Elective Myocardial Revascularization Research Articles

Factors determining the prognosis after elective myocardial revascularization in patients with coronary artery disease with multifocal atherosclerosis

Aim. To identify factors determining the prognosis after elective myocardial revascularization in patients with coronary artery disease (CAD) with multifocal atherosclerosis (MFA).Material and methods. The study is based on the prospective registry REGATA-1, ClinicalTrials NCT04347200 (1500 patients with stable coronary artery disease; men, 78,6%, age, 65±8,7 years). We selected 238 patients with MFA, the criteria of which were multivessel CAD (at least 2 arteries) in combination with stenosis ≥50% of at least one of the peripheral vascular system. The selection criteria was elective myocardial revascularization followed by dual antiplatelet therapy for at least 6-12 months. Unfavorable outcomes were analyzed, namely thrombotic events (TEs) in any vascular system and bleeding (BARC type 2-5).Results. The median follow-up was 859 days (interquartile range [523;1665]). Thrombosis dominated in the structure of events: the total incidence of TEs was 18,5% (including fatal — 4,2%), and the total incidence of bleeding was 7,5% (including BARC type 3 — 1,7%). Predictors of TE were smoking (hazard ratio (HR)=2,18), myocardial infarction (HR=2,6) and ischemic stroke/transient ischemic attack (HR=2,81) more than a year ago, as well as revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting. For PCI, the prognosis was worse in case of incomplete revascularization, as well as when the intervention was limited to ≤2 arterial segments and the total length of stents <26 mm. Among all predictors of poor prognosis, the most significant was high-risk PCI in combination with dual antiplatelet therapy for <12 months (HR=6,7).Conclusion. For the first time, TE predictors in patients with CAD and MFA have been identified, which will improve secondary prevention in a category of patients with an extremely high risk of TEs.

Impact of prophylactic intra-aortic balloon pump on early outcomes in patients with severe left ventricular dysfunction undergoing elective coronary artery bypass grafting with cardiopulmonary bypass

ObjectiveOur aim was to analyse whether prophylactic preoperative intraaortic balloon pump (IABP) improves outcomes in hemodynamically stable patients with low left ventricular ejection fraction (LVEF ≤30%) undergoing elective myocardial revascularization (CABG) using cardiopulmonary bypass (CPB). Secondary aim was to identify the predictors for low cardiac output syndrome (LCOS). MethodsProspectively collected data of 207 consecutive patients with LVEF ≤30% undergoing elective isolated CABG with CPB from 01/2009 to 12/2019, 136 with and 71 patients without IABP, were retrieved retrospectively. Patients with prophylactic IABP were matched 1:1 with patients without IABP by a propensity score matching. Stepwise logistic regression was conducted to identify predictors of postoperative LCOS in the propensity-matched cohort. P value ≤0.05 was considered significant. ResultsReduced postoperative LCOS (9.9% vs. 26.8%, P = 0.017) was observed in patients receiving prophylactic IABP. Stepwise logistic regression identified preoperative IABP as preventive factor for postoperative LCOS [Odds Ratio (OR) 0.19,95% Confidence Interval (CI), 0.06–0.55, P = 0.004]. The need of vasoactive and inotropic support was lower in patients with prophylactic IABP at 24, 48 and 72 h after surgery (12.3 [8.2–18.6] vs. 22.2 [14.4–28.8], P < 0.001, 7.7 [3.3–12.3] vs.16.3 [8.9–27.8], P < 0.001 and 2.4 [0–7] vs. 11.5 [3.1–26], P < 0.001, respectively). The patients in both groups did not differ in terms of in-hospital mortality (7.0% vs. 9.9%, P = 0.763). There were no major IABP-related complications. ConclusionsElective patients with left ventricular ejection fraction ≤30% undergoing CABG with CPB and prophylactic IABP insertion had less low cardiac output syndrome and similar in-hospital mortality.

