Lower Preoperative Ejection Fraction Research Articles

The Perioperative Use of Levosimendan as a Means of Optimizing the Surgical Outcome in Patients with Severe Heart Insufficiency Undergoing Cardiac Surgery.

Postoperative myocardial dysfunction following cardiac surgery is a relatively common occurrence. Levosimendan, a calcium sensitizer and inotropic drug, has shown potential in improving outcomes for patients with low preoperative ejection fraction (EF) and myocardial dysfunction after cardiac surgery. This study aims to evaluate the efficacy of levosimendan in optimizing the surgical outcome for such patients. A retrospective analysis was conducted on 314 patients with preoperative severe heart failure who underwent cardiac surgery. Among them, 184 patients received perioperative adjunctive therapy with levosimendan, while a comparable group of 130 patients received conventional treatment. The use of levosimendan demonstrated several advantages in postoperative outcomes. It significantly improved short- and long-term survival rates after cardiac surgery, enhanced hemodynamic stability, reduced the requirement for inotropic support, and facilitated faster weaning from ventilator support. Patients who received levosimendan reported reduced angina and dyspnea symptoms, as well as fewer postoperative arrhythmias. Furthermore, levosimendan helped minimize myocardial injury inevitable after cardiac surgery. The levosimendan group also exhibited a notable reduction in hospital readmissions. This study provides evidence of several benefits associated with the perioperative use of levosimendan. However, further prospective randomized studies are warranted to standardize and comprehensively document the other perioperative therapies, in order to validate these findings and establish stronger conclusions.

Perioperative Application of Levosimendan Optimizes Postoperative Renal Function and Organ Perfusion in Patients with Severe Heart Failure.

Background: Renal dysfunction and impaired organ perfusion are common concerns following cardiac surgery. Levosimendan, a calcium sensitizer inotropic drug, is investigated in this study for its potential to improve postoperative renal function and organ perfusion in patients with low preoperative ejection fraction and severe myocardial dysfunction after cardiac surgery. Methods: A retrospective analysis was conducted on 314 patients with preoperative heart failure who underwent cardiac surgery. Among them, 184 patients received perioperative adjunctive therapy with levosimendan, while 130 patients with similar characteristics received conventional treatment. Results: The perioperative administration of levosimendan resulted in a significantly lower need for renal replacement therapy (p < 0.001) and improvements in the serum creatinine levels, glomerular filtration rate, and creatinine clearance. Similarly, the C-reactive protein levels, blood pH, and lactic acid levels showed comparable improvements. Conclusions: The use of levosimendan was associated with a significant enhancement in postoperative renal function and a reduction in the need for renal replacement therapy. Furthermore, it resulted in a decrease in the extent of organ malperfusion. Postoperative inflammatory reactions and metabolic balance also exhibited improvements.

Concomitant intra-aortic balloon pump and veno-arterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

We aimed to compare the outcomes of ECMO with and without IABP for postcardiotomy cardiogenic shock. The study included 103 patients who needed ECMO for postcardiotomy cardiogenic shock. Patients were grouped according to the use of IABP into ECMO without IABP (n = 43) and ECMO with IABP (n = 60). The study endpoints were hospital complications, successful weaning, and survival. Patients with IABP had lower preoperative ejection fraction (p = 0.002). There was no difference in stroke (p = 0.97), limb ischemic (p = 0.32), and duration of ICU stay (p = 0.11) between groups. Successful weaning was non-significantly higher with IABP (36 (60%) vs 19 (44.19%); p = 0.11). Predictors of successful weaning were inversely related to the high pre-ECMO lactate levels (OR: 0.89; p = 0.01), active endocarditis (OR: 0.06; p = 0.02), older age (OR: 0.95; p = 0.02), and aortic valve replacement (OR: 0.26; p = 0.04). There was no difference in survival between groups (p = 0.80). Our study did not support the routine use of IABP during ECMO support.

Outcome of Coronary Artery Bypass Graft Surgery with Low Preoperative Ejection Fraction: A Cross-sectional study

Background: Coronary artery bypass graft (CABG) surgery has been proven in several trials to have excellent outcomes in patients with coronary artery disease who have reasonably preserved cardiac function. Nonetheless, determining the value of coronary artery bypass grafting (CABG) in patients with low left ventricular ejection faction (shown as left ventricular ejection fraction 40B) has been challenging due to worries about increased operating mortality and decreased long-term survival.&#x0D; Objective: Our main goal is to evaluate the Outcome of Coronary Artery Bypass Graft Surgery with Low Preoperative Ejection Fraction.&#x0D; Methods: This cross-sectional study carried out at tertiary hospital from June 2021 to June 2022. Where 100 patients who underwent coronary artery bypass graft (CABG) surgery in the Department of Cardiac Surgery were included in the study. The patients were divided into 2 groups as follows: Group—I, EF &lt; 40% (n = 50) and Group-ll EF&gt;40% (n = 50).&#x0D; Results: During the study, where 55% were belong to 50-60 years age group and majority were male. In both group majority had diabetes and hypertension. All of the co—morbidities/risk factors were almost equally distributed between groups (p &gt; 0,05). Except incidence of bleeding, which was significantly higher in Croup—I than that in Group—II (p = 0.01 0). In addition to that, in group 1 Heart failure seen in 1.5% cases followed by 2.3% had pneumonia, prolonged ventilation seen in 13.5%. Where as in group 2 Heart failure seen in 0.5% cases followed by 1.8% had pneumonia, prolonged ventilation seen in 11%.&#x0D; Conclusion: Lastly, the current study's large sample size suggests that CABG may be performed on patients with low EF &lt;40% with outcomes (in terms of morbidity and death) that are equivalent to those of patients with EF &gt; 40.

Fate of aortic regurgitation after isolated repair of ventricular septal defect with concomitant aortic regurgitation in children

ObjectivesThe aim of the study was to evaluate the course of aortic valve regurgitation in patients with preoperative aortic valve regurgitation and ventricular septal defect who underwent repair of the ventricular septal defect without aortic valve repair. MethodsA total of 37 consecutive patients with a ventricular septal defect and aortic regurgitation who underwent surgery between April 2007 and March 2016 were included in the study. Demographic, echocardiographic, operative, and clinical data were reviewed. Early and late mortality and morbidity were analyzed. Aortic regurgitation grade, left ventricular function, and dimensions were compared between the preoperative transesophageal echocardiography and postoperative transthoracic echocardiogram at last follow-up. Multivariate logistic regression analysis was performed to determine factors associated with improvement of aortic valve function. ResultsThere was no early or late mortality. No reoperations or reinterventions were required. A total of 17 patients had mild or greater aortic regurgitation preoperatively. Only 5 patients had mild or greater aortic regurgitation at follow-up of 4.3 years (0.5-10.1). Twenty-eight (76%) of the 37 patients showed an improvement in their aortic regurgitation grade. Left ventricular end-systolic and end-diastolic diameter z-scores were significantly lower at follow-up (P = .007 and P = .001, respectively). Multivariable logistic regression identified low preoperative left ventricular ejection fraction as the only predictor of nonimprovement of aortic regurgitation (95% confidence interval, 0.732-0.999, P = .002). ConclusionsRepair of a ventricular septal defect with accompanying aortic regurgitation can be performed with excellent results without surgical intervention on the aortic valve. Accompanying aortic regurgitation, especially trivial to mild, at the time of ventricular septal defect repair improves in the majority of cases. Low preoperative left ventricular ejection fraction is predictive of nonimprovement of aortic regurgitation grade.

Post-Operative Cerebral Oximetry for Detection of Low - Cardiac Output Syndrome after Coronary Artery Bypass Surgery in Patients with Low Pre-Operative Left Ventricular Ejection Fraction - A Protocol for an Observational Study on Simultaneous Monitoring of Cerebral Oximetry and Cardiac Index

Post-Operative Cerebral Oximetry for Detection of Low - Cardiac Output Syndrome after Coronary Artery Bypass Surgery in Patients with Low Pre-Operative Left Ventricular Ejection Fraction - A Protocol for an Observational Study on Simultaneous Monitoring of Cerebral Oximetry and Cardiac Index

Incidence of and Risk Factors for Prolonged Intensive Care Unit Stay After Open Heart Surgery Among Elderly Patients.

Open heart surgery (OHS) is frequently performed on elderly patients. We aimed to investigate the risk factors associated with prolonged intensive care unit (ICU) stay in elderly patients undergoing open heart surgery. Medical records of all patients ≥ 75 years who underwent OHS (coronary artery bypass grafting (CABG) and/or heart valve surgery) between June 1, 2013, and December 31,2020, were retrospectively analyzed. Those staying in the ICU longer than five days were determined as prolonged ICU stay. Patients were divided into two groups, according to ICU stay <5 days and ≥5 days. Out of the 198 patients included in the study, 130 (65.7%) were male. Seventy patients (35.4%) had prolonged ICU stay. The mean age was higher in patients within the prolonged ICU stay group when compared to the other group (79.9±3.5 years vs.78.1±2.7 years, p<0.001). The patients who used statins and angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARBs) in the preoperative period had a shorter ICU stay compared to those who did not (45% vs 31.4%, p=0.04; 57% vs 42.9%, p=0.03). The history of previous thoracic surgery (2.3% vs 10% p=0.03), emergency surgery (12.5% vs 24.5% p=0.04), and preoperative pacemaker usage (0.8% vs 7%, 1 p=0.01) were higher in the group of patients with prolonged ICU stay compared to the other group. Preoperative ejection fraction (EF)% (47.7±11.3 vs 51.1±8.8, p<0.001) and hemoglobin level (11.8±1.9 mg/dL vs 12.9±1.6, p<0.001) were lower in the group with prolonged ICU stay compared to the other group. Incidence of cardiac arrest (3.9% vs 15.7% p=0.006), presence of arrhythmia (16.4% vs 41.6%,p<0.001), frequency of pacemaker and intra-aortic balloon pump (IABP) usage (0 vs 10% p=0.002; 1.6% vs 8.6% p=0.02), and need for renal replacement therapy (3.1% vs 12.9%,p=0.02) were higher in the group with prolonged ICU stay compared to the other group. According to the logistic regression analysis; higher age (OR: 1.225, 95%CI 1.104-1.360, p<0.001), preoperative pacemaker usage (OR: 0.100, 95%CI 0.01-0.969, p<0.04), preoperative statin non-use (OR: 2.056, 95%CI 1.040-4.066, p<0.03) and preoperative low EF (OR: 0.947, 95%CI 0.915-0.981, p=0.002) were determined as independent risk factors for prolonged ICU stay. The incidence of prolonged ICU stay after OHS among patients ≥75 years was 35.4% in our cohort. Higher age, preoperative pacemaker usage, preoperative statin non-use, and low preoperative EF were associated with prolonged ICU stay.

The long-term impact of acute renal failure after aortic arch replacement for acute type A aortic dissection.

To determine the long-term impact of developing acute renal failure (ARF) on survival after open aortic arch reconstruction for acute type A aortic dissection (ATAAD). This was an observational study of consecutive aortic surgeries from 2007 to 2021. Patients with ATAAD were identified via a prospectively maintained institutional database and were stratified by the presence or absence of postoperative ARF (by RIFLE criteria). Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed. A total of 601 patients undergoing open surgery for ATAAD were identified, of which 516 (85.9%) did not develop postoperative ARF, while 85 (14.1%) developed ARF, with a median follow-up time of 4.6 years (1.6, 7.9). Baseline characteristics were similar across each group, except for higher rates of branch vessel malperfusion and lower preoperative ejection fraction in the ARF group. Patients with ARF underwent more total arch replacement and elephant trunk procedures, with longer cardiopulmonary bypass and circulatory arrest times than patients without ARF. ARF was associated with worse short-term outcomes, including increased in-hospital mortality, prolonged mechanical ventilation, higher rates of sepsis, more blood transfusions