to identify an optimal cut-off and timing for a proprietary high-sensitivity cardiac troponin I (hs-cTnI) assay to facilitate post-operative clinical decision-making. METHODS AND RESULTS We performed a retrospective analysis of all patients undergoing elective isolated CABG at our centre between January 2013 and May 2019. Of 4684 consecutive patients, 161 patients (3.48%) underwent invasive coronary angiography after surgery, of whom 86 patients (53.4%) underwent repeat revascularization. We found an optimal cut-off value for peak hs-cTnI of >13 000 ng/L [>500× the upper reference limit (URL)] to be significantly associated with repeat revascularization within 48 h after surgery, which was internally validated through random repeated sampling with 1000 iterations. The same cut-off also predicted 30-day major adverse cardiovascular events and all-cause mortality after a median follow-up of 3.1 years, which was validated in an external cohort. A decision tree analysis of serial hs-cTnI measurements showed no added benefit of hs-cTnI measurements in patients with electrocardiographic or echocardiographic abnormalities or haemodynamic instability. Likewise, early post-operative hs-cTnI elevations had a low yield for clinical decision-making and only later elevations (at 12-16 h post-operatively) using a threshold of 8000 ng/L (307× URL) were significantly associated with repeat revascularization with an area under the curve of 0.92 (95% confidence interval 0.88-0.95). CONCLUSION Our data suggest that for hs-cTnI, higher cut-offs than currently recommended should be used in the post-operative management of patients following CABG.
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Affiliation(s)
| | - Marcus A Deutsch
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Elena Groezinger
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545 Bad Oeynhausen, Germany
| | - Armin Zittermann
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - André Renner
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Johannes T Neumann
- Clinic for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Dirk Westermann
- Clinic for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Paul Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
| | - Burim Ramosaj
- Faculty of Statistics, Technical University of Dortmund, Dortmund, Germany
| | - Markus Pauly
- Faculty of Statistics, Technical University of Dortmund, Dortmund, Germany
| | - Werner Scholtz
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545 Bad Oeynhausen, Germany
| | - Kavous Hakim-Meibodi
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Tanja K Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545 Bad Oeynhausen, Germany
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8
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Zhou S, Diehl R, Sessler DI, Liang C, Mascha EJ, Soltesz EG, Duncan AE. Procedure-Specific Relationships Between Postoperative Troponin T and a Composite of Mortality and Low Cardiac Output Syndrome: A Retrospective Cohort Analysis. Anesth Analg 2022; 134:1260-1269. [PMID: 35110515 DOI: 10.1213/ane.0000000000005850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Myocardial injury after coronary artery bypass grafting (CABG) is defined as troponin concentrations >10 times 99th percentile upper reference limit (URL) according to the Fourth Universal Definition. However, troponin concentrations after non-CABG cardiac surgery which indicate greater-than-expected myocardial injury and increased risk for complications remain unclear. Our goal was to assess procedure-specific relationships between troponin T and a composite outcome of low cardiac output syndrome and in-hospital mortality in cardiac surgical patients. METHODS Patients having cardiac surgery between January 2010 and December 2017 were categorized into 4 groups by procedure: (1) CABG; (2) mitral valve repair; (3) aortic valve repair/replacement (AVR); (4) mitral valve replacement (MVR) or CABG + valve surgeries. Exclusion criteria were elevated preoperative troponin T, preoperative kidney failure, circulatory arrest, or preoperative/planned mechanical circulatory support. Logistic regression was used to assess the association between troponin T and composite outcome, both overall and by procedure, including assessment of the interaction between procedure and troponin T on outcome. RESULTS Among 10,253 patients, 37 (0.4%) died and 393 (3.8%) developed the primary outcome. Troponin T concentrations differed by procedure (P < .001). Compared to CABG, AVR had 0.53 (99.2% confidence interval [CI], 0.50-0.56; unadjusted P < .001) times lower troponin T concentrations, while MVR/CABG + valve were 1.54 (99.2% CI, 1.45-1.62, unadjusted P < .001) times higher. There were linear relationships between log2 troponin T concentration and log odds mortality/low cardiac output syndrome. The (unadjusted) relationships were parallel for various types of surgery (interaction P = .59), but at different levels of the outcome. CONCLUSIONS The relative increase in odds for mortality/low cardiac output syndrome per a similar increase in troponin T concentrations did not differ among cardiac surgical procedures, but the absolute troponin T concentrations did. Troponin concentrations should thus be interpreted in context of surgical procedure.