Surgical site infection in adult patients after heart procedures: an integrative review

Objective: to identify the risk factors for surgical site infection in patients after heart procedure. Methods: integrative literature review by searching the Medical Literature Analyses and Retrieval System online, Latin American and Caribbean Literature on Health Sciences, Scientific Electronic Library Online, Nursing Database. The search for the articles occurred during the month of February 2022. Results: 24 articles were eligible for the review. In all studies, the population was mostly male, aged between 51 and 70 years, who underwent elective myocardial revascularization surgery. The main comorbidities presented were diabetes mellitus, hypertension, and obesity. The infection rates ranged from 2.4% to 38.9%, and the main pathogen identified was Staphylococcus aureus. Conclusion: the main comorbidities present in patients who manifested surgical site infection were diabetes, hypertension, obesity, and smoking. The risk factors were gender, age, and prolonged preoperative hospitalization. Antibiotic prophylaxis, trichotomy, nasal decolonization, and adequate skin antisepsis were the most adopted prophylactic measures. Contributions to practice: knowing the profile of patients who developed infection may favor planning risk control actions.

Recollection of Physician Information about Risk Factor and Lifestyle Changes in Chronic Coronary Syndrome Patients.

A patient’s compliance to a physician’s lifestyle information is essential in chronic coronary syndrome (CCS) patients. We assessed potential characteristics associated with a patient’s recollection of physician information and lifestyle changes. This study recruited and interviewed patients (aged ≤ 80 years) 6–18 months after hospitalization due to acute coronary syndrome or elective myocardial revascularization. A physician’s information on risk factors was recognized if patients recollected the assessment of their diet, weight management, blood pressure control, cholesterol level, diabetes, and other lifestyle factors by the doctor. Of a total of 946 chronic coronary syndrome patients, 52.9% (501) of them declared the recollection of providing information on more than 80% of the risk factors. A good recollection of risk factor information was associated with the following: a patient’s age (OR per year: 0.97; 95% CI: 0.95 to 0.99), obesity (OR: 4.41; 95% CI: 3.09–6.30), diabetes (OR: 4.16; 95% CI: 2.96–5.84), diuretic therapy (OR: 1.41; 95% CI: 1.03–1.91), calcium channel blockers (OR: 1.47; 95% CI: 1.04–2.09), and ACEI/sartan (OR: 0.65; 95% CI: 0.45–0.94) at hospitalization discharge. In terms of goal attainment, better adherence to antihypertensive drugs (OR: 1.80; 95% CI: 1.07–3.03) was observed in the patients with a good compared to a poor recollection of risk factor information. The recollection of physician risk factor information was significantly associated with more comorbidities. Strategies to tailor the conveying of information to a patient’s perception are needed for optimal patient–doctor communication.

Associação de exames hematológicos e bioquímicos e complicações pós-cirurgia cardiovascular

Cardiac surgery has postoperative complications of varying severities. Knowing the predictors of such complications can minimize risks and increase patient survival. However, studies address postoperative complications without any standardization of predictors of such complications. The objective of this study was to evaluate the association of hematological and biochemical parameters in the pre- and postoperative period with general clinical complications and those according to organ affected in the postoperative period of cardiac surgery. This is a cross-sectional, retrospective, analytical and documentary study. Inclusion criteria: Elective myocardial revascularization surgeries and/or valve replacements with a cardiopulmonary bypass from January to December 2017, in patients older than 18 years old, survivors until hospital discharge. Incomplete medical records were excluded. Ethical research precepts were followed. 194 patients were included. Preoperative leukocyte alterations increased the chance of postoperative complications by 8.24 times (p=0.039); high mean INR values in the first postoperative period were associated with complications (p=0.036); changes in creatinine (p=0.020) and INR (p=0.002) in the first and second postoperative period were associated with complications, in addition to changes in hemoglobin associated with cardiac complications on the third postoperative day (p≤0.001). There was an association between: leukocyte alteration prior to surgery and total postoperative complications; postoperative hematological and biochemical changes and complications in general and by affected organ. These results can support the development of risk indicators. This also indicates the need to improve monitoring of leukocyte levels, INR, hemoglobin, and creatinine, perceived as predictors of surgical complications.

