Balloon Pump Use Research Articles

Effect of Body Mass Index on Postoperative Complications in Beating Coronary Artery Surgery.

Body Mass Index (BMI) is considered as an important risk factor in cardiovascular surgery. We designed a historical cohort study for the evaluation of perioperative complications related to BMI in patients who underwent off-pump coronary artery bypass grafting (OPCAB). We studied 1120 consecutive patients who underwent OPCAB between January 2008 and December 2011 in Imam Ali Hospital, Kermanshah, Iran. Patients were divided into four groups according to BMI: underweight/low BMI (< 18.5 kg/m2), healthy weight (between 18.5 kg/m2 and 24.9 kg/m2), overweight/high BMI (between 25 kg/m2 and 30 kg/m2), and obese/very high BMI (> 30 kg/m2). In multivariable regression analysis, an important correlation between the underweight/low BMI group and mortality was observed (p=0.037). Postoperative stroke, postoperative atrial fibrillation (AF) and intra-aortic balloon pump (IABP) use were not associated with BMI. In linear regression analysis, significant correlations between low BMI, reintubation, ICU stay time and intubation time were found. Re-exploration for bleeding was significantly correlated with having a low or high BMI. Having a low BMI (which is association with malnutrition and respiratory muscles weakness) was significantly associated with reintubation, prolonged intubation time and ICU stay time. The obese group was also associated with postoperative atelectasia and fever.

TCT-117 Impact of Intra-aortic Balloon Pump use on mortality in patients with cardiogenic shock treated with Primary Percutaneous Coronary Intervention: An Observational Study of 21,210 patients with ST-Elevation Myocardial Infarction from the London Heart Attack Group

TCT-117 Impact of Intra-aortic Balloon Pump use on mortality in patients with cardiogenic shock treated with Primary Percutaneous Coronary Intervention: An Observational Study of 21,210 patients with ST-Elevation Myocardial Infarction from the London Heart Attack Group

Levosimendan Use Increases Cardiac Performance after Coronary Artery Bypass Grafting in End-Stage Renal Disease Patients.

The effect of levosimendan on myocardial performance has not been studied in dialysis-dependent end-stage renal disease patients who have undergone coronary artery bypass grafting (CABG) surgery. Our aim was to investigate the effect of levosimendan on postoperative hemodynamic effects in end-stage renal disease patients undergoing CABG operation. We performed 58 elective isolated CABG operations in end-stage renal disease patients. The study group received levosimendan at a slow bolus dose of 3 µg/kg, followed by a 24-hour infusion of 0.03-0.05 µg/kg/kg/min. (study group [SG]: n = 25). The remaining patients received a placebo (control group [CG]: n = 33). The mean left ventricular ejection fraction of both groups was similar (44.6 ± 55.4% versus 42.8 ± 53.9%). Hemodynamic data were collected at the end, at 1 hour after CPB, and thereafter at 6, 12, and 24 hours in the ICU. Preoperatively, at the end of the operation, at 1 hour after CPB, and thereafter at 6, 12, and 24 hours in the ICU, blood samples from the peripheral vein were collected for cardiac troponin-I (c-TnI) and lactate levels. Norepinephrine if needed started during the rewarming period in both groups. One patient in SG (4%) and 4 patients (12.1%) in CG died postoperatively (P &lt; .01). Cardiac output and cardiac index values did not change early after weaning from extracorporeal circulation, and they were nearly similar during the next 6 hours in both groups. In SG, cardiac output and cardiac index significantly improved at 6 hours, and were stable at the end of 24 hours (P &lt; .001). Hemodynamic parameters were nearly similar after the operation, and did not change significantly at the end of 24 hours in CG. Hemodynamic improvement caused a significant reduction in systemic and pulmonary artery vascular resistance index in SG (P &lt; .002). Pulmonary capillary wedge pressure decreased significantly in SG (P &lt; .034). Cumulative inotrope dose requirement and intraaortic balloon pump use were significantly lower in SG. In addition, blood lactate and cTnI levels were significanly lower in SG (P &lt; .044). No important adverse effect was detected during levosimendan infusion. Because levosimendan at a dose of 0.03-0.05 μg/kg/min increased myocardial performance significantly in the postoperative period, it can be used safely in end-stage renal disease patients undergoing isolated CABG. The requirement of vasopressors were lower in SG.