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Affiliation(s)
- Shan Zhou
- From the Department of Cardiothoracic Anesthesiology
| | - Rachel Diehl
- From the Department of Cardiothoracic Anesthesiology
| | | | - Chen Liang
- Department of Outcomes Research.,Department of Quantitative Health Sciences
| | - Edward J Mascha
- Department of Outcomes Research.,Department of Quantitative Health Sciences
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Andra E Duncan
- From the Department of Cardiothoracic Anesthesiology.,Department of Outcomes Research
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9
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6514981. [DOI: 10.1093/ejcts/ezac019] [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: 09/02/2021] [Revised: 11/17/2021] [Accepted: 01/07/2022] [Indexed: 11/14/2022] Open
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10
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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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11
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Abstract
Ischemic heart disease (IHD) is commonly recognized as the consequence of coronary atherosclerosis and obstructive coronary artery disease (CAD). However, a significant number of patients may present angina or myocardial infarction even in the absence of any significant coronary artery stenosis and impairment of the coronary microcirculation has been increasingly implicated as a relevant cause of IHD. The term "coronary microvascular dysfunction" (CMD) encompasses several pathogenic mechanisms resulting in functional and/or structural changes in the coronary microcirculation and determining angina and myocardial ischemia in patients with angina without obstructive CAD ("primary" microvascular angina), as well as in several other conditions, including obstructive CAD, cardiomyopathies, Takotsubo syndrome and heart failure, especially the phenotype with preserved ejection fraction. The pathogenesis of CMD is complex and involves the combination of functional and structural alterations leading to impaired coronary blood flow and resulting in myocardial ischemia. In the absence of therapies specifically targeting CMD, attention has been focused on the role of modifiable risk factors. Here, we provide updated evidence regarding the pathophysiological mechanisms underlying CMD, with a particular focus on the role of cardiovascular risk factors and comorbidities. Moreover, we discuss the specific pathogenic mechanisms of CMD across the different cardiovascular diseases, aiming to pave the way for further research and the development of novel strategies for a precision medicine approach.
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Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS
| | - Riccardo Rinaldi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart
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12
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Wang X, Chen X, Ye Y, Peng J, Lin J, Deng X, Lin L, You J, Wang X, Zhou D, Chen Q, Ge J. Troponin T Elevation After Percutaneous Left Atrial Appendage Occlusion. Front Cardiovasc Med 2021; 8:721224. [PMID: 34660722 PMCID: PMC8517138 DOI: 10.3389/fcvm.2021.721224] [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: 06/06/2021] [Accepted: 08/31/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Cardiac troponin T (cTNT) has been widely used in detecting cardiac damage. Elevated cTNT level has been reported to be associated with increased mortality in multiple cardiac conditions. It is not uncommon to observe an increased level of cTNT in patients after left atrial appendage occlusion (LAAO). The objective of the study is to study the incidence, significance, and factors associated with cTNT elevation after LAAO. Methods: We prospectively included patients who underwent LAAO from January 2019 to July 2020 in Fudan Zhongshan Hospital. Patients were divided into those with elevated cTNT after procedure and those with normal postprocedure cTNT. All individuals were followed up for 1 year. The primary outcome is major adverse cardiovascular events, which include myocardial infarction, heart failure, cardiac death, and stroke. The second outcome is periprocedure complication, including chest pain, tachycardia, cardiac tamponade, change of electrocardiograph, and atrial thrombus. Results: A total of 190 patients were enrolled. Of the patients, 85.3% had elevated cTNT after LAAO, while 14.7% of them did not. Exposure time, dosage of contrast, types of devices, shapes, and sizes of LAA could contribute to elevated postprocedure cTNT. We found that patients with a Watchman device were more likely to have elevated postprocedure cTNT than those with a Lambre device (89.2 vs. 76.7%, p = 0.029). LAAO shapes were associated with cTNT levels in patients with a Watchman device, while the diameter of the outer disc and LAA depth mattered for the Lambre device. There was no significant difference in the primary and second outcome between the two groups (p-value: 0.619, 0.674). Conclusion: LAAO was found to be commonly accompanied with cTNT elevation, which might not to be related to the complications and adverse cardiac outcomes within 1 year of follow-up. Moreover, eGFR at baseline, exposure time, dosage of contrast, types of LAAO device, and LAA morphology could contribute to cTNT elevation.