Prognostic benefit of nonemergent revascularization on ischaemic dilated cardiomyopathy depending on patient symptoms

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION Both angina and dyspnea symptoms are the most common clinical manifestations of cardiac ischaemia. Nevertheless, cardiac ischaemia may be detected on control functional tests of patients with ischaemic dilated cardiomyopathy despite being asymptomatic. The aim of this study was to assess the effect of elective myocardial revascularization on patient’s prognosis depending on baseline clinical symptoms. METHODS All consecutive patients with ischaemic left ventricular dysfunction (LVEF &amp;lt;40% determined by gated-SPECT) who underwent stress-rest SPECT in our hospital between January 2010 and February 2018 were included. Baseline patients’ clinical presentation (angor pectoris, dyspnea or asymptomatic) and major adverse events (myocardial infarction, heart failure hospitalization and cardiovascular death) were retrospective recorded. RESULTS A total of 748 patients with multiple comorbid conditions (smoking habit 69%, hypertension 78,7%, diabetes mellitus 49,5%, atrial fibrillation 22,1%, previous myocardial infarction 69% and previous heart failure hospitalization 24,9%) were included. Nonemergent coronary intervention during the first year (17,9% of patients) was associated with a reduction in the composite event (HR 0.69 [0.5-0.95]) but the multivariate analysis showed a prognostic benefit of revascularization in symptomatic patients (HR = 0.59 [0.37 - 0.94]) that was not observed among asymptomatic patients. The relative risk of the composite endpoint was RR = 0.63 (p &amp;lt;0.001) for asymptomatic vs. symptomatic non-revascularized patients and RR = 1.09 (p = 0.60) for asymptomatic vs. symptomatic revascularized patients. Finally, asymptomatic patients presented more necrosis (17.3 vs. 20.2%, p &amp;lt;0.01) and less ischemia (9.7 vs. 5.7%, p &amp;lt;0.001) than symptomatic patients. CONCLUSION Patients with ischaemic dilated cardiomyopathy without symptoms of dyspnea or angina present less ischaemia and more necrosis in stress-rest SPECT than symptomatic patients. Moreover, unlike symptomatic patients, asymptomatic patients do not benefit from elective revascularization. Therefore, the clinical presentation should be considered when deciding revascularization of patients with ischaemic dilated cardiomyopathy and a positive SPECT test. Abstract Figure. Kaplan-Meyer curves

Predictiveness of different preoperative risk assessments for postoperative bleeding after coronary artery bypass grafting surgery.

Postoperative bleeding is a significant cause of morbidity and mortality in patients undergoing cardiac surgery. Studies have been conducted, and guidelines have been published regarding patient blood management and aiming to prevent blood loss in the perioperative period. Various bleeding risk assessments were developed for preoperative period. We aimed to examine the correlations of scoring systems in the literature with the amount of postoperative bleeding in patients undergoing first time coronary artery bypass graft surgery, and to show the most suitable preoperative bleeding risk assessment for coronary artery bypass graft patients. The study included 550 consecutive patients who underwent coronary artery bypass graft operation. The inclusion criteria were considered as patients to be older than 18 years old and to undergo elective or emergent myocardial revascularization using cardiopulmonary bypass. All variables required for scoring systems were recorded. The initial results of the study were determined as the amount of chest tube drainage, the use of blood products, the change in hematocrit level, reoperation due to bleeding, duration of ventilation, duration of intensive care unit stay, and hospital stay. Mortality which occurred during first 30 days after operation was considered as operative mortality. Operative mortality was accepted as the primary endpoint. Secondary endpoints were massive bleeding and high amount of transfusion. Data were obtained from a series of 550 consecutive patients treated with isolated coronary artery bypass graft. It was seen that PAPWORTH and WILL-BLEED risk assessments responded better for E-CABG grade 2 and 3 bleeding compared to other risk assessments. TRACK, TRUST, and ACTA-PORT scales were found to have low ability to distinguish patients with E-CABG bleeding grade 2 and 3. Predicting postoperative bleeding and transfusion rates with preoperative risk scores in patients undergoing coronary artery bypass graft surgery will provide valuable information to physicians for establishing a proper patient blood management protocol and this will decrease excessive transfusions, unnecessary reoperations as well as improve postoperative outcomes.