Modern hydroxyethyl starch and acute kidney injury after cardiac surgery: a prospective multicentre cohort

BackgroundRecent trials have shown hydroxyethyl starch (HES) solutions increase the risk of acute kidney injury (AKI) in critically ill patients. It is uncertain whether these adverse effects also affect surgical patients. We sought to determine the renal safety of modern tetrastarch (6% HES 130/0.4) use in cardiac surgical patients. MethodsIn this multicentre prospective cohort study, 1058 consecutive patients who underwent cardiac surgery from 15th September 2012 to 15th December 2012 were recruited in 23 Spanish hospitals. ResultsWe identified 350 patients (33%) administered 6% HES 130/0.4 intraoperatively and postoperatively, and 377 (36%) experienced postoperative AKI (AKI Network criteria). In-hospital death occurred in 45 (4.2%) patients. Patients in the non-HES group had higher Euroscore and more comorbidities including unstable angina, preoperative cardiogenic shock, preoperative intra-aortic balloon pump use, peripheral arterial disease, and pulmonary hypertension. The non-HES group received more intraoperative vasopressors and had longer cardiopulmonary bypass times. After multivariable risk-adjustment, 6% HES 130/0.4 use was not associated with significantly increased risks of AKI (adjusted odds ratio 1.01, 95% CI 0.71–1.46, P=0.91). These results were confirmed by propensity score-matched pairs analyses. ConclusionsThe intraoperative and postoperative use of modern hydroxyethyl starch 6% HES 130/0.4 was not associated with increased risks of AKI and dialysis after cardiac surgery in our multicentre cohort.

Role of intra-aortic balloon pump counterpulsation in the treatment of acute myocardial infarction complicated by cardiogenic shock: Evidence from the Portuguese nationwide registry.

In previous guidelines, intra-aortic balloon pump (IABP) use was strongly recommended in the treatment of cardiogenic shock in the context of acute myocardial infarction. The recent IABP-SHOCK II trial demonstrated no benefit in short- and medium-term mortality with the use of IABP. It was our objective to evaluate in a real life nationwide population of patients with acute myocardial infarction the impact of IABP in short- and medium-term mortality. We included patients admitted with acute myocardial infarction in Killip class IV in the first 24 hours, all submitted to urgent coronary angiography. Our study objective was the occurrence of hospital and six-month all-cause mortality. From the 33,300 patients included in the registry, 4.2% presented with Killip class IV in the first 24 hours and 646 (43.6%) were submitted to urgent coronary angiography. IABP was implanted in 19.8% of these patients. The IABP group was younger, had higher admission heart rate, more multivessel disease and more left main disease. There were 260 hospital deaths (40.2%), similar between groups (46.1% vs. 38.8%, p=0.132). IABP use was associated with a deleterious effect in patients with previous MI and beneficial effect in patients with mechanical complications. IABP use had a neutral effect on mortality (hazard ratio 1.14, 95% confidence interval 0.84-1.56). This was further confirmed in a propensity score matching analysis. In a real life population of patients with acute myocardial infarction, the use of IABP for the treatment of cardiogenic shock was associated with a neutral effect.

Effects of radial versus femoral artery access in patients with acute myocardial infarction: Alarge centre prospective registry.

AimThis study sought to assess whether radial artery access improves clinical outcomes in patients presenting with acute myocardial infarction compared with femoral artery access.MethodsThis is a single-centre, prospective observational registry of all STEMI and NSTEMI patients who underwent coronary angiography and/or primary PCI in the period January 2010 to December 2013. Primary endpoint was 30-day all-cause mortality. Choice of access was left to the discretion of the cardiologist. Differences in the risk of death at 30 days between patients undergoing transradial intervention versus transfemoral intervention was assessed on an intention-to-treat comparison.ResultsRetrospective analysis of prospectively collected data was performed in 3580 patients with an acute coronary syndrome who underwent coronary angiography, of which 1310 had radial artery access. PCI was performed in 77 % of the patients. Before propensity score matching, patients who underwent transradial intervention and those intended to undergo transfemoral approach differed significantly in intra-aortic balloon pump use (1.7 % vs. 6.7 %, p < 0.001), and Killip class (Killip 1: 10.8 % vs. 17.3 %, p < 0.001). 30-day mortality rates were 1.7 % in the transradial group and 4.6 % in the transfemoral group (p < 0.001). After matching on the propensity score, the hazard ratio for 30-day mortality in the transradial group was 0.56 (95 % CI: 0.29–1.07, p = 0.08).ConclusionThis registry-based study showed that radial access is associated with improved outcome in patients with an acute coronary syndrome. However, this difference was no longer significant after multivariate and propensity score adjustment for differences in baseline characteristics.