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Affiliation(s)
- Xiaoyan Wang
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Institute of Biomedical Science, Fudan University, Shanghai, China
| | - Xueying Chen
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Institute of Biomedical Science, Fudan University, Shanghai, China
| | - Yong Ye
- Department of Cardiovascular Medicine, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Juan Peng
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Institute of Biomedical Science, Fudan University, Shanghai, China
| | - Jinyi Lin
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Institute of Biomedical Science, Fudan University, Shanghai, China
| | - Xin Deng
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Institute of Biomedical Science, Fudan University, Shanghai, China
| | - Li Lin
- Department of Cardiovascular Medicine, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jieyun You
- Department of Cardiovascular Medicine, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xingxu Wang
- Department of Cardiovascular Medicine, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Daxin Zhou
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Institute of Biomedical Science, Fudan University, Shanghai, China
| | - Qingxing Chen
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Institute of Biomedical Science, Fudan University, Shanghai, China
| | - Junbo Ge
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Institute of Biomedical Science, Fudan University, Shanghai, China
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13
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Del Buono MG, Montone RA, Camilli M, Carbone S, Narula J, Lavie CJ, Niccoli G, Crea F. Coronary Microvascular Dysfunction Across the Spectrum of Cardiovascular Diseases: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:1352-1371. [PMID: 34556322 PMCID: PMC8528638 DOI: 10.1016/j.jacc.2021.07.042] [Citation(s) in RCA: 183] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/08/2021] [Accepted: 07/19/2021] [Indexed: 12/12/2022]
Abstract
Coronary microvascular dysfunction (CMD) encompasses several pathogenetic mechanisms involving coronary microcirculation and plays a major role in determining myocardial ischemia in patients with angina without obstructive coronary artery disease, as well as in several other conditions, including obstructive coronary artery disease, nonischemic cardiomyopathies, takotsubo syndrome, and heart failure, especially the phenotype associated with preserved ejection fraction. Unfortunately, despite the identified pathophysiological and prognostic role of CMD in several conditions, to date, there is no specific treatment for CMD. Due to the emerging role of CMD as common denominator in different clinical phenotypes, additional research in this area is warranted to provide personalized treatments in this "garden variety" of patients. The purpose of this review is to describe the pathophysiological mechanisms of CMD and its mechanistic and prognostic role across different cardiovascular diseases. We will also discuss diagnostic modalities and the potential therapeutic strategies resulting from recent clinical studies.
