Elective Coronary Surgery Research Articles

INVESTIGATING THE EFFECT OF INSPIRED OXYGEN FRACTION ON RIGHT VENTRICULAR 3D STRAIN DURING GENERAL ANAESTHESIA IN PATIENTS WITH STABLE CORONARY ARTERY DISEASE.

<h3>Introduction</h3> Patients with coronary artery disease (CAD) undergoing general anesthesia are at risk of perioperative complications. Hyperoxia is a known coronary vasoconstrictor. However, it is also a pulmonary vasodilator, reducing right ventricular afterload. Thus, there may be competing effects of hyperoxia on right ventricular function. In this study we investigated the effects of hyperoxia and normoxia on right ventricular (RV) function assessed by 3D transesophageal echocardiography (TEE) during general anesthesia in CAD patients before elective coronary artery bypass graft surgery. <h3>Methods</h3> In this randomized clinical trial study participants (n=106) were prospectively recruited using a crossover design. In anesthetized patients the fraction of inspired oxygen (FiO2) was titrated to a normoxic state (FiO2=0.3) and a hyperoxic state (FiO2=0.8). At both states TEE images were acquired to assess RV ejection fraction (RVEF) and global longitudinal free-wall strain (RVGLS). <h3>Results</h3> There was no difference between normoxia and hyperoxia in RVEF (46±6% vs. 45±8, p=0.504) nor in RVGLS (-22.4±4.8 vs. -21.9±4.3, p=0.352). However, RV function improved and worsened in some patients. ROC analysis (Figure A) shows that RVGLS at normoxia can better predict, which patients will worsen with excess oxygen. With a cut-off of -20% for RVGLS (Sensitivity: 87%, Specificity: 49%), it was demonstrated that hyperoxia was beneficial for patients with a poor strain at normoxia (>-20%) but detrimental for those with normal strain at normoxia (<-20%, Figure B), while RVEF with a cut-off of 40% (Sens: 88%, Spec: 33%) was unable to predict this response (Figure C.). <h3>Conclusion</h3> In CAD patients undergoing general anaesthesia, hyperoxia has heterogenous effects on the RV and the potential detrimental effects of hyperoxia were best predicted by RVGLS. Intraoperative strain analysis might be a tool to target oxygen levels based on individual needs.

Predictive value of age, creatinine, and ejection fraction (ACEF) scoring system for operative mortality in patients with Stanford type A aortic dissection.

Stanford type A aortic dissection (TAAD) is the most common and fatal type of dissection. An easier-to-use risk stratification may help eliminate bias in patients at high risk of dissection. The age, serum creatinine, and ejection fraction (ACEF) score is a simple risk model developed to predict the mortality risk of elective coronary artery bypass graft surgery. This study aimed to evaluate the relationship between preoperative ACEF score and operative mortality in patients with TAAD undergoing emergency surgery. In this retrospective cohort study, 113 patients diagnosed with TAAD between January 2017 and September 2021 were evaluated. The primary endpoint was operative mortality. Receiver operating characteristic analysis was performed for the ACEF score, ACEF II score, and European System for Cardiac Operative Risk Evaluation II. Univariate and multivariate analyses of operative mortality were performed using the logistic regression model. Operative mortality occurred in 23 (20.4%) patients. The cutoff ACEF score was calculated as 1.1 for predicting operative mortality (area under the curve = 0.712, P value = 0.002, sensitivity = 74.0%, specificity = 67.8%, likelihood ratio = 2.3). Based on the cutoff value, 46 (40.7%) patients had a high ACEF score (ACEF ≥ 1.1) and 67 (59.3%) patients had a low ACEF score (ACEF < 1.1). The high ACEF score was associated with an increased incidence of operative mortality compared with the low ACEF score (37.0% vs. 9.0%; P = 0.001). The ACEF score can be used as a useful and relatively simple tool for risk stratification before TAAD surgery. However, the ACEF score is only indicated for risk assessment and should not affect treatment.