Does Aortic Valve Replacement Restore Normal Life Expectancy: a Twenty-Year Relative Survival Study

&lt;strong&gt;Background &lt;/strong&gt;This 20-year relative survival study investigates life expectancy in defined age cohorts&lt;strong&gt; &lt;/strong&gt;and evaluates the role of patient, procedural and peri-operative variables on absolute survival after aortic valve replacement.&lt;p&gt; &lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods &lt;/strong&gt;Absolute long-term survival variance was calculated using Cox regression analysis in 585 consecutive aortic valve replacement patients. Relative survival curves in defined age groups were constructed using age- and gender-matched controls.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results&lt;/strong&gt; There were 12 peri-operative deaths (2.1%), and 11 further deaths (1.9%) during the first year. 154 patients (26.3%) died subsequently and 408 patients (69.7%) were alive after 20 years. Relative survival increased with age: in patients over 68 survival was equivalent to an age- and gender-matched population. Patient risk indicators for decreased absolute survival included age, Parsonnet score, additive and logistic EuroSCORE, and for increased absolute survival included weight, body surface area, and stroke volume. Procedural risk indicators for decreased absolute survival included bypass time, use of a tissue valve, and prosthesis-patient mismatch with size 19 valves, and for an increased absolute survival included use of a mechanical valve. Post-operative risk indicators for decreased absolute survival included ITU stay, ventilation time, transfusion, haemorrhage volume and new-onset atrial fibrillation/flutter. Strong risk indicators included intra-aortic balloon pump use, and dialysis.&lt;/p&gt;&lt;p&gt; &lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions&lt;/strong&gt; Patients over 68 years discharged from hospital after aortic valve replacement had a similar 10-year survival as an age- and gender-matched population. In this age cohort surgery restored the patient’s normal life expectancy.&lt;/p&gt;&lt;p&gt; &lt;/p&gt;&lt;p&gt;Key words: aortic valve replacement; absolute survival predictors; relative survival&lt;/p&gt;

Temporal Trends and Outcomes of Patients Undergoing Percutaneous Coronary Interventions for Cardiogenic Shock in the Setting of Acute Myocardial Infarction: A Report From the CathPCI Registry.

The purpose of this study was to examine the temporal trends in demographics, clinical characteristics, management strategies, and in-hospital outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (CS-AMI) who underwent percutaneous coronary intervention (PCI) from the Cath-PCI Registry (2005 to 2013). The authors examined contemporary use and outcomes of PCI in patients with CS-AMI. The authors used the Cath-PCI Registry to evaluate 56,497 patients (January 2005 to December 2013) undergoing PCI for CS-AMI. Temporal trends in clinical variables and outcomes were assessed. Compared with cases performed from 2005 to 2006, CS-AMI patients receiving PCI from 2011 to 2013 were more likely to have diabetes, hypertension, dyslipidemia, previous PCI, dialysis, but less likely to have chronic lung disease, peripheral vascular disease, or heart failure within 2 weeks (p < 0.01). Between 2005 and 2006 to 2011 and 2013, intra-aortic balloon pump use decreased (49.5% to 44.9%; p < 0.01), drug-eluting stent use declined (65% to 46%; p < 0.01), and the use of bivalirudin increased (12.6% to 45.6%). Adjusted in-hospital mortality; increased (27.6% in 2005 to 2006 vs. 30.6% in 2011 to 2013, adjusted odds ratio: 1.09, 95% confidence interval: 1.005 to .173; p = 0.04) for patients who were managed with an early invasive strategy (<24 h from symptoms). Our study shows that despite the evolution of medical technology and use of contemporary therapeutic measures, in-hospital mortality in CS-AMI patients who are managed invasively continues to rise. Additional research and targeted efforts are indicated to improve outcomes in this high-risk cohort.