Temporal changes in the secondary prevention of coronary artery disease in patients following myocardial revascularization.

IntroductionWell-organized, effective secondary prevention of coronary artery disease (CAD) has a potential to improve the patients’ prognosis following myocardial revascularization procedures.AimTo evaluate overtime changes in the implementation of the ESC guidelines for secondary prevention by assessing control of the main risk factors and the rate of cardioprotective drug use in patients following myocardial revascularization procedures.Material and methodsPatients aged < 81 years who had been hospitalized for a myocardial revascularization procedure in five hospitals serving Krakow and surrounding districts were recruited and interviewed 6–18 months following discharge. Their personal medical history, medication use and control of the main cardiovascular risk factors were evaluated using a standard questionnaire in 2006–2007, 2011–2013, and 2016–2017. The same five hospitals took part in surveys on each occasion.ResultsWe examined 260 patients in 2006–2007, 200 in 2011–2013 and 190 in 2016–2017. We noted a significant difference in the management of surveys participants: 62% underwent percutaneous coronary intervention (PCI) and 38% coronary artery coronary artery bypass grafting (CABG) in 2006–2007 whereas the corresponding proportions in 2016–2017 were 90% and 10%. The proportion of patients who did not achieve target blood pressure (according to ESC guidelines valid at the time of each survey) in 2006–2007, 2011–2013 and 2016–2017 was 53.5%, 52.3%, and 38.9%, respectively, the proportion of those who did not achieve the LDL cholesterol target (according to ESC guidelines valid at the time of each survey) was 36.3%, 64.0%, and 61.7%, respectively, and the proportion of those with high fasting glucose was 12.6%, 14.6%, and 19.7%, respectively. The proportion of smokers was 16.2%, 19.5%, and 16.8%, whereas 30.5%, 28.6% and 40.5% of patients were obese in 2006–2007, 2011–2013 and 2016–2017, respectively. The proportion of patients taking antiplatelets (91.8% vs. 92.0% vs. 96.3%), β-blockers (90.3% vs. 87.5% vs. 92.6%), and lipid-lowering drugs (88.7% vs. 91.0% vs. 93.7%) did not change significantly.Conclusions: The analysis of three multicenter surveys provides evidence of the considerable potential for a further reduction in cardiovascular risk in patients following elective myocardial revascularization in Poland.

Coronary Artery Calcium and Cardiovascular Events in Patients With Familial Hypercholesterolemia Receiving Standard Lipid-Lowering Therapy

ObjectivesThe aim of this study was to evaluate the role of coronary artery calcium (CAC) as a predictor of atherosclerotic cardiovascular disease (ASCVD) (fatal or not myocardial infarction, stroke, unstable angina requiring revascularization, and elective myocardial revascularization) events in asymptomatic primary prevention molecularly proven heterozygous familial hypercholesterolemia (FH) subjects receiving standard lipid-lowering therapy. BackgroundFH is associated with premature ASCVD. However, the clinical course of ASCVD in subjects with FH is heterogeneous. CAC score, a marker of subclinical atherosclerosis burden, may optimize ASCVD risk stratification in FH. MethodsSubjects with FH underwent CAC measurement and were followed prospectively. The association of CAC with ASCVD was evaluated using multivariate analysis. ResultsA total of 206 subjects (mean age 45 ± 14 years, 36.4% men, baseline and on-treatment low-density lipoprotein cholesterol 269 ± 70 mg/dl and 150 ± 56 mg/dl, respectively) were followed for a median of 3.7 years (interquartile range: 2.7 to 6.8 years). CAC was present in 105 (51%), and 15 ASCVD events (7.2%) were documented. Almost one-half of events were hard outcomes, and the others were elective myocardial revascularizations. The annualized rates of events per 1,000 patients for CAC scores of 0 (n = 101 [49%]), 1 to 100 (n = 62 [30%]) and >100 (n = 43 [21%]) were, respectively, 0, 26.4 (95% confidence interval: 12.9 to 51.8), and 44.1 (95% confidence interval, 26.0 to 104.1). In multivariate Cox regression analysis, log(CAC score + 1) was independently associated with incident ASCVD events (hazard ratio: 3.33; 95% CI: 1.635 to 6.790; p = 0.001). ConclusionsCAC was independently associated with ASCVD events in patients with FH receiving standard lipid-lowering therapy. This may help further stratify near-term risk in patients who might be candidates for further treatment with newer therapies.