Prediction of depression among patients with cardiovascular disease scheduled cardiac surgery using an AI-empowered pipeline

Abstract Introduction Several studies have demonstrated, that one in three patients with cardiovascular disease (CVD) suffers from depression, and depression increases the likelihood for cardiac morbidity and mortality in the CVD population by 2–3-fold, independently of traditional risk factors or gender. Purpose The aim of this work is to predict depression in patients with CVD. Methods The clinical study was conducted in the cardiac surgical intensive care unit of The Central Clinical Hospital, the Medical University of Lodz in Poland, among patients scheduled for elective coronary artery bypass graft surgery (CABG). 224 patients signed an informed consent form, met the inclusion criteria and were enrolled in the study. All the patients had chronic coronary syndromes. The inclusion criteria were: consecutive adult patients scheduled for CABG surgery or CABG surgery with cardiac valve repair or replacement (CVR). The study population was examined by a psychiatrist the day prior to the scheduled operation, a diagnosis of major depressive disorder (MDD) was established on the basis of DSM-5 criteria. A data curation pipeline was applied to automatically remove outliers and duplicated fields in the input dataset. An AI-empowered pipeline was developed to classify patients at higher risk for depression. Random downsampling with replacement was applied to deal with the increased class imbalance by taking into consideration two confound factors, namely the Mini Mental State Examination and Hemoglobin concentration &amp;lt;10mg/dl. The downsampling process was repeated K times. In each iteration, three bagging and boosting ML schemas were utilized for the classification task including the AdaBoost (adaptive boosting), Random Forests and Extreme Gradient boosting trees (XGBoost). To this end, a nested cross-validation process was applied for hyperparameter optimization and model validation, where: (i) a 3-fold cross-validation process was first applied to seek for the optimal set of hyperparameters based on the grid search approach by tuning core parameters, including the learning rate, number of estimators, and max depth, among others, and (ii) a stratified 5-fold cross-validation process was subsequently used to evaluate the performance of the best model from the previous stage by computing the classification accuracy, sensitivity, specificity, and area under the ROC curve (AUC). The performance evaluation results were averaged across the 5 folds and across the downsampling iterations. Shappley additive explanation analysis was finally applied to provide explainable risk factors for depression. Results sRAGE was significantly correlated with depression (r=0.32, p=0.038). The Random forests classifier presented the highest performance to predict depression (Accuracy: 0.71, Sensitivity: 0.71, Specificity: 0.75 and AUC: 0.74). Conclusions Depression can be predicted with 71% accuracy at patients with CVD and elevated sRAGE values. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): HORIZON2020

Elective Coronary Artery Bypass Graft Surgery Using Reduced Homologous Blood Transfusion

Elective Coronary Artery Bypass Graft Surgery Using Reduced Homologous Blood Transfusion

Characteristics and some factors affecting perioperative ventricular arrhythmias in patients undergoing coronary artery bypass graft surgery

&#x0D; Introduction and objectives: Ventricular tachyarrhythmia perioperative coronary artery bypass graft is common and the occurrence has been described, but the incidence and risk factors are not well defined. However, little is known about incidence, risk factors, and treatment of early postoperative arrhythmias. Aim: To evaluate the incidence of arrhythmias and to detect high-risk populations.&#x0D; Methods: Cross sectional description. The study involved 171 consecutive patients scheduled for elective coronary surgery at Hanoi Heart Hospital from 6/2016 – 8/2018.&#x0D; Main results:Mean age 65,05 ± 7,41 years; 78,4% male.The number and percentage of preoperative ventricular extrasystoles in patients with myocardial infarction (n=52) was higher than in patients with stable coronary artery disease (n=119) with p&lt;0.05.Severe ventricular arrhythmias (Lown ≥ 3) were higher in patients with myocardial infarction 7 days before and after surgery than in stable coronary artery disease at the same time (p&lt;0.05).Patients with stable coronary artery disease have characteristics of increased ventricular extrasystoles 7 days after surgery, patients with myocardial infarction have no change in ventricular arrhythmias before and 7 days after surgery.The cut-off point of the proBNP test value ≥1000 pg/ml showed a significantly increased number and incidence of severe ventricular arrhythmias both before and 7 days after surgery in both stable coronary artery disease and myocardial infarction.With the same risk factors, if the patient has proBNP ≥1000 pg/ml, the severity of ventricular extrasystoles (Lown ≥ 3) increases 3.04 times (p = 0.05).At 7 days postoperatively, for the same risk factors, women, EF &lt;50% and proBNP ≥1000 pg/ml were independent factors that increased the occurrence of severe ventricular extrasystoles(Lown ≥ 3) increased from 2.9 to 3.4 times p&lt;0.05.&#x0D; Conclusions: Patients with myocardial infarction had characteristics of ventricular arrhythmias perioperative more than with stable coronary artery disease patients. ProBNP ≥ 1000pg/ml had a risk factor for the development of severe ventricular arrhythmias both before and after coronary artery bypass graft surgery.