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Affiliation(s)
- Marco Giuseppe Del Buono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy. https://twitter.com/marcodelbuono3
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Massimiliano Camilli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Salvatore Carbone
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia, USA; VCU Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Carl J Lavie
- Department of Cardiovascular Diseases, Ochsner Clinical School, New Orleans, Louisiana, USA
| | | | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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14
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Ross JDW, Newland RF, Hamson RTJ, Rice GD, Baker RA. Del Nido cardioplegia in adult cardiac surgery: analysis of myocardial protection and post-operative high-sensitivity Troponin T. ANZ J Surg 2021; 91:2192-2198. [PMID: 34427030 DOI: 10.1111/ans.17135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 07/28/2021] [Accepted: 08/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND del Nido cardioplegia has been adopted for use in adult cardiac surgery, despite a lack of robust randomised evidence supporting equivalence or superiority to conventional hyperkalaemic blood cardioplegia. We investigated the clinical surrogates of myocardial protection, and performed an extensive analysis of post-operative high-sensitivity Troponin T (hs-TnT) values in a general adult cardiac surgery population receiving del Nido, in comparison to a historical hyperkalaemic blood cohort. METHOD 171 consecutive patients of a single surgeon from between November 2018 and June 2020 received del Nido, and were compared to a historical cohort of 326 patients between January 2016 and November 2018 who received hyperkalaemic blood cardioplegia. Clinical markers of myocardial protection were compared, as were hs-TnT values at 6, 12, 24, and 72-h post-operatively. Equivalence between groups was determined using the two one-sided tests procedure. RESULTS There was no difference between the groups in the incidence of post-operative low cardiac output state, inotropic support, or myocardial infarction. Del Nido patients had less defibrillation requirement, and more spontaneous resumption of normal sinus rhythm. High-sensitivity Troponin T values were similar at all time-points including in a coronary artery bypass graft subgroup, and in those patients with elevated pre-operative hs-TnT. CONCLUSION In a broad cohort of adult cardiac surgery patients, including those undergoing coronary artery bypass surgery and those with recent myocardial infarction, del Nido provides equivalent myocardial protection and clinical outcomes when compared to hyperkalemic blood cardioplegia. Post-operative high-sensitivity Troponin T values were also equivalent between the groups.
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Affiliation(s)
- Jordan D W Ross
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Richard F Newland
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Rhys T J Hamson
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Gregory D Rice
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Robert A Baker
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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15
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Gu Y, Shan L, Liu B, Lv M, Chen X, Yan T, Shi Y, Chen J, Li Z, Zhang Y. Release Profile of Cardiac Troponin T and Risk Factors of Postoperative Myocardial Injury in Patients Undergoing CABG. Int J Gen Med 2021; 14:2541-2551. [PMID: 34163222 PMCID: PMC8214547 DOI: 10.2147/ijgm.s315691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Cardiac troponin T (cTnT) is currently one of the important indicators for clinical diagnosis of myocardial injury, which is inevitable in cardiac surgery, especially coronary artery bypass grafting (CABG). Describing the release profile of cTnT and finding out the risk factors of postoperative myocardial injury (PMI) are of great significance. The purposes of this study are to explore the release profile of cTnT in patients undergoing CABG and to search for independent risk factors of PMI. Methods In this retrospective study, clinical data of CABG patients were collected. The cTnT was measured at 24 hours before and 6, 12, 24, 48, 72, 96 and 120 hours after operation separately. The release profiles and peak time of cTnT in total cohort and sub-cohorts were observed. Independent risk factors of PMI were explored via univariate and multivariate logistic regression analyses. Results In total, 2084 patients were enrolled, including 998 patients in a cTnT group and 1086 patients in a high-sensitive cTnT (hs-cTnT) group. PMI was recognized in 797 patients. In both groups, cTnT showed a trend of rising first and then falling within 120 hours after operation. The peak cTnT appeared within 12–24 hours after operation, while the peak hs-cTnT occurred mostly within 24–48 hours after operation. Univariate logistic analysis showed that body mass index (BMI), New York Heart Association (NYHA) classification, coronary artery disease (CAD) classification, cerebrovascular disease, left ventricular ejection fraction, number of diseased vessels, valvular disease, intra-aortic balloon pump (IABP) implantation, chronic obstructive pulmonary disease, pulmonary hypertension, previous percutaneous coronary intervention (PCI), BMI, bypass graft number, cardiopulmonary bypass, and preoperative cTnT were related risk factors. Multivariate logistic regression analysis showed that NYHA classification, CAD classification, valvular disease, IABP implantation, pulmonary hypertension, previous PCI, bypass graft number, cardiopulmonary bypass, and preoperative cTnT were independent risk factors of PMI. Conclusion NYHA classification, CAD classification, valvular disease, IABP implantation, pulmonary hypertension, previous PCI, bypass graft number, cardiopulmonary bypass, and preoperative cTnT are independent risk factors of PMI in patients undergoing CABG.