Are Patients Undergoing an Elective Myocardial Revascularization Nowadays at Worse Pre-Surgery Quality of Life than Before?

Background: The purpose of this study is to outline whether patients, undergoing elective myocardial revascularization nowadays have a better or worse preoperative Quality of Life (QoL) than years ago. Methods: The EuroQol instrument, EQ-5D and EQ-VAS is used for assessing QoL. Preoperative QoL data of 3175 patients undergoing elective isolated coronary bypass operations, January 2002–December 2013 were analyzed. The total group was divided into three time cohorts. Group A (879 patients) operated between January 2002 and December 2005, group B (944 patients) operated between January 2006 and December 2009, and group C (1352 patients) operated between January 2010 and December 2013 (n=803). Results: There is no statistical significant difference among the three groups for the registered EQ-5D index. The registered EQ-VAS index is significantly lower for group A versus B and C (p=0.001). The domains of the EQ-5D, ‘mobility’, ‘usual activities’ and ‘pain/discomfort’ show a statistically significant difference over time with an increased percentage of patients with no problems in these domains. However, in contrast with these domains, the domain anxiety/depression, shows, a statistical significant increase of the percentage patients with problems. Conclusion: Patients nowadays are not at a worse QoL than years ago. Nevertheless, the percentage of patients with anxiety and problems of depression increased the last years.

Factores asociados a insuficiencia renal postoperatoria en cirugía de revascularización miocárdica

MotivationTo determine which medical history and surgical procedure factors are associated to the onset of postoperative kidney failure in patients undergoing myocardial revascularisation. MethodsCase-control cohort study carried out between January 2005 and December 2013 which included patients who had undergone elective myocardial revascularisation and showed postoperative kidney failure immediately after surgery and until discharge. Controls consisted of patients who had undergone elective myocardial revascularisation and did not develop postoperative kidney failure immediately after surgery. A logistic regression model was used to determine the factors associated to postoperative kidney failure. Associations were expressed as grounds of disparity with their corresponding confidence intervals. Resultsold age [OR 1.03 CI 95% (1.01-1.04)], preoperative presence of diabetes mellitus [OR 1.8 CI 95% (1.9-3.4)], cardiac insufficiency [OR 2.7 CI 95% (1.1-6.7)] and a longer perfusion time [OR 1.02 CI 95% (1.01-1.03)] were associated to a higher risk of postoperative kidney failure, while higher hematocrit [OR 0.86 CI 95% (0.82-0.91)] and higher ejection fraction [OR 0.94 CI 95% (0.92-0.96)] were associated with a decrease of the risk of postoperative kidney failure. ConclusionsIn patients who had undergone myocardial revascularisation, risk factors associated to postoperative kidney failure where comorbidities related to internal and external gradual kidney damage outside the context of the surgery. This implies that strategies to minimise this event should be focused on identifying these patients in a timely manner and offering appropriate nephroprotection.