Efficacy and safety of preoperative intra-aortic balloon pump use in patients undergoing cardiac surgery: a systematic review and meta-analysis

BackgroundIntra-aortic balloon pump (IABP) can be used prior to coronary artery bypass graft surgery (CABG) in high-risk patients. Whether this technique remains safe and effective in contemporary practice is controversial. ObjectiveWe have completed a systematic review and meta-analysis of randomized trials and observational studies to evaluate the safety and benefits of IABP prior to CABG surgery. MethodsWe searched PubMed, EMBASE, Cochrane Library databases, with cross-referencing of relevant articles for studies assessing the impact of IABP prior to and after isolated CABG. Two investigators independently sorted the potentially relevant studies, and three extracted data. The assessed outcomes included in-hospital and 30-day mortality, IABP-related complications and length of intensive care unit and hospital stay. ResultsFrom 1977 to 2015 we included 11 randomized controlled trials (n=1293) (RCTs) and 22 observational studies, including a total of 46,067 patients. Analyses from RCTs suggested that IABP prior to CABG was associated with a significant reduction in hospital mortality (odds ratio (OR) 0.20; 95% confidence interval (CI): 0.09–0.44; P<0.0001) and 30-day mortality compared to no preoperative IABP (OR 0.43, 95% CI: 0.25–0.76; P=0.003). IABP prior to CABG was also associated with shorter intensive care unit (weighted mean difference (WMD) −1.47day; 95% CI: −1.82 to −1.12day; P<0.00001) and hospital length of stay (WMD −3.25days; 95% CI: −5.18 to −1.33days; P=0.0009). However, there were significant bias and limitations among included studies. Furthermore, results for similar outcomes from observational studies remained inconclusive. ConclusionsIn contemporary practice, evidence showing clinical benefit for preoperative IABP in high-risk patients remains limited and requires further validation in an appropriately sized multicenter randomized trial.

Abstract 14055: Trend and Predictors of Prolonged Length of Hospital Stay Following Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction in The United States: A 10 Year Perspective

Background: Length of hospital stay (LOS) following percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) significantly affects healthcare utilization and cost. There is paucity of data in the United States on the optimal LOS following PCI for STEMI. Our study objective is to assess the trend and predictors of prolonged LOS following PCI with stent placement for STEMI. Methods: Data were obtained from nationwide inpatient sample from 2003-2012, which is a 20% stratified probability sample of all non-federal acute care hospitalizations. Study outcome was prolonged LOS defined as stay in hospital for &gt;4 days following PCI for STEMI. Cochrane-Armitage trend test and multivariable logistic regression models were used to delineate the predictors of prolonged LOS which included patient’s demographics, baseline comorbidities, presenting illnesses and in-hospital complications following PCI for STEMI. Results: A total of 223,267 patients with STEMI underwent PCI with stent placement with a mean LOS of 3.3±3.3 days. There were 16.1% patients who had prolonged LOS. The trend analysis showed that incidence of prolonged LOS decreased from 17.1% in year 2003 to 14.3% in year 2012 (p&lt;0.05) (figure 1A). Pneumonia and peri-procedural intra-aortic balloon pump use were the strongest predictors for prolonged LOS. Other significant predictors for prolonged LOS following PCI for STEMI were history of congestive heart failure, anemia, respiratory failure requiring ventilator use; peri-procedural stroke and anemia or hemorrhage requiring blood transfusion (figure 1B). Conclusions: Incidence of prolonged LOS has consistently decreased over 10 years. Patient’s baseline comorbidities, illnesses at presentation and in-hospital complications can predict prolonged LOS following PCI for STEMI. Implementing an aggressive standard of care to prevent in-hospital complications can further shorten the LOS following PCI for STEMI.