Myocardial Protecting Role of Glutamine in Patients with Low Ejection Fraction Undergoing Elective On-Pump Coronary Artery Bypass Graft Surgery.

PurposeMyocardial injury due to on-pump coronary artery bypass grafting (CABG) in patients with low ejection fraction (EF) is associated with poor outcomes. This study determines whether intravenous glutamine could protect the myocardium during on-pump CABG in patients with low EF.Materials and MethodsThis was a double-blind, randomized controlled trial to assess glutamine as a myocardial protector during on-pump CABG in patients with left ventricle EF of 31–50%, conducted from January to October 2021. Patients in the glutamine group (n = 30) received 0.5 g/kg of 20% glutamine solution diluted with 0.9% NaCl up to 500 mL in total volume over a period of 24 hours. Patients in the control group (n = 30) received 0.9% NaCl over the same period. The primary outcomes were plasma troponin I and plasma glutamine levels. Secondary outcomes included α-ketoglutarate (α-KG) levels and histopathology scoring of the right atrial appendage tissue, plasma lactate levels, hemodynamic measurement, and morbidity.ResultsTwenty-nine patients from each group (58 in total) were included in the analysis. Plasma troponin I levels at 6 and 24 hours after cardiopulmonary bypass (CPB) were significantly lower in the glutamine than the control group (mean 3.43 ± 1.51 ng/mL vs mean 4.41 ± 1.89 ng/mL; p = 0.034; median 3.08 ng/mL [min–max: 1.30–6.59] vs median 3.77 ng/mL [min–max: 0.00–36.53]; p = 0.038, respectively). Plasma glutamine levels at 24 hours after CPB were significantly higher in the glutamine than the control group (mean 935.42 ± 319.10 μmol/L vs mean 634.79 ± 243.89 μmol/L, p = 0.001). Plasma lactate levels at 6 and 24 hours after CPB were significantly lower in the glutamine than the control group (median 5.30 mmol/L [min-max: 1.20–9.50] vs median 5.70 mmol/L [min-max: 2.80–11.30], p = 0.042; mean 2.08 ± 0.67 mmol/L vs mean 2.46 ± 0.69 mmol/L, p = 0.044, respectively). Myocardial injury score was significantly lower in the glutamine than the control group (mean 1.30 ± 0.24 vs mean 1.48 ± 0.26, p = 0.011).ConclusionPerioperative administration of 0.5 g/kg intravenous glutamine solution over the period of 24 hours has myocardial protection effect in patients with low EF who undergo elective on-pump CABG.

The Prognostic Potential of Growth Differentiation Factor-15 on Bleeding Events and Patient Outcome after Cardiac Surgery-A Prospective Cohort Study.

GDF-15 (growth/differentiation factor 15) is induced by myocardial stretch, volume overload, inflammation, and oxidative stress. Its expression is tightly linked with cardiovascular events as well as the risk for major bleeding and all-cause mortality. The present study aimed to elucidate the prognostic potential of GDF-15 in patients after cardiac surgery. A total of 504 patients undergoing elective cardiac valve and/or coronary artery bypass graft surgery were prospectively enrolled. GDF-15 levels were measured prior to surgery to evaluate the impact on bleeding events, thromboembolic events, and mortality. Preoperative GDF-15 was associated with the primary endpoint of intra- and postoperative red blood cell transfusion (for bleeding risk factors adjusted [adj] OR [odds ratio] per 1-SD [standard deviation] of 1.62 [95% confidence interval [CI]: 1.31-2.00]; p < 0.001). Higher concentrations of GDF-15 were observed in patients reaching the secondary endpoint of major or clinically relevant minor bleeding (for bleeding risk factors adj. OR per 1-SD of 1.70 [95% CI: 1.05-2.75]; p = 0.030) during the first postoperative year, but not for thromboembolic events. GDF-15 was a predictor for cardiovascular mortality (for comorbidities adj. HR [hazard ratio] per 1-SD of 1.67 [95% CI: 1.23-2.27]; p = 0.001) and all-cause mortality (for comorbidities adj. HR per 1-SD of 1.55 [95% CI: 1.19-2.01]; p = 0.001). A combined risk model of GDF-15 and EuroSCORE II outperformed the EuroSCORE II alone for long-term survival (C-index: 0.75 [95% CI: 0.70-0.80], p = 0.046; net reclassification improvement: 33.6%, p < 0.001). Preoperative GDF-15 concentration is an independent predictor for intra- and postoperative major bleeding, major bleeding during the first year, and for long-term cardiovascular or all-cause mortality after cardiac surgery.