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Affiliation(s)
- Yuying Gu
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Lingtong Shan
- Department of Thoracic Surgery, Sheyang County People's Hospital, Yancheng, Jiangsu, People's Republic of China
| | - Ban Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Mengwei Lv
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Xi Chen
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Tao Yan
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yu Shi
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Jiapeng Chen
- Xinglin College, Nantong University, Nantong, Jiangsu, People's Republic of China
| | - Zhi Li
- Department of Cardiovascular Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Yangyang Zhang
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
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16
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Li Y, Li Y, Hu Q, Zheng S, Tian B, Meng F, Chen Z, Han J, Wang S, Zhang H, Xu C, Jia Y, Jiao Y, Fu J, Meng X. Association of early elevated cardiac troponin I concentration and longitudinal change after off-pump coronary artery bypass grafting and adverse events: a prospective cohort study. J Thorac Dis 2020; 12:6542-6551. [PMID: 33282356 PMCID: PMC7711399 DOI: 10.21037/jtd-20-1691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background The elevation of troponin after coronary artery bypass grafting (CABG) is common This study aimed to investigate the association between very early cardiac troponin I (cTnI) concentration and its longitudinal change within 24 hours after CABG and 30-day adverse events. Methods This study prospectively enrolled 633 patients who underwent isolated off-pump CABG from January 2019 to May 2019. Serum cTnI levels were measured in all patients at two examinations within 24 hours postoperatively (1 hour and 12–18 hours), and a proportional hazards model was used to determine the association between cTnI levels and their change with adverse events, which were defined as a composite of 30-day mortality, stroke, heart failure, myocardial infarction (MI), and ventricular fibrillation. Results cTnI levels of the two examinations and absolute change of cTnI levels were significantly higher in the event group than in the non-event group (P<0.01, both). Earlier and later cTnI concentrations were associated with 30-day complications [adjusted hazard ration (HR) 1.598, 95% confidence interval (CI), 1.158–2.204 and HR 1.499, 95% CI, 1.228–1.831, respectively]. With regard to longitudinal change in cTnI levels, participants with persistently high levels of cTnI and those with progression from a low level to high level concentration experienced a significantly increased risk of adverse events than did participants who had a trend of persistently low cTnI levels (HR 3.105, 95% CI, 1.748–5.517 versus HR 2.944, 95% CI, 1.488–5.824). Conclusions Longitudinal change in cTnI levels within 24 hours and early cTnI concentrations, even less than 1 hour after CABG, are associated with adverse events. These data will be useful in identifying patients at an increased risk of complications.
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Affiliation(s)
- Yan Li
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuqi Li
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qiuming Hu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shuai Zheng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Baiyu Tian
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fei Meng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zonghao Chen
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jie Han
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shengyu Wang
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haibo Zhang
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chunlei Xu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yixin Jia
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuqing Jiao
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jintao Fu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xu Meng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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17
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Keppel MH, Kolbitsch T, Hoppe UC, Auer S, Felder TK, Oberkofler H, Mrazek C, Haschke-Becher E, Cadamuro J. The clinically effective use of cardiac markers by restructuring laboratory profiles at Cardiology wards. Clin Chem Lab Med 2020; 58:1565-1571. [PMID: 32305953 DOI: 10.1515/cclm-2019-1229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/04/2020] [Indexed: 12/20/2022]
Abstract
Background Laboratory overutilization is associated with diagnostic error and potential patient risk. We applied a demand management strategy in collaboration with the local Department of Cardiology to reduce the cardiac markers high-sensitive troponin T (hsTropT) and N-terminal pro brain natriuretic peptide (NTproBNP) in laboratory ordering profiles (LOPs). The present study aimed to retrospectively evaluate the implemented strategies. Methods Strategies included educational measures and evidence-guided, active test de-selection from all cardiology ward LOPs, and/or permanent removal from LOPs. Tests remained available at all times. We evaluated overutilization by reductions in monthly orders, and assessed differences in 30-day all-cause readmission rate and length of patients' hospital stay. Results Overall, we observed a mean reduction of 66.1% ± 7.6% (n = 277 ± 31) in hsTropT tests. Educational measures effectively reduced NTproBNP orders by 52.8% ± 17.7% (n = 60 ± 20). Permanent removal of tests from LOPs additionally decreased orders to a final extent of 75.8% ± 8.0% (n = 322 ± 31) in NTproBNP tests. The 30-day readmission rate and overall length of hospital stay did not increase. Conclusions Our results indicate that cardiac markers in routine care are subject to extensive overutilization when used within LOPs. Educational measures are an effective strategy to overcome the overutilization of cardiac markers but may be more effective when combined with the removal of cardiac markers from LOPs.