Abstract 15115: Including Intra- and Post-operative Factors in Delirium Predictive Rule After Coronary Artery Bypass Graft Could Increase Its Accuracy

Objectives: Postoperative Delirium (POD) frequently occurs after coronary artery bypass graft (CABG). Patients screened with an appropriate POD predictive rule (PR) may benefit from targeted preventive treatment. The accuracy of current available PRs, however, remained modest with the C statistic below 0.75, partially because none of which include intra- and post-operative (IPOP) as well as preoperative (preop) risk factors at the same time. Since POD is a postoperative (postop) phenomenon, IPOP factors might play important roles. This study aimed to develop and validate a PR based on perioperative (periop) factors to predict POD after CABG. Methods: This prospective study included two cohorts (derivation [n = 132] and validation [n = 53]) of patients who underwent first isolated CABG. POD was assessed using the Confusion Assessment Method for Intensive Care Unit twice daily until 5 days after operation. Logistic regression and a bootstrap resampling procedure were used for model development and internal validation. Rule performance was measured with the C statistic. Points were assigned to each variable and a simplified rule was derivated to identify subjects at low, moderate, and high risk of POD based on their total risk score. The proportion of subjects with POD in each risk group was calculated. Results: The PR included 5 periop factors: age (≥68y), female, intraoperative intra-aortic balloon pump use, postop atrial fibrillation and serum IL-6 ≥ 478 pg/ml at 18th hour. The relative risk of POD in moderate (2~5 points) and high risk group (6~8 points) were 6.7 and 10.9 folds higher compared with low risk group (0~1 point), respectively (Fig A). The model C statistic was 0.861 (Fig B) in the derivation cohort, 0.829 in internal validation, and 0.754 in validation cohort. Conclusion: We developed a POD PR for patients undergoing CABG, which includes IPOP risk factors as well as preop risk factors. The new developed rule demonstrated more powerful in predicting POD after CABG.

CLINICAL OUTCOMES IN ACUTE CORONARY SYNDROME PATIENTS FOLLOWING CORONARY ARTERY BYPASS GRAFTING IN RELATION TO TIMING OF TICAGRELOR DISCONTINUATION: INSIGHTS FROM THE CAPITAL REGISTRY

Patients with acute coronary syndromes (ACS) may require immediate or urgent coronary artery bypass grafting (CABG). Ticagrelor is a potent P2Y12 receptor antagonist increasingly used in the management of ACS. Although current guidelines suggest discontinuing ticagrelor at least 5 days prior to CABG, the optimal timing of CABG following ticagrelor administration has not been well established. We sought to assess in-hospital clinical outcomes in ACS patients following CABG in relation to the duration of ticagrelor discontinuation prior to surgery. We identified consecutive ACS patients who underwent CABG after having received ticagrelor. Patients were divided into 3 groups based on the timing of surgery after discontinuation of ticagrelor (<48 hours, 48 hours to <5 days, 5 or more days). We then compared clinical outcomes following CABG in relation to the duration of ticagrelor discontinuation. Clinical variables evaluated included postoperative bleeding, need for surgical reopening or blood transfusions, and length of stay in the intensive care unit (ICU). Of 336 patients undergoing CABG following ACS between January 2012 and December 2013, 38 received ticagrelor prior to CABG. Ticagrelor had been discontinued <48 hours prior to CABG in 14 patients (37%); 48 hours to <5 days in 14 (37%); and 5 days or more in 10 (26%). Baseline characteristics were comparable between ticagrelor discontinuation strata. CABG was deemed to be needed immediately in 21% of patients; within 24 hours in 11%; and on an urgent basis in the remaining 68%. Patients who underwent CABG <48 hours after ticagrelor discontinuation had more preoperative intra-aortic balloon pump use, and were more likely to require blood transfusions and a prolonged ICU stay (defined as >3 days). In addition, they had numerically higher, but non-statistically significant, rates of postoperative bleeding. Patients who underwent CABG 48 hours to <5 days after ticagrelor discontinuation had similar rates of postoperative bleeding and duration of ICU stay compared to patients who waited at least 5 days. A significant proportion of ACS patients who require CABG undergo surgery before the guideline recommended ticagrelor discontinuation period of 5 days. Patients who undergo CABG <48 hours after ticagrelor discontinuation are more like to require postoperative blood transfusions and a prolonged ICU stay. Notably, patients who undergo CABG 48 hours to <5 days after ticagrelor discontinuation have similar postoperative outcomes compared to patients who undergo CABG after 5 days of ticagrelor discontinuation. Large prospective series are needed to corroborate these findings.View Large Image Figure ViewerDownload (PPT)

Analysis of clinical outcomes of intra-aortic balloon pump use during coronary artery bypass surgery.