Структура осложнений у пациентов с различными вариантами нарушения костно-мышечного статуса, подвергшихся коронарному шунтированию

Th e aim of the research. To analyse the structure of complications in patients with coronary artery disease and different musculoskeletal disorders (MSD) undergoing elective coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass. Material and methods. From 2019 to 2020, a single-centre cohort study was conducted on 387 stable coronary artery disease patients aged over 50 before elective CABG. The following MSD were assessed: sarcopenia, osteopenia, and osteosarcopenia. Patients were divided into four groups according to the MSD type: group I included 52 (13.4 %) patients with sarcopenia, group II included 28 (7.2 %) patients with osteopenia, group III was composed of 25 (6.5 %) patients with osteosarcopenia, and group IV included 282 (72.9 %) patients without MSD. Patients underwent CABG using cardiopulmonary bypass. Cardiovascular, infectious and non-infectious complications, death, a composite endpoint including cardiovascular complications and death, as well as the total number of complications were analysed. Results. Infectious complications were revealed in 23 (5.9 %) patients. Th e highest frequency of infectious complications was noted in patients with osteosarcopenia while the lowest frequency was found in patients without MSD (24 % vs 5.8 % in group I, 7.1 % in group II, 4.3 % in group IV). The highest number of surgical complications was noted in patients with sarcopenia and osteosarcopenia (17.3 % in group I, 7.1 % in group II, 12 % in group III, 5.3 % in group IV; p = 0.002). The composite endpoint was significantly more prevalent in patients with osteopenia (32.1 vs. 9.6 % in group I, 12 % in group III, and 12.8 % in group IV). Th ere were no statistically signifi cant diff erences in the total number of complications between the groups of patients with MSD. Th e complications were 2-fold more likely to occur in patients with osteopenia and osteosarcopenia compared to patients without MSD. Moreover, MSD increased the risk of the composite endpoint by 1.7 times (odds ratio (OR) 1.73, 95 % confi dence interval (CI) 1.04-2.89; p = 0.035); osteopenia increased the risk of the combined endpoint by 3 times (OR 3.01, 95 % CI 1.02-8.9; p = 0.046). Surgical complications were associated with baseline MSD (OR 1.71, 95 % CI 1.06-2.76; p = 0.026); sarcopenia increased the risk of surgical complications by 2 times (OR 2.02, 95 % CI 1.05-3.88; p = 0.034). Conclusion. The frequency of complications in patients with MSD was 1.79-fold higher compared with patients without MSD. Cardiovascular and infectious complications as well as complications associated with surgical treatment were more common in patients with MSD. MSD can be used as a risk factor for the development of in-hospital complications because the presence of these disorders increases the risk of cardiovascular complications, non-infectious complications and death by 1.7 times. Moreover, osteopenia was associated with a threefold increase in the composite endpoint risk, while sarcopenia doubled the risk of non-infectious complications.

Risk Factors for Mortality of Patients Waiting for Elective Coronary Artery Bypass Graft Surgery

Risk Factors for Mortality of Patients Waiting for Elective Coronary Artery Bypass Graft Surgery

Effect of Cyclosporine on Cytokine Production in Elective Coronary Artery Bypass Grafting: A Sub-Analysis of the CiPRICS (Cyclosporine to Protect Renal Function in Cardiac Surgery) Study

The augmented inflammatory response to cardiac surgery is a recognized cause of postoperative acute kidney injury. The present study aimed to investigate the effects of preoperative cyclosporine treatment on cytokine production and delineate factors associated with postoperative kidney impairment. A randomized, double-blind, placebo-controlled, single-center study. At a tertiary care, university hospital. Patients eligible for elective coronary artery bypass grafting surgery; 67 patients were enrolled. Patients were randomized to receive 2.5 mg/kg cyclosporine or placebo before surgery. Cytokine levels were measured after the induction of anesthesia and 4 hours after the end of cardiopulmonary bypass. Tissue-aggressive (interleukin [IL]-1β, macrophage inflammatory protein [MIP]-1β, granulocyte colony-stimulating factor [G-CSF], IL-6, IL-8, IL-17, MCP-1), as well tissue-lenient (IL-4) cytokines, were significantly elevated in response to surgery. Changes in cytokine levels were not affected by cyclosporine pretreatment. Elective coronary artery bypass grafting surgery with cardiopulmonary bypass triggers cytokine activation. This activation was not impacted by preoperative cyclosporine treatment.