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Affiliation(s)
- Martin H Keppel
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Tobias Kolbitsch
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Uta C Hoppe
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Simon Auer
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Thomas K Felder
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Hannes Oberkofler
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Cornelia Mrazek
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University, Salzburg, Austria
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18
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Deneer R, Boxtel AGMV, Boer AK, Hamad MAS, Riel NAWV, Scharnhorst V. Detecting patients with PMI post-CABG based on cardiac troponin-T profiles: A latent class mixed modeling approach. Clin Chim Acta 2020; 504:23-29. [PMID: 32001234 DOI: 10.1016/j.cca.2020.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/20/2020] [Accepted: 01/24/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Diagnosis of perioperative myocardial infarction (PMI) after coronary artery bypass grafting (CABG) is fraught with complexity since it is primarily based on a single cut-off value for cardiac troponin (cTn) that is exceeded in over 90% of CABG patients, including non-PMI patients. In this study we applied an unsupervised statistical modeling approach to uncover clinically relevant cTn release profiles post-CABG, including PMI, and used this to improve diagnostic accuracy of PMI. METHODS In 624 patients that underwent CABG, cTnT concentration was serially measured up to 24 h post aortic cross clamping. 2857 cTnT measurements were available to fit latent class linear mixed models (LCMMs). RESULTS Four classes were found, described by: normal, high, low and rising cTnT release profiles. With the clinical diagnosis of PMI as golden standard, the rising profile had a diagnostic accuracy of 97%, compared to 83% for an optimally chosen cut-off and 21% for the guideline recommended cut-off value. CONCLUSION Clinically relevant subgroups, including patients with PMI, can be uncovered using serially measured cTnT and a LCMM. The LCMM showed superior diagnostic accuracy of PMI. A rising cTnT profile is potentially a better criterion than a single cut-off value in diagnosing PMI post-CABG.
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Affiliation(s)
- Ruben Deneer
- Clinical Laboratory, Catharina Hospital Eindhoven, The Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, The Netherlands.
| | | | - Arjen-Kars Boer
- Clinical Laboratory, Catharina Hospital Eindhoven, The Netherlands
| | | | - Natal A W van Riel
- Department of Biomedical Engineering, Eindhoven University of Technology, The Netherlands; Department of Vascular Medicine, Amsterdam University Medical Centers, The Netherlands
| | - Volkher Scharnhorst
- Clinical Laboratory, Catharina Hospital Eindhoven, The Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, The Netherlands
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Analysis of Myocardial Ischemia Parameters after Coronary Artery Bypass Grafting with Minimal Extracorporeal Circulation and a Novel Microplegia versus Off-Pump Coronary Artery Bypass Grafting. Mediators Inflamm 2020; 2020:5141503. [PMID: 32148439 PMCID: PMC7056992 DOI: 10.1155/2020/5141503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/07/2019] [Accepted: 12/17/2019] [Indexed: 12/21/2022] Open
Abstract
Background To compare the performance of our institutionally refined microplegia protocol in conjunction with minimal extracorporeal circulation system (MiECC) with off-pump coronary artery bypass grafting (OPCAB). Methods We conducted a single center study including patients undergoing isolated CABG surgery performed either off-pump or on-pump using our refined microplegia protocol in conjunction with MiECC. We used propensity modelling to calculate the inverse probability of treatment weights (IPTW). Primary endpoints were peak values of high-sensitivity cardiac troponin T (hs-cTnT) during hospitalization, and respective first values on the first postoperative day. Endpoint analysis was adjusted for intraoperative variables. Results After IPTW, we could include 278 patients into our analyses, 153 of which had received OPCAB and 125 of which had received microplegia. Standardized differences indicated that treatment groups were comparable after IPTW. The multivariable quantile regression yielded a nonsignificant median increase of first hs-cTnT by 39 ng/L (95% CI -8 to 87 ng/L, p = 0.11), and of peak hs-cTnT by 35 ng/L (CI -13 to 84, p = 0.11), and of peak hs-cTnT by 35 ng/L (CI -13 to 84, p = 0.11), and of peak hs-cTnT by 35 ng/L (CI -13 to 84, p = 0.11), and of peak hs-cTnT by 35 ng/L (CI -13 to 84. Conclusion The use of our institutionally refined microplegia in conjunction with MiECC was associated with similar results with regard to ischemic injury, expressed in hs-cTnT compared to OPCAB. MACCE was seen equally frequent. ICU discharge was earlier if microplegia was used.