Assessing Endothelial Responsiveness After Cardiopulmonary Bypass: Insights on Different Perfusion Modalities

Cardiopulmonary bypass (CPB) exerts several deleterious effects on inflammatory pathways. Most of these can be related to an endothelial insult leading to endothelial dysfunction. To date, the degree of endothelial damage only has been evaluated on a cellular and molecular level, but no studies exist looking at the functional effects of CPB on the endothelium. Previous studies hypothesized a negative effect of continuous flow as opposed to the physiologic pulsatile flow. The aim of the present retrospective study was to investigate how different perfusion modalities during CPB (ie, continuous v pulsatile flow) or its avoidance differently impact endothelial function. Cardiovascular operating room and intensive care unit of a large tertiary University Hospital in Monza, Italy. Flow-mediated dilatation (FMD) of the brachial artery was assessed in 29 patients undergoing elective myocardial revascularization. Ten patients receiving continuous-flow CPB, 10 receiving pulsatile-flow CPB, and 9 scheduled for beating-heart revascularization were studied. Patients were studied at baseline (after induction of general anesthesia), after CPB upon intensive care unit (ICU) admission after surgery, and on the first postoperative day before discharge from the ICU (on average, 24 hours after CPB discontinuation). The continuous-flow CPB group demonstrated a significant reduction in FMD after CPB, (12.8% ± 9.7% v 1.6% ± 1.5%, p<0.01), which lasted up to the first postoperative day (5.9% ± 4.1%). On the other hand, FMD did not change in the pulsatile-flow group (12.5% ± 10.5%, 11.0% ± 7.2%, and 16.6% ± 11.7%, respectively). FMD also was unaffected in the beating-heart group, thus suggesting a direct effect of CPB itself on endothelial function. In conclusion, in this study population of adult patients undergoing elective coronary revascularization, continuous-flow CPB markedly impaired endothelial function, although this was not the case with pulsatile-flow CPB. This study posed the rationale for further investigations on the potential value of FMD to predict cardiovascular events in these patients.

Influence of Pleural Drain Insertion in Lung Function of Patients Undergoing Coronary Artery Bypass Grafting

Longitudinal, prospective, randomized, blinded Trial to assess the influence of pleural drain (non-toxic PVC) site of insertion on lung function and postoperative pain of patients undergoing coronary artery bypass grafting in the first three days post-surgery and immediately after chest tube removal. Thirty six patients scheduled for elective myocardial revascularization with cardiopulmonary bypass (CPB) were randomly allocated into two groups: SX group (subxiphoid) and IC group (intercostal drain). Spirometry, arterial blood gases, and pain tests were recorded. Thirty one patients were selected, 16 in SX group and 15 in IC group. Postoperative (PO) spirometric values were higher in SX than in IC group (p<0.05), showing less influence of pleural drain location on breathing. PaO(2) on the second PO increased significantly in SX group compared with IC group (p<0.0188). The intensity of pain before and after spirometry was lower in SX group than in IC group (p<0.005). Spirometric values were significantly increased in both groups after chest tube removal. Drain with insertion in the subxiphoid region causes less change in lung function and discomfort, allowing better recovery of respiratory parameters.

Prognostic value of preoperative quality of life on mortality after isolated elective myocardial revascularization

This study evaluates whether a low preoperative quality of life (QoL), measured with the EuroQoL instruments EQ-5D and EQ-visual analogue scale (VAS) can be used as a predictor of mortality after elective isolated myocardial revascularization. A total of 2501 patients, with a mean age of 65.3 ± 9.4 (range 18-93) years and a mean additive EuroSCORE of 2.7 ± 2.1 (0-12), undergoing an elective isolated coronary artery bypass graft between January 2002 and June 2011 completed preoperative EQ-5D and EQ-VAS. Hospital mortality [1.0% (25/2501 patients)] and 30-day mortality [1.2% (29/25 patients)] were the studied outcomes. The EQ-5D was 0.69 ± 0.26 (-0.30 to 1.0) with a median of 0.77 and the EQ-VAS was 59.7 ± 22.4 (0-100) with a median of 60. Regression analysis showed a significant correlation between hospital mortality and EQ-5D (P = 0.016) and EQ-VAS (P = 0.033). There is a significant correlation between 30-day mortality and EQ-5D (P = 0.048), but not for EQ-VAS (P = 0.06). The c-statistics (95% confidence interval) for EQ-5D and EQ-VAS for predicting hospital mortality are 0.36 (0.24-0.46) and 0.33 (0.23-0.42), respectively. The c-statistics for predicting 30-day mortality are 0.39 (0.30-0.49) for EQ-5D and 0.35 (0.26-0.44) for EQ-VAS. Based on these results, we conclude that, in isolation, poor low preoperative EQ-5D and EQ-VAS scores do not contribute to deciding which patients should undergo cardiac surgery.