OR55. Risk Factor For Mortality Of Patients Waiting For Elective Coronary Artery Bypass Graft Surgery

Abstract Background and Aims Insufficient capacity for cardiac surgery results in extensive waiting time of patients requiring coronary artery bypass grafting (CABG). Previous studies have reported a consequence of an increased risk of mortality while waiting for CABG. Identification of mortality rates and risk factors for mortality is important in patients waiting for CABG. Methods and results This retrospective cohort study was done on patients awaiting for elective CABG in dr. Kariadi General Hospital from January 2018 to December 2020. Identification of risk factors that associated with mortality was done on patients who were waiting CABG using logistic regression methods. There were 162 patients fulfilling the criteria, with a mean waiting time for an operation of 9.8 months. While waiting for CABG surgery, 32 (19.7%) patients died of any cause. Independent risk factors for death while waiting for CABG included : left ventricular ejection fraction &amp;lt; 45% (OR 4.75; 95% CI 1.76-12.78; p = 0.002), left main disease (OR 4.12; 95% CI 1.50-11.27; p = 0.006), serum creatinin &amp;gt; 1.5 mg/dl (OR 3.71; 95% CI 1.41-9.74; p = 0.008), and number of coronary artery disease risk factor &amp;gt; 3 (OR 3.34; 95% CI 1.24-8.99; p = 0.017). Conclusions Long waiting lists for CABG is associated with high mortality rate which is influenced by left ventricular ejection fraction &amp;lt; 45%, left main disease, serum creatinin &amp;gt; 1.5 mg/dl, and number of coronary artery disease risk factor &amp;gt; 3.

Abstract 11027: Short-and Long-Term Prognostic Value of Multiple Cardiac Biomarker Measurement in Patients Undergoing Elective Coronary Artery Bypass Graft Surgery

Introduction: Coronary artery bypass grafting (CABG) is associated with defined degree of myocardial injury reflected by perioperative rise of cardiac biomarkers. The present study aimed to evaluate multiple cardiac biomarkers and their association with short- and long-term outcome following CABG. Methods: In this prospective study, a total of 1030 patients with coronary artery disease (CAD) were enrolled between 07/2008 and 11/2018, undergoing elective, isolated, on-pump CABG. Perioperative cardiac troponin I and T (cTnI, cTnT) or ultra-sensitive (us-) cTnI were measured over 72hrs after surgery. Mean Follow-up was 5.5±2.7years with 100% completeness. Primary study endpoint was in-hospital mortality (IHM) and major adverese cardiac and cerebrovascular event (MACCE) rate at 30 days, as well as mortality in the long-term, defined as death from any cause. Results: Patients were 67.6±9.4years of age, 81.8% male, presenting 3-vessel CAD in 82% and/or left-main disease in 38%. Log EuroSCORE-I was 4.3±3.7%. Perioperative serum concentrations of cTnI ( P =0.05), us-cTnI ( P =0.02), but not cTnT ( P =0.79) differed significantly between survivors and non-survivors and cTnI ( P &lt;0.001) and us-cTnI ( P &lt;0.001) between patients with and without MACCE within the first 30 days after surgery (2-way ANOVA). Kaplan-Meier analysis for time to event variables, clearly showed poor long-term prognosis in patients with high perioperative cTnI, having a 1-, 5- and 10-years survival of 93.5%, 81.3% and 54.5%, as compared to patients with medium or low cTnI ( P =0.03). Multivariable logistic regression analyses revealed cTnI, but not cTnT and us-cTnI, as a strong and independent predictor for IHM ( P &lt;0.001) and MACCE ( P =0.02). In a receiver operating curve (ROC) analysis, cTnI of 9.2ng/mL with an area under curve (AUC) of 0.72 ( P =0.02) was identified as an optimal cut-off value for predicting IHM and a cut-off value of 6.38ng/mL with an AUC of 0.85 ( P &lt;0.001) for the prediction of MACCE. Conclusion: Serial perioperative cTnI measurment and/or its ultra-sensitive isoform allows for identifying patients with worse clinical short- and long-term outcomes following CABG. CTnT however, failed to identify patients at risk and was inferior in predicting short- and long-term outcomes.

