864 ISOLATED CARDIAC METASTASIS FROM CARCINOMA OF THE CERVIX: RARE CASE OF ACS-NSTE. CASE REPORT

Introduction

The heart is a rare site of tumor metastasis. Although rarely, cardiac metastases may be secondary to a primary intra-abdominal tumor.

Aim

we report the case of a 60-years-old woman, ante-mortem finding of an isolated cardiac metastasis from cervical carcinoma presented as ACS-NSTE, who was evaluated in our Division of Cardiology.

Materials and methods

electrocardiogram, transthoracic echocardiography, angioTC, cardiac surgery and histopathologic analysis were performed.

Results

electrocardiogram showed incomplete right branch block with diffuse negative T waves. On the echocardiogram evidence of a voluminous hypo-isoechoic formation almost completely occupying the cavity of the right ventricule (RV) which appeared dilated and dysfunctional; D-shape aspect of the left ventricule as from the overload of the right sections and with moderate pericardial effusion, mildly reduced ejection fraction (EF50%Q). An urgent Angio-CT was performed and revealed a voluminous solid neoformation with inhomogeneous content and progressive contrast enhancement in the right ventricule. Following admission, the patient's haemodynamic status gradually worsened. Therefore, urgent cardiac surgery was performed. After drainage of abundant serum/haematic effusion, probably neoplastic infiltration of RV was seen. Therefore, given the extension it was decided to perform only multiple biopsies. Histopathological examination revealed moderately differentiated squamous cell carcinoma, as from metastasis from K. cervix.

Conclusions

there is no standardized therapy for the treatment of cardiac metastases, it is necessary to evaluate on a case-by-case basis. The most important prognostic factors are the obstructive effect of the intracardiac mass and the extent of any pericardial effusion. In fact, they can adversely affect hemodynamic stability.

MO354: Selenium-Binding Protein 1 (Sepp1) as an Early Sensitive Biomarker of Acute Kidney Injury in Patients Undergoing Cardiopulmonary Bypass

BACKGROUND AND AIMS

Acute kidney injury (AKI) often occurs in patients undergoing major cardiac surgery with cardiopulmonary bypass (CPB). Despite renal ischemia remains the key trigger, sustained oxidative stress is now acknowledged as a significant contributor. Selenium-binding protein 1 (SEPP1) is an intracellular protein whose blood levels increase in response to systemic cardiovascular and oxidative stress, as well as in the course of chronic kidney injury.

METHOD

In this pilot prospective study, we measured circulating SEPP1 levels in a cohort of 45 patients undergoing cardiac surgery with CPB in order to test its possible role in predicting the following occurrence of AKI. Serum samples of SEPP1 were collected before CPB (baseline) and at 4, 8 and 12 h after the end of the procedure and measured with a commercially available ELISA kit.

RESULTS

In the whole cohort, there was a significant statistical trend in SEPP1 levels from baseline to 12 h after CPB [39 (10–45) versus 3263 (1886–5042) ng/mL; P < 0.0001]. Within 48 h from CPB end, 12/45 patients (27%) developed AKI, as defined as an increase in serum creatinine >0.3 mg/dL or an absolute 1.5-fold increase from baseline and/or a reduced urine output (<0.5 mL/kg/h). Circulating SEPP1 displayed an earlier and more prominent increase in AKI patients as compared with others [4 h SEPP1: 52 (39–233) versus 546 (260–1000) ng/mL; P < 0.001]. 8 h SEPP1: 638 (437–1254) versus 1959 (1055–5303) ng/mL; P < 0.001; difference between overall trends: P < 0.001 (Fig. 1). At ROC analyses, either 4 or 8 h circulating SEPP1 had a remarkable diagnostic capacity in identifying AKI patients (AUCs 0.854 and 0.790, both P < 0.001). The crude OR of AKI in patients with 4 and 8 h SEPP1 above the best ROC-derived cut-off values (178 and 1840 ng/mL, respectively) was 22 (95%CI 2.5–192.9) and 14.5 (95% CI 2.9–71.2), respectively. At multivariate analysis, such a risk was independent from potential confounders, including CPB duration, clamping time and age.

CONCLUSION

Increased SEPP1 levels in patients undergoing CPB may reflect a sustained response to systemic oxidative stress. Such a response becomes more prominent when renal damage is also occurring. Studies on larger and more heterogeneous cohorts are needed to confirm whether SEPP1 may be a candidate as an early and specific biomarker of AKI in this high-risk setting.