SummaryAimThe mortality rate of coronary artery bypass surgery increases with advanced patient age. This intra-aortic balloon pump (IABP) study was conducted to compare older patients (above 65 years of age) with younger patients (below 65 years of age) who had undergone coronary artery bypass surgery and had had an IABP inserted, with regard to hospital stay, clinical features, intensive care unit stay, postoperative complications, and mortality and morbidity rates.MethodsOne hundred and ninety patients who had undergone coronary artery bypass surgery and had required IABP support were enrolled in this study. Patients younger than 65 years of age were considered younger, and the others were considered older. Ninety-two patients were in younger group and 98 patients were older group. The mortality rates, pre-operative clinical characteristics, postoperative complications, and duration of intensive care unit and hospital stay of the groups were compared. The risk factors for mortality and complications were analysed.ResultsOne hundred and thirty-eight of the patients were male, and the mean age was 62.7 ± 9.9 years. The mortality rate was higher in the older patient group than the younger group [34 (37.7%) and 23 (23.4 %), respectively (p = 0.043)]. The crossclamp time, mean ejection fraction, cardiopulmonary bypass time, and length of stay in the intensive care unit were similar between the two groups (p > 0.05). Cardiopulmonary bypass time was the unique independent risk factor for mortality in both groups.ConclusionIn this study, high mortality rates in the postoperative period were similar to those in prior studies regarding IABP support. The complication rates were higher in the older patient group. Prolonged cardiopulmonary bypass time and advanced age were determined to be significant risk factors for mortality.

Beating-Heart Versus Conventional On-Pump Coronary Artery Bypass Grafting: A Meta-Analysis of Clinical Outcomes

Beating-heart on-pump coronary artery bypass grafting (BH-ONCAB) offers a hybrid coronary revascularization technique that may confer the benefits of an "off-pump" operation while maintaining the hemodynamic stability and mechanical support of conventional on-pump CABG (C-ONCAB). This study aimed to identify whether BH-ONCAB confers a morbidity or mortality benefit over C-ONCAB in the immediate and midterm postoperative period. A systematic literature review identified 13 studies incorporating 3,930 patients (937 BH-ONCAB; 2,993 C-ONCAB) fulfilling our inclusion criteria. Outcomes were meta-analyzed using random-effects modelling. Between-study heterogeneity was investigated through quality assessment, subgroup, and risk of bias analysis. No difference was seen in overall 30-day mortality (13 studies; odds ratio, 0.60; 95% confidence interval, 0.32 to 1.14; p = 0.12), or midterm survival (5 studies; hazard ratio, 0.65; 95% confidence interval, 0.22 to 1.88; p = 0.43) between BH-ONCAB and C-ONCAB. BH-ONCAB was associated with significantly fewer postoperative myocardial infarction events (odds ratio, 0.32; 95% confidence interval, 0.11 to 0.92; p = 0.03); however, no significant difference was observed in other postoperative morbidity outcomes. Intraoperatively, BH-ONCAB resulted in significantly less intraaortic balloon pump use, shorter cardiopulmonary bypass time, and less blood loss. The number of anastomoses and vessels grafted were not significantly different between BH-ONCAB and C-ONCAB. BH-ONCAB is a safe and comparable alternative to C-ONCAB in terms of early mortality and late survival. Furthermore, BH-ONCAB may confer a particular advantage in preventing perioperative myocardial infarction and reducing overall blood loss. Future work should focus on larger matched studies and multicenter randomized controlled trials that risk-stratify patients according to preoperative ventricular function and renal insufficiency to allow us to optimize our surgical revascularization strategy in these high-risk patients.