Preoperative cardiopulmonary exercise testing for risk assessment before elective coronary artery bypass grafting surgery

Objective: To evaluate the feasibility and results of performing cardiopulmonary exercise test (CPET) in coronary artery disease (CAD) patients before elective coronary artery bypass grafting surgery (CABG). CPET has been increasingly employed in the evaluation of preoperative risk before noncardiac surgeries, but is still underutilized before cardiac surgery and may be useful, as clinical risk scores for preoperative assessment before cardiac surgeries have several limitations. Methods: Patients with CAD underwent CPET within 1 week before CABG. Oxygen consumption, oxygen pulse, oxygen consumption at the anaerobic threshold, minute ventilation/carbon dioxide relationship slope (VE/VCO2 slope), oxygen uptake efficiency slope (OUES) and heart rate recovery (HRR) were analyzed. The occurrence of complications during the test was recorded. Results: Twenty-eight patients (75% men), aged 61 (8) years, underwent preoperative CPET. There were no complications during CPET, even though 71.4% were interrupted by signs or symptoms of ischemia, and only 57% of the patients reached the anaerobic threshold. Conclusions: Preoperative CPET before elective CABG was feasible and safe. However, a large proportion of patients did not achieve the anaerobic threshold. Therefore, VE/VCO2 slope, OUES and HRR may be the most useful CPET variables in the preoperative period. Key words: coronary artery disease, coronary artery bypass grafting, cardiopulmonary exercise test, preoperative assessment

Dexmedetomidine as an Anaesthetic Adjunct in Patients Undergoing Elective Off-Pump Coronary Artery Bypass Graft Surgery

Background: The aim of the present study was to study the hemodynamic profile of dexmedetomidine during induction and distal anastomosis of coronary arteries in patients undergoing OPCAB in comparison to the institutional practice of using midazolam. Methods: In Group I, (n=25) patients were anaesthetised using fentanyl, pancuronium bromide, Isoflurane and midazolam. Group II (n=25) patients received a loading dose of dexmedetomidine infusion (1µg/Kg) over 10 minutes followed by an infusion of dexmedetomidine at the rate of 0.6 µg/Kg/hour, along with fentanyl, Pancuronium bromide and isoflurane. Heart rate (HR) mean arterial pressure (MAP), pulmonary artery (PA) catheter derived data and BIS were recorded at baseline, at 1 and 3 minutes after induction, at 1, 3 and 5 minutes after intubation, and at 5 and 30 minutes after protamine administration. MAP and HR were recorded every 10 min during the operation, except during distal anastomosis of the coronary arteries when it was recorded every 5 minutes after application of the Octopus tissue stabilising system. Results: The intubation response by way of increase in HR was much less in group II and stabilized by 5 min after intubation. The accompanying hypotension at 1 minute after induction was more in group II, but it was clinically acceptable (81.68±21.74 mm Hg). During distal graft anastomoses HR was in the range of 68 beats/min to 85 beats/min in group II vs. 85 beats/min to 100 beats/min in Group I. The MAP was lower in this group during the distal anastomosis, but it was within clinically acceptable range (&gt; 65 mm Hg). Conclusion: Dexmedetomidine is a viable option as an anaesthetic adjunct in a loading dose of 1µg/Kg followed by an infusion of 0.6 µg/Kg. Future studies will be necessary to show if this provides any outcome benefits.

The prognostic potential of growth differentiation factor-15 on bleeding events and patient outcome after cardiac surgery

Abstract Background GDF-15 (growth/differentiation factor 15) is induced by myocardial stretch, volume overload, inflammation and oxidative stress. Its expression is tightly linked with cardiovascular events as well as the risk for major bleeding and all-cause mortality. Objective The objective of the present study was to elucidate the prognostic potential of GDF-15 in patients after cardiac surgery. Methods 504 patients undergoing elective cardiac valve and/or coronary artery bypass graft surgery were prospectively enrolled. GDF-15 levels were measured prior surgery to evaluate the impact on bleeding events, thromboembolic events and mortality. Results Preoperative GDF-15 was associated with the primary endpoint of intra- and postoperative red blood cell transfusion (for bleeding risk factors adjusted [adj] OR [odds ratio] per 1-SD [standard deviation] of 1.62 [95% CI: 1.31–2.00]; p&amp;lt;0.001) and postoperative atrial fibrillation (for atrial fibrillation risk factors adj. OR per 1-SD of 1.49 [95% CI: 1.22–1.81]; p&amp;lt;0.001). Higher concentrations of GDF-15 were observed in patients reaching the secondary endpoint of major or clinically relevant minor bleeding (for bleeding risk factors adj. OR per 1-SD of 1.70 [95% CI: 1.05–2.75]; p=0.030) during the 1stpostoperative year, but not for thromboembolic events. GDF-15 was a predictor for cardiovascular mortality (for comorbidities adj. HR [hazard ratio] per 1-SD of 1.67 [95% CI: 1.23–2.27]; p=0.001) and all-cause mortality (for comorbidities adj. HR per 1-SD of 1.55 [95% CI: 1.19–2.01]; p=0.001). A combined risk model of GDF-15 and EuroSCORE II outperformed the EuroSCORE II alone for long-term survival (c-index: 0.75 [95% CI: 0.70–0.80], p=0.046; net reclassification improvement: 33.6%, p&amp;lt;0.001). Conclusion Preoperative GDF-15 concentration is an independent predictor for intra- and postoperative major bleeding, major bleeding during the first year and for long-term cardiovascular or all-cause mortality after cardiac surgery. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Medical University of Vienna Central illustration