MO413EFFECTS OF CHRONIC, LONG-TERM ACE-INHIBITOR TREATMENT ON CYTOKINE STORM AND RENAL FUNCTION AFTER CARDIO-PULMONARY BYPASS: A PROSPECTIVE OBSERVATIONAL STUDY

Background and Aims

Cardiopulmonary bypass (CPB) may trigger organs damage, including kidney injury, due to a massive cytokine release. In this observational, prospective study, we have analyzed the possible impact of chronic treatment with ACE-Inhibitors (ACE-I) on the inflammatory response and renal function after CPB.

Method

Sixty-nine patients undergoing major cardiac surgery with CPB were enrolled. Patients were stratified according to long-term (>6 mo.) ACE-I use (n=38) or not (n=31). The primary endpoint was to analyze the changes in their IL-1 alpha, IL-1beta, IL-2, IL-4, IL-6, IL-8, IL-10, TNF alpha, EGF and VEGF plasma levels. Secondary (renal) endpoints were: postoperative acute kidney injury (AKI), recovery of baseline GFR values and the absolute changes in renal function indexes.

Results

After CPB, IL-1alpha, IL-1beta, IL-4 and TNF-alpha remained stable overtime, while a significant decrease in IL-2 plasma levels was noticed in the ACE-I group (p=0.01). IL-6 and IL-8 plasma levels increased after surgery and tended to decrease after 48h. IL-10 plasma levels showed a similar variation, but both their rise and decrease were more pronounced in patients under ACE-I treatment (p=0.007). Finally, VEGF and EGF showed a marked initial decrease with a tendency to normalization 10 days after surgery (p for trend ranging from 0.01 to 0.001) (Figure 1-2).

The occurrence of AKI within 2 days after surgery, the rate of GFR recovery and the absolute changes in renal function indexes were not statistically different between groups (Figure 3).

Conclusion

Chronic, long-term ACE-I treatment may influence the inflammatory response following CPB. On the other hand, this drug class apparently has neutral impact on perioperative renal outcomes.

Relation of Prolonged Pacemaker Dependency After Cardiac Surgery to Mortality

Permanent pacemaker implantation (PPI) represents a rare complication after cardiac surgery, with no uniform agreement on timing and no information on follow-up. A multicenter retrospective study was designed to assess pacemaker dependency (PMD) and long-term mortality after cardiac surgery procedures. Between 2004 and 2016, PPI-patients from 18 centers were followed. Time-to-event data were evaluated with semiparametric regression Cox models and semiparametric Fine and Gray model for competing risk framework. Of 859 (0.90%) PPI-patients, 30% were pacemaker independent (PMI) at 6 months. PMD showed higher mortality compared with PMI (10-year survival 80.1% ± 2.6% and 92.2% +2.4%, respectively, log-rank p-value < 0.001) with an unadjusted hazard ratio for death of 0.36 (95% CI 0.20 to 0.65, p< 0.001 favoring PMI) and an adjusted hazard ratio of 0.19 (95% CI 0.08 to 0.45, p< 0.001 with PMD as reference). Crude cumulative incidence function of restored PMI rhythm at follow-up at 6 months, 1 year and 12 years were 30.5% (95% CI 27.3% to 33.7%), 33.7% (95% CI 30.4% to 36.9%) and 37.2% (95% CI 33.8% to 40.6%) respectively. PMI was favored by preoperative sinus rhythm with normal conduction (SR) (HR 2.37, 95% CI 1.65 to 3.40, p< 0.001), whereas coronary artery bypass grafting and aortic valve replacement were independently associated with PMD (HR 0.63, 95% CI 0.45 to 0.88, p = 0.006 and HR 0.807, 95% CI 0.65 to 0.99, p = 0.047 respectively). Time-to-implantation was not associated with increased rate of PMI. Although 30% of PPI-patients are PMI after 6 months, PMD is associated with higher mortality at long term.

Antecedent ACE-inhibition, inflammatory response, and cardiac surgery associated acute kidney injury

Cardiopulmonary bypass (CPB) may trigger organs damage, including kidney injury, due to a massive cytokine release. In this observational, prospective study, we analyzed the possible impact of chronic treatment with ACE-Inhibitors (ACE-I) on the inflammatory response and renal function after CPB. Sixty-nine patients undergoing major cardiac surgery with CPB were enrolled. Patients were stratified according to long-term (> 6 mo.) ACE-I use (n = 38) or not (n = 31). The primary endpoint was the change in IL-1alpha, IL-1beta, IL-2, IL-4, IL-6, IL-8, IL-10, TNF alpha, EGF and VEGF plasma levels. Secondary (renal) endpoints were postoperative acute kidney injury (AKI), recovery of baseline GFR values and the absolute changes in renal function indexes. After CPB, IL-1alpha, IL-1beta, IL-4 and TNF-alpha remained stable over time while a significant decrease in IL-2 levels was noticed in the ACE-I group (p = 0.01). IL-6 and IL-8 increased after surgery and tended to decrease after 48 h. IL-10 levels showed a similar variation, but both their rise and decrease were more pronounced in patients under ACE-I treatment (p = 0.007). Finally, VEGF and EGF showed a marked initial decrease with a tendency to normalization 10 days after surgery (p for trend ranging from 0.01 to 0.001). The occurrence of AKI within 2 days after surgery, the rate of GFR recovery and the absolute changes in renal function indexes were not statistically different between groups. Chronic, long-term ACE-I treatment may influence the inflammatory response following CPB. On the other hand, this drug class apparently has neutral impact on perioperative renal outcomes.