Prospective Randomized Clinical Study of Arterial Pumps Used for Routine on Pump Coronary Bypass Grafting

In a number of studies, centrifugal blood pumps--in comparison with roller pumps--have been shown to attenuate trauma to blood components. Nevertheless, the impact of these results on the postoperative course needs to be discussed controversially. In a prospective randomized study, 240 consecutive adult patients underwent elective myocardial revascularization with cardiopulmonary bypass employing five different pumps (Roller, Avecor, Sarns, Rotaflow, Bio-Medicus). We analyzed clinical course, blood loss, damage of blood components, and impairment of the hemostatic system. The study population was homogenous with respect to age, gender, myocardial function, and operative data. No differences were found with respect to time of ventilation, duration of intensive care stay, hospitalization, and laboratory data. The choice of arterial pump during standard extracorporeal bypass for elective coronary artery bypass grafting is no matter of concern.

Incidência de complicações pulmonares na cirurgia de revascularização do miocárdio

despite the increasingly careful attempts to reduce perioperative risks, pulmonary complications following surgery are still very common, leading to longer length of hospital stays or death.to describe the incidence of pulmonary complications and identify their association with duration of extracorporeal circulation (ECC), surgery and ischemia, number of bypass grafts performed, location of drains and length of drainage following myocardial revascularization (MRV).this contemporaneous cohort consisted of 202 patients undergoing elective myocardial revascularization (MRV) with saphenous vein graft and internal mammary artery graft and ECC, at a referral university cardiology hospital in Southern Brazil, from April 2006 to November 2007. The following outcomes were analyzed: duration of mechanical ventilation; pneumonia onset; atelectasis; pleural effusion; location of drains and time of removal; and length of hospital stay.of the 202 patients, 90 developed some sort of pulmonary complication. The incidence of pleural effusion was 84%, whereas atelectasis was 65%. The following variables were associated with pulmonary complications: duration of ECC (p = 0.003), surgery (p = 0.040) and ischemia (p = 0.001); length of drainage (p = 0.050) and location of pleural drains (p = 0.033); age (p = 0.001); ejection fraction (p = 0.010); diagnosis of asthma (p = 0.047) and preoperative abnormal chest X-ray findings (p = 0.029).variables related to the complexity of the surgery and preexisting comorbidities are associated with a high incidence of postoperative pulmonary complications. These data reinforce the importance of having patients undergo perioperative clinical assessment to detect early respiratory complications after MRV.

Intensive versus conventional insulinotherapy after elective and on-pump myocardial revascularization in the elderly patient: a prospective and randomized study

Background In cardiac surgery patients, hyperglycemia was found to be an independent post-operative risk factor for the development of hyperlactatemia and associated with increased morbidity and mortality [1].