Predictors of acute kidney injury after coronary artery surgery in Jordanians

Acute kidney injury after coronary artery bypass surgery is associated with increased morbidity and mortality. We investigated the predictors of acute kidney injury in a major hospital in Jordan. A retrospective analysis was conducted of clinical, operative, and outcome data of 867 patients (mean age 59 ± 9.8 years) who underwent isolated coronary bypass surgery with cardiopulmonary bypass. Acute kidney injury postoperatively, defined as ≥100% increase in serum creatinine level, was the outcome variable. Retrospective clinical, laboratory, and demographic data, and medication use, were obtained from electronic medical records. Univariate analysis revealed that chronic obstructive pulmonary disease, recent myocardial infarction, emergency surgery, preoperative intraaortic balloon pump use, left atrial size >4 cm, grade 1 mitral regurgitation, pneumonia, intensive care unit stay, prolonged vasopressor support, and stroke or transient ischemic attack were significantly associated with postoperative renal failure. On multivariate logistic regression, emergency surgery (adjusted odds ratio = 2.17, p = 0.017), grade 1 mitral regurgitation (adjusted odds ratio = 2.05, p = 0.020), prolonged support (adjusted odds ratio = 3.16, p = 0.000), and stroke (adjusted odds ratio = 20.1, p = 0.004) were independent predictors of kidney injury following coronary bypass surgery. Emergency coronary surgery, mitral regurgitation, prolonged inotropic support, and stroke or transient ischemic attack are independent predictors of acute kidney injury following coronary bypass surgery. Further studies involving patients with isolated coronary bypass surgery as well as valve and combined surgeries may be necessary to complete our understanding of this subject.

Contrast induced acute kidney injury in acute coronary syndrome patients: A single centre experience

The aim of the study was to investigate predictors of contrast induced acute kidney injury, in-hospital and long-term mortality in patients with acute coronary syndrome treated by percutaneous coronary intervention. We investigated 536 consecutive patients with acute coronary syndrome who underwent percutaneous coronary intervention. Contrast induced acute kidney injury was classified according to risk, injury, failure, loss of kidney function and end-stage kidney disease/acute kidney injury network (RIFLE/AKIN) criteria into those with normal kidney function, risk, RIFLE stage I and those with stage ⩾ II. We investigated in-hospital, all-cause mortality during index hospitalization and long-term all-cause mortality during the follow-up period of 94 months (interquartile 81.6-108.9 months) in adjustment with parameters of the Global Risk of Acute Coronary Events score. Patients with contrast induced acute kidney injury had worse baseline clinical characteristics and displayed more co-morbidities than patients with normal kidney function. In multivariate logistic regression analysis intra-aortic balloon pump use, congestive heart failure, age >75 years and admission serum creatinine >1.5mg/dl were independent predictors of contrast induced acute kidney injury development. contrast induced acute kidney injury RIFLE stage ⩾ II was an independent predictor of in-hospital mortality (odds ratio 33.16, confidence interval 1.426-770.79, p=0.029) and long-term mortality (hazard ratio 4.713, confidence interval 1.53-14.51, p=0.007) even after adjustment for confounders (variables of Global Risk of Acute Coronary Events score). Contrast induced acute kidney injury is a common complication of acute coronary syndrome patients treated by percutaneous coronary intervention. Advanced deterioration in renal function after percutaneous coronary intervention is an independent predictor for in-hospital and long-term mortality.

Cardiopulmonary bypass and intra-aortic balloon pump use is associated with higher short and long term mortality after transcatheter aortic valve replacement: a PARTNER trial substudy.

Transcatheter aortic valve replacement (TAVR) with the balloon-expandable Sapien transcatheter heart valve improves survival compared to standard therapy in patients with severe aortic stenosis (AS) and is noninferior to surgical aortic valve replacement (AVR) in patients at high operative risk. Nonetheless, a significant proportion of patients may require pre-emptive or emergent support with cardiopulmonary bypass (CPB) and/or intra-aortic balloon pump (IABP) during TAVR due to pre-existing comorbid conditions or as a result of procedural complications. We hypothesized that patients who required CPB or IABP would have increased periprocedural complications and reduced long-term survival. In addition, we sought to determine whether preprocedural variables could predict the need for CPB and IABP. The study population included 2,525 patients in the PARTNER Trial (Cohort A and B) and the continuing access registry (CAR). Patients that received CPB or IABP were compared to patients that did not receive either, and then further divided into those that received support pre-TAVR and those that were placed on support emergently. One-hundred sixty-three patients (6.5%) were placed on CPB and/or IABP. The use of CPB or IABP was associated with higher 1 year mortality (49.1% vs. 21.6%, P < 0.001). In multivariable analysis, utilization of CPB or IABP was an independent predictor of 30 day (HR 6.95) and 1-year (HR 2.56) mortality. Although mortality was highest in emergent cases, mortality was also greater in planned CPB and IABP cases compared with non-CPB/IABP cases (53.3% and 40.3% vs. 21.6%, P < 0.001). These findings indicate that CPB and IABP use in TAVR portends a poor prognosis and its utilization, particularly in the setting of pre-emptive use, needs reconsideration.