The predictive role of pelvic magnetic resonance in the follow up of spontaneous or induced puberty in turner syndrome

Puberty is a critical age for patients with Turner syndrome (TS): infertility is reported to be linked to karyotype and spontaneous puberty and menarche occur in approximately 30% of patients, especially in mosaicism. However, it is not always predictable considering hormonal pattern and pelvic transabdominal ultrasound scan (US).

The aim of the study is to compare the accuracy of Magnetic Resonance Imaging (MRI) and US to evaluate uterine and gonads volume, to visualize the presence of follicles and to predict spontaneous puberty and menarche in girls with TS. In a retrospective study, we evaluated 19 TS patients (age: 9–16 years), who underwent transabdominal pelvic US and pelvic MRI as required by parents. We correlated pelvic imaging with karyotype, hormonal data and pubertal outcome, and we compared US resolution to MRI.

MRI revealed a higher accuracy in the study of uterus and ovaries, and permitted to measure ovaries not visualized by US. Ovarian volume, the presence of follicles and the occurrence of spontaneous puberty were not related to the karyotype; spontaneous puberty started in one patient with a karyotype 45,X and in two patients with mosaicism (45,X/46,XX; 47,XXX/45, X). Ovarian follicles were relieved by MRI in patients with a spontaneous menarche and the persistence of menstrual cycles correlated with an ovarian volume corresponding to Tanner stage 3–4. We stress the role of MRI in the follow-up of TS adolescents, guide in the choice of the timing of treatment.

Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials

Background

Anaemia, coagulopathic bleeding and transfusion are strongly associated with organ failure, sepsis and death following cardiac surgery.

Objective

To evaluate the clinical effectiveness and cost-effectiveness of medical devices used as diagnostic and therapeutic tools for the management of anaemia and bleeding in cardiac surgery.

Methods and results

Workstream 1 – in the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from point-of-care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of laboratory reference tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review concluded that POC-based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Workstream 2 – in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial and a systematic review we demonstrated that personalised near-infrared spectroscopy-based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically effective nor cost-effective. Workstream 3 – in the REDWASH trial we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed red cells compared with standard (unwashed) red cells.

Limitations

Existing studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy or near-infrared spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective.

Conclusions

A systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical effectiveness or cost-effectiveness. The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may lead to more accurate diagnoses, more effective treatments and potentially improved clinical outcomes.

Study registration

Current Controlled Trials ISRCTN20778544 (COPTIC study) and PROSPERO CRD42016033831 (systematic review) (workstream 1); Current Controlled Trials ISRCTN23557269 (PASPORT trial) and PROSPERO CRD4201502769 (systematic review) (workstream 2); and Current Controlled Trials ISRCTN27076315 (REDWASH trial) (workstream 3).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 17. See the NIHR Journals Library website for further project information.

Surgical ablation in patients undergoing mitral valve surgery: impact of lesion set and surgical techniques on long-term success

AIMS

To assess the results and impact of lesion set and surgical technique on long-term success of surgical ablation during mitral surgery.

METHODS AND RESULTS

The patient population consisted of 685 subjects with persistent and long-standing persistent atrial fibrillation (AF) undergoing cardiac surgery for mitral valve disease as the primary indication and concomitant ablation between January 2003 and January 2012 at three institutions. One hundred and sixty-six underwent unipolar (24.2%), 371 (54.2%) bipolar, and 148 (21.6%) had combined ablation. Median follow-up was 58.4 months (interquartile range 43.3-67.9). To appropriately account for death, a competing risk model was employed to identify predictors of cumulative incidence of recurrent AF among lesion set and surgical techniques. Eight-year freedom from recurrent arrhythmia without antiarrhythmic drugs was 0.60 ± 0.02. Success rate was higher using bipolar radiofrequency (RF) (P < 0.001), after performing mitral isthmus line (P = 0.003) and following the biatrial technique (P < 0.001). Competing risk regression revealed that use of unipolar RF [sub-hazard ratio (SHR) 2.41 (1.52-3.43), P < 0.001], combined unipolar/bipolar ablation [SHR 1.93 (0.89-2.57), P = 0.003] and the absence of right atrial ablation [SHR 2.79 (1.27-3.48), P < 0.001] were predictors of cumulative incidence of long-term recurrence.