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20
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Tevaeara Stahel H, Barandun S, Kaufmann E, Gahl B, Englberger L, Jenni H, Weber A, Aymard T, Gygax E, Carrel T. Single-center experience with the combination of Cardioplexol™ cardioplegia and MiECC for isolated coronary artery bypass graft procedures. J Thorac Dis 2019; 11:S1471-S1479. [PMID: 31293796 DOI: 10.21037/jtd.2019.04.47] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Cardioplexol™ with its low volume (100 mL) was originally conceived as cardioplegic solution for MiECC procedures. Introduced in its current form in 2008 in our clinic, it has immediately demonstrated attractive advantages including the easy and rapid administration by the surgeon him/herself, the almost immediate cardiac arrest and a prolonged delay before a second dose is necessary. We report here the results of our initial experience with this simple solution. Methods Single centre, retrospective observational analysis of prospectively collected data of isolated coronary artery bypass graft (CABG) procedures performed with a MiECC. Results Of 7,447 adult cardiac surgical operations performed during a 76 months period, 2,416 were isolated CABG-MiECC procedures. Patients were 81.3% males, 66.2±9.7 years old and had a median logistic EuroSCORE of 3.2. In average 3.2±0.8 vessels were bypassed. Median cross-clamp time was 45 minutes and more than 75% of the patients received only one 100 mL dose of Cardioplexol™. At reperfusion more than 90% of the hearts spontaneously recovered a rhythmic activity. Maximal value of troponin T during the first hours following myocardial reperfusion was 0.9±4.5 ng/mL (median =0.4 ng/mL). Mortality at 30 days was 0.9%. Conclusions Cardioplexol™ seems very promising. It appears especially efficient and safe when used for CABG procedures performed with a MiECC.
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Affiliation(s)
- Hendrik Tevaeara Stahel
- Swiss Cardio Technologies, Stansstad, Switzerland.,Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Silvio Barandun
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Emilie Kaufmann
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Brigitta Gahl
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Institute of Social and Preventive Medicine (ISPM) and Clinical Trial Unit (CTU) Bern, Bern, Switzerland
| | - Lars Englberger
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Hirslanden Clinics, Zurich, Switzerland
| | - Hansjoerg Jenni
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - Erich Gygax
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Fumedica, Muri, Switzerland
| | - Thierry Carrel
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Hirslanden Clinics, Zurich, Switzerland
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Tanihata J, Nishioka N, Inoue T, Bando K, Minamisawa S. Urinary Titin Is Increased in Patients After Cardiac Surgery. Front Cardiovasc Med 2019; 6:7. [PMID: 30800662 PMCID: PMC6375839 DOI: 10.3389/fcvm.2019.00007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 01/21/2019] [Indexed: 11/26/2022] Open
Abstract
Background: Few non-invasive biomarkers have been used to detect myocardial injury in patients with heart diseases. Recently, the N-terminal fragment (N-titin) of titin, a giant sarcomeric protein, which is involved in muscular passive tension and viscoelasticity, has been reported to detect muscle damage in patients with cardiomyopathy as well as in patients with skeletal muscle dystrophy and in healthy volunteers with endurance exercise. In the present study, we evaluated whether urinary N-titin is changed during a perioperative period and whether its increase reflects myocardial damage. Materials and Methods: In 18 patients who underwent cardiac surgery, blood and urine samples were obtained before and after surgery. We measured the urinary levels of N-titin with a highly sensitive ELISA system. Results: Urinary N-titin to creatinine (N-titin/Cr) was significantly increased in all patients postoperatively (43.3 ± 39.5 pmol/mg/dL on the day of operation) and remained significantly high for at least 4 days postoperatively. Urinary N-titin/Cr was positively correlated with serum cardiac troponin T (r = 0.36, p = 0.0006, n = 90) but not creatine kinase-MB (CK-MB). We also found that urinary N-titin/Cr in patients after a coronary artery bypass grafting operation was higher by day 2 postoperatively than in patients following open cardiac surgeries. Conclusion: The cleaved N-titin was significantly increased in urine after cardiac surgery. Urinary N-titin may be useful for detecting the risk of latent postoperative cardiac damage.