Predictors of Survival and Favorable Functional Outcomes After an Out-of-Hospital Cardiac Arrest in Patients Systematically Brought to a Dedicated Heart Attack Center (from the Harefield Cardiac Arrest Study)

Despite advances in cardiopulmonary resuscitation (CPR), survival remains low after out-of-hospital cardiac arrest (OOHCA). Acute coronary ischemia is the predominating precipitant, and prompt delivery of patients to dedicated facilities may improve outcomes. Since 2011, all patients experiencing OOHCA in London, where a cardiac etiology is suspected, are systematically brought to heart attack centers (HACs). We determined the predictors for survival and favorable functional outcomes in this setting. We analyzed 174 consecutive patients experiencing OOHCA from 2011 to 2013 brought to Harefield Hospital-a designated HAC in London. We analyzed (1) all-cause mortality and (2) functional status using a modified Rankin scale (mRS 0 to 6, where mRS0-3(+) = favorable functional status). The overall survival rates were 66.7% (30 days) and 62.1% (1 year); and 54.5% had mRS0-3(+) at discharge. Patients with mRS0-3(+) had reduced mortality compared to mRS0-3(-): 30 days (1.2% vs 72.2%, p <0.001) and 1 year (5.3% vs 77.2%, p <0.001). Multivariate analyses identified lower patient comorbidity, absence of cardiogenic shock, bystander CPR, ventricular tachycardia/ventricullar fibrillation as initial rhythm, shorter duration of resuscitation, prehospital advanced airway, absence of adrenaline and inotrope use, and intra-aortic balloon pump use as predictors of mRS0-3(+). Consistent predictors of increased mortality were the presence of cardiogenic shock, advanced airway use, increased duration of resuscitation, and absence of therapeutic hypothermia. A streamlined delivery of patients experiencing OOHCA to dedicated facilities is associated with improved functional status and survival. Our study supports the standardization of care for such patients with the widespread adoption of HACs.

Complications of intra-aortic balloon pump use: does the final position of the IABP tip matter?

We report results of a retrospective review of intra-aortic balloon pump (IABP) use in two Australasian centres and evaluate the effect of final IABP tip position on outcome. Indications for counterpulsation, patient demographics and in-hospital outcomes and complications were retrospectively collected. The chest X-ray reports provided the 'final' position of the IABP tip. The position was defined as acceptable (tip was seen just below the aortic arch, at T2-T5 vertebrae), malpositioned (tip > 5 cm below aortic arch or at T5-T6) or severely malpositioned (tip > 10 cm below aortic arch or at T7 or below).?Major complications were considered a composite of death secondary to IABP, major limb ischaemia, major IABP malfunction, balloon rupture or haemorrhage, severe renal dysfunction (rise in creatinine > 200 µmol/l), stroke and mesenteric ischaemia. Six hundred and forty-five cases were reviewed. The overall major complication rate was 26.2% and 24.3%. Severe renal impairment was the most common complication (16.6%), and second, severe catheter dysfunction (5.4%). ?Final IABP position was acceptable in 39.9%, malpositioned in 11.1%,?severely malpositioned in 6.7% and unavailable for 42.4%. Logistic regression analysis showed IABP tip malposition (compared with satisfactory position odds ratio=3.9 [95% confidence interval=2.0-7.6, P < 0.001] and severely malpositioned odds ratio=13.0 [95% confidence interval 5.3-31.7, P < 0.001]) was associated with major complications more than the presence of shock (odds ratio=3.8, confidence interval=2.1-6.8 P < 0.001). The acceptance of a less-than-ideal final position was highly predictive of morbidity directly related to IABP device therapy.

Intraortic balloon pump use in cardiac surgery: analysis of data from the ARIAM Registry of Cardiac Surgery

The aim of the study is to analyze IABP use in patients undergoing cardiac surgery included in the ARIAM Registry of Cardiac Surgery.