CONCLUSIONS

Our experience suggests that the use of bipolar clamp improves long-term results in surgical treatment of AF and that right-sided ablation should be routinely added. Randomized studies are necessary to confirm our findings.

Acute kidney injury after composite valve-graft replacement for ascending aorta aneurysms

Acute kidney injury (AKI) following cardiac surgery is a continuing source of morbidity and mortality. Although several studies have attempted to determine its etiology and prophylactic measures, limited data exist after thoracic aortic surgery. The aim of this study was to evaluate the incidence and predictors of AKI in patients undergoing aortic root replacement (ARR) with valve conduit for ascending aorta aneurysms. A multi-center observational study of 414 patients undergoing ARR with a valve conduit was conducted, focusing on clinical outcome and AKI defined by consensus RIFLE (risk, injury, failure, loss of function, end-stage renal disease) criteria. Mean age was 62.5 years (range: 21-82 years) with 327 males (79%). Emergent operations were performed in 5% of the cases, while concomitant surgical procedures were performed in 24.9%. Postoperative AKI (all RIFLE classes) occurred in 69 (16.7%) patients, while eight (1.9%) required dialysis. Independent AKI predictors were packed red blood cells (pRBCs) >4 units (OR 2.28; 95% CI 1.20-4.30), cardiopulmonary bypass (CPB) time longer than 180 min (OR, 2.08; 95% CI, 1.16-3.73), and concomitant surgical procedures (OR, 1.85; 95% CI, 1.04-3.29). The severity of RIFLE class was associated with longer ICU stay, hospitalization, and higher hospital mortality (p < 0.001 for each variable). AKI after ARR operations with valve conduit for ascending aorta aneurysms increases utilization of health resources and is associated with adverse events. Concomitant surgical procedures, prolonged CPB-time, and pRBCs >4 units as independent AKI predictors merit further researches enhancing possible preventive strategies.

Results of atrial fibrillation ablation during mitral surgery in patients with poor electro-anatomical substrate

BACKGROUND AND AIM OF THE STUDY

Enlarged (> 50 mm) atria, longstanding (> 5 years) persistent atrial fibrillation (AF) and age > 70 years are considered predictive of recurrent AF following surgical ablation. The electrophysiological and clinical outcome after AF-ablation was evaluated in high-risk patients undergoing concomitant procedures.

METHODS

Between January 2005 and January 2009, a total of 45 patients who complied with the three major predictors of failure, but who had undergone AF ablation ('left + right bipolar radiofrequency Maze') during concomitant mitral surgery were followed up. Freedom from AF, atrial flutter (AFL) and atrial tachycardia (AT), without anti-arrhythmic therapy (discontinued at the sixth month) was the primary endpoint. Survival, freedom from AF/AFL/AT with anti-arrhythmic therapy, early events during post-ablation blanking period, freedom from congestive heart failure (CHF) and from re-hospitalization, and changes in NYHA functional class were registered.

RESULTS

Postoperatively, 18 patients (40%) showed sinus rhythm (SR) at admission to the intensive care unit, while 16 (26%) showed junctional rhythm and five (11%) required definitive pacemaker. Eleven of the 40 patients (28%) were discharged without a pacemaker, and experienced early events during the post-ablation blanking period. After a mean of 21 +/- 14 months' follow up, the actuarial survival was 88 +/- 7%. The prevalence of SR at six, 12, and 18 months was 74%, 64%, and 64% respectively. Freedom from AF/AFL/AT was 54 +/- 10% without anti-arrhythmic medications, and 51 +/- 9% with such drugs. Freedom from CHF was 85 +/- 6%, and significantly better in SR patients (94 +/- 6%) than in AF patients (69 +/- 13%; p = 0.018). Freedom from rehospitalization was 75 +/- 8%, and better in SR patients (94 +/- 6%) than in AF patients (37 +/- 14%; p = 0.0001). Accordingly, when compared to AF patients, the NYHA class was significantly ameliorated in SR patients at both six months (1.4 +/- 0.6 versus 2.7 +/- 0.9) and at the final follow up control (1.2 +/- 0.5 versus 1.9 +/- 0.7; p < 0.0001). The E/A wave recovered in 22 (85%) of the SR patients.

CONCLUSION

AF ablation during mitral valve surgery achieves good electrophysiological results, even in patients traditionally considered as poor candidates. SR recovery allows a higher freedom from CHF and rehospitalization, with a better functional recovery when compared to AF.