Study design for a randomized crossover study investigating myocardial strain analysis in patients with coronary artery disease at hyperoxia and normoxemia prior to coronary artery bypass graft surgery (StrECHO-O2)

BackgroundSupplemental oxygen (O2) is used routinely during anesthesia. In the treatment of acute myocardial infarction, it has been established that hyperoxia is to be avoided, whereas information on benefit and risk of hyperoxia in patients with stable coronary artery disease (CAD) remain scarce, especially in the setting of general anesthesia. This study will compare the immediate effects of normoxemia and hyperoxia on cardiac function, with a primary focus on changes in peak longitudinal left-ventricular strain, in anesthetized stable chronic CAD patients using peri-operative transesophageal echocardiography (TEE). MethodsA single-center randomized cross-over clinical trial will be conducted, enrolling 106 patients undergoing elective coronary artery bypass graft surgery. After the induction of anesthesia and prior to the start of surgery, cardiac function will be assessed by 2D and 3D TEE. Images will be acquired at two different oxygen states for each patient in randomized order. The fraction of inspired oxygen (FIO2) will be titrated to a normoxemic state (oxygen saturation of 95–98%) and adjusted to a hyperoxic state (FIO2 = 0.8). TEE images will be analyzed in a blinded manner for standard cardiac function and strain parameters. ConclusionBy using myocardial strain assessed by TEE, early and subtle signs of biventricular systolic and diastolic dysfunction can be promptly measured intraoperatively prior to the onset of severe signs of ischemia. The results may help anesthesiologists to better understand the effects of FIO2 on cardiac function and potentially tailor oxygen therapy to patients with CAD undergoing general anesthesia.

Comparison of hemodynamic effects of etomidate and propofol as an induction agent in patients with LVEF 40% undergoing elective coronary artery bypass grafting surgery – A prospective and randomized study

This study aims to compare the hemodynamic response of two commonly used induction agents Propofol and Etomidate in patients with left ventricular ejection fraction ≤40% undergoing Coronary Artery Bypass Grafting surgery. To compare the effects of Propofol and Etomidate on hemodynamics in terms of heart rate, rhythm, blood pressure, and central venous pressure. Narayana Multispeciality Hospital, Jaipur. Prospective, double-blinded, randomized, hospital based study.100 patients with LVEF≤40% scheduled for elective CABG, were randomly assigned to one of the two groups receiving either of the inducing agents, group A (PROPOFOL 2mg/kg) and group B (ETOMIDATE 0.2mg/kg). Unpaired t-test and Chi square test/Fisher exact test, p&amp;#60;0.05 was taken as significant. HR, SBP, DBP and MAP decreased from post induction 1 min. to post induction 3 min. (fall greater in propofol, p&amp;#62;0.005) then increased from post intubation 1 min. to post intubation 5 min. in both the groups (rise greater in etomidate group, p&amp;#60;0.005). Need of drugs to control hypotension (62% and 26%, p=0.001) and to control pressor response (10% and 38%, p=0.002) was observed in both the groups. Etomidate is superior to propofol in providing hemodynamic stability before and after laryngoscopy and intubation, but less effective in controlling the pressor response to intubation. Therefore, Etomidate can be used as an induction agent with suitable adjuvants to control pressor response to tracheal intubation in patients undergoing CABG with low LVEF.