Prevalência de estenose carotídea em pacientes com indicação de cirurgia de revascularização miocárdica

FUNDAMENTO: Embora a aterosclerose carotídea seja a principal causa de acidente vascular cerebral, a prevalência de estenose clinicamente significativa (>50%) permanece desconhecida em nosso meio, principalmente em indivíduos com indicação de cirurgia eletiva de revascularização do miocárdio. OBJETIVO: Identificar a prevalência e o grau de estenose carotídea em indivíduos com indicação de cirurgia de revascularização miocárdica em um centro de referência em cardiologia no Brasil. MÉTODOS: Estudo transversal no qual 457 pacientes consecutivos e de ambos os gêneros foram avaliados, entre maio de 2007 e abril de 2008, através de ultrassonografia com Doppler em cores de artérias carótidas, no pré-operatório de cirurgia de revascularização miocárdica eletiva. Para a análise estatística foi usado o programa SPSS 10.1. Um valor-p<0,05 foi considerado significativo. Houve perda de 7 pacientes no decorrer do estudo. RESULTADOS: A média de idade (±desvio padrão) foi de 62,2 ± 9,4 anos sendo que 65,6% eram do gênero masculino. A prevalência de estenose carotídea significativa foi de 18,7%. Quanto à estratificação do grau de estenose carotídea: ausência de estenose ocorreu em 3,6%, estenose inferior a 50%, em 77,8%, estenose entre 50% e 69% em 11,6%, estenose entre 70% e 99% em 6,9% e oclusão da artéria em 0,2%. A sensibilidade e especificidade em relação ao sopro carotídeo foram, respectivamente, 34,5% e 88,8%. CONCLUSÃO: A prevalência de estenose carotídea significativa foi alta na amostra estudada, sugerindo tratar-se de população de alto risco para acidente vascular cerebral.

Alveolar Recruitment Strategy During Cardiopulmonary Bypass Does Not Improve Postoperative Gas Exchange and Lung Function

Pulmonary dysfunction with impairment of lung function and oxygenation is one of the most serious problems in the early postoperative period after cardiac surgery. In this study we investigated the effect of alveolar recruitment strategy during cardiopulmonary bypass on postoperative gas exchange and lung function. This prospective randomized study included 32 patients undergoing elective myocardial revascularization with cardiopulmonary bypass. In 16 patients 5 cm H(2)O of positive end-expiratory pressure was applied after intubation and maintained until extubation (Group I). In the other 16 patients (group II) a positive end expiratory pressure (PEEP) of 5 cm H(2)O was maintained as well but was increased to 14 cm H(2)O every 20 min for 2 min during cross clamp. Measurements were taken preoperatively, before skin incision, before and after (3, 24, 48 h) cardiopulmonary bypass and before discharge (6th postoperative day). Postoperative gas exchange, extravascular lung water and lung function showed no significant difference between the groups. Postoperative pulmonary function variables were lower in both groups compared to baseline values. In patients with normal preoperative pulmonary function, application of an alveolar recruitment strategy during cardiopulmonary bypass does not improve postoperative gas exchange and lung function after cardiac surgery.

Levosimendan pre-treatment improves outcomes in patients undergoing coronary artery bypass graft surgery

The calcium sensitizer levosimendan has anti-ischaemic effects mediated via the opening of sarcolemmal and mitochondrial ATP-sensitive potassium channels. These properties suggest potential application in clinical situations where cardioprotection would be beneficial, such as cardiac surgery. We thus decided to investigate whether pharmacological pre-treatment with levosimendan reduces intensive care unit (ICU) length of stay in patients undergoing elective myocardial revascularization under cardiopulmonary bypass. One hundred and six patients undergoing elective coronary artery bypass grafting were randomly assigned in a double-blind manner to receive levosimendan or placebo. Levosimendan (24 microg kg(-1)) or placebo was administered as a slow i.v. bolus over a 10 min period before the initiation of bypass. Tracheal intubation time and the length of ICU stay were significantly reduced in the levosimendan group (P<0.01). The number of patients needing inotropic support for >12 h was significantly higher in the control group (18.0% vs 3.8%; P=0.021). Compared with control patients, levosimendan-treated patients had lower postoperative troponin I concentrations (P<0.0001) and a higher cardiac power index (P<0.0001). Pre-treatment with levosimendan in patients undergoing surgical myocardial revascularization resulted in less myocardial injury, a reduction in tracheal intubation time, less requirement for inotropic support, and a shorter length of ICU stay.