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Affiliation(s)
- Jun Tanihata
- Department of Cell Physiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Naritomo Nishioka
- Department of Cell Physiology, The Jikei University School of Medicine, Tokyo, Japan.,Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Inoue
- Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Ko Bando
- Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Susumu Minamisawa
- Department of Cell Physiology, The Jikei University School of Medicine, Tokyo, Japan
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Feng YQ, He XY, Song FE, Chen JY. Association between Contrast Media Volume and 1-Year Clinical Outcomes in Patients Undergoing Coronary Angiography. Chin Med J (Engl) 2019; 131:2424-2432. [PMID: 30334527 PMCID: PMC6202589 DOI: 10.4103/0366-6999.243563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: The excess volume of contrast media (CM) is a marker of a more severe coronary culprit lesion and longer intervention duration in patients undergoing cardiac procedures. However, it is unclear whether the contrast volume is directly correlated with worse clinical outcomes. The aim of this study was to investigate the association between contrast dose and the incidence of 1-year major adverse cardiac and cerebrovascular events (MACCE) and all-cause bleeding events in patients undergoing cardiac catheterization and coronary angiography (CAG). Methods: We prospectively enrolled 10,961 consecutive patients diagnosed with coronary heart disease expecting CAG from 2012 to 2013. The study population was pursued with a follow-up duration of 1 year. The predictive value of contrast volume, divided into quartiles, for the risk of MACCE and all-cause bleeding events was assessed using logistic regression analysis. Results: The cumulative incidence of 1-year MACCE was 8.65%, which was directly associated with increasing contrast volume. In particular, MACCE was observed in 7.16%, 7.89%, 9.31%, and 11.73% of cases in the contrast volume quartile Q1 (≤100 ml), Q2 (101–140 ml), Q3 (141–200 ml), and Q4 (>200 ml), respectively (P < 0.001). Moreover, the incidence of 1-year all-cause bleeding events was noted in 4.70%, 5.93%, 7.28%, and 8.21% of patients in Q1, Q2, Q3, and Q4, respectively (P < 0.001). The survival analysis showed that the 1-year MACCE rate was higher in patients using greater CM volume during the CAG. CM volume used >140 ml was associated with the occurrence of 1-year MACCE, and the incidence was dramatically elevated in patients exceeding a contrast volume of 200 ml (P = 0.007). Conclusion: Our data suggested that higher contrast volume was significantly correlated with an increased risk of MACCE and all-cause bleeding events in patients undergoing cardiac catheterization. Trial Registration: ClinicalTrials.gov, NCT01735305; https://clinicaltrials.gov/ct2/show/NCT01735305?id=NCT017353057rank=1.
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Affiliation(s)
- Ying-Qing Feng
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China
| | - Xu-Yu He
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China
| | - Fei-Er Song
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China
| | - Ji-Yan Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China
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Huber K. Current Definitions of Non-ST-Segment Elevation Myocardial Infarction: Challenges for Further Improvement. JACC Cardiovasc Interv 2018; 11:865-867. [PMID: 29747916 DOI: 10.1016/j.jcin.2018.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 03/13/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Kurt Huber
- 3rd Medicine Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria; and Sigmund Freud University, Medical School, Vienna, Austria.
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