Novel autologous, high concentrated fibrin as advanced hemostatic agent for coronary surgery

BackgroundVariability in transfusion outcomes and excessive postoperative bleeding represents a significant problem in cardiac surgery. The effort to reduce bleeding complications and transfusion outcomes is desirable. Our study investigated the feasibility of reducing bleeding complications and transfusion requirements by applying perioperatively prepared autologous bio-regenerative fibrin sealant. MethodsA prospective, case-control study enrolled 74 patients undergoing coronary artery bypass grafting by a single surgeon. Patients in the control group (N = 43), received traditional methods of hemostasis, while patients in the experimental group (N = 31) were treated additionally with autologous bio-regenerative fibrin. ResultsPatients were well-matched with regard to basic demographic, laboratory and procedural data. Allogeneic blood transfusion requirement in control group was 39.5 % (17 of 43 patients), compared to 6.5 % (2 of 31 patients) in treated group (p < 0,001). The lower infection rate in the experimental group was also noted. No safety issues were identified during the preparation and application process. ConclusionAutologous bio-regenerative fibrin can be safely prepared, with no time consuming, and was demonstrated to be a useful tool to decrease allogeneic blood transfusion requirements following elective coronary artery bypass grafting surgery. A prospective randomized trial is needed to confirm these findings.

Impact of Postoperative Infections on Readmission and Resource Use in Elective Cardiac Surgery

BackgroundEfforts to reduce postoperative infections have garnered national attention, leading to practice guidelines for cardiac surgical perioperative care. The present study characterized the impact of health care–acquired infection (HAI) on index hospitalization costs and postdischarge health care utilization. MethodsAdults undergoing elective coronary artery bypass graft surgery (CABG) or valve operations were identified in the 2016 to 2018 Nationwide Readmissions Database. Infections were categorized into bloodstream, gastrointestinal, pulmonary, surgical site, or urinary tract infections. Generalized linear or flexible hazard models were used to assess associations between infections and outcomes. Observed-to-expected ratios were generated to examine interhospital variation in HAI. ResultsOf an estimated 444,165 patients, 8% had HAI. Patients with HAI were older, had a greater burden of chronic diseases, and more commonly underwent CABG/valve or multivalve operations (all P < .001). HAI was independently associated with mortality (odds ratio 4.02; 95% confidence interval [CI], 3.67 to 4.40), non-home discharge (odds ratio 3.48; 95% CI, 3.21 to 3.78), and a cost increase of $23,000 (95% CI, $20,900 to $25,200). At 90 days, HAI was associated with greater hazard of readmission (1.29; 95% CI, 1.24 to 1.35). Pulmonary infections had the greatest incremental impact on patient-level costs ($24,500; 95% CI, $23,100 to $26,000) and annual cohort costs ($121.8 million; 95% CI, $102.2 to $142.9 million). Significant hospital level variation in HAI was evident, with observed-to-expected ratios ranging from 0.17 to 4.30 for cases performed in 2018. ConclusionsInfections after cardiac surgery remain common and are associated with inferior outcomes and increased resource use. Interhospital variation in this contemporary cohort emphasizes the ongoing need for systematic approaches in their prevention and management.

Effect of Melatonin on Delirium After on-Pump Coronary Artery Bypass Graft Surgery: A Randomized Clinical Trial.

Background: Patients undergoing cardiac surgery are particularly prone to delirium. This study aimed to evaluate the effect of melatonin administration on the inhibition of postoperative delirium in patients undergoing open-heart surgery. Methods: This study was conducted as a double-blind randomized clinical trial in Golestan Hospital. Ahvaz, Iran, (September 2018 to March 2019). Sixty patients undergoing elective on-pump coronary artery bypass graft surgery were enrolled in the study, and they were randomly divided into a group receiving 3 mg of melatonin and a group receiving a placebo. The main outcomes were delirium occurrence and delirium intensity up to 48 hours after extubation. The data were analyzed using SPSS, version 22, (SPSS, Chicago, IL). Group comparisons were performed using the t test and the Chi-square test. Statistical significance was defined as a P value of less than 0.05. Results: On the first postoperative day, delirium developed in four (13.3%) patients in the melatonin group and 11 (36.6%) patients in the control group; the difference between the groups was statistically significant (P=0.037). On the second postoperative day, delirium developed in three (10%) patients in the melatonin group and 14 (46.6%) patients in the control group, with the difference in the incidence of delirium between the groups constituting statistical significance (P=0.029). The severity of delirium between group was significant on the first and second postoperative days (P=0.003).Conclusion: Melatonin may be effective in reducing the severity of delirium after cardiac surgery. The effect of melatonin as a delirium prevention agent should be considered in patients admitted in the cardiovascular intensive care. Trial Registration Number IRCT20180909040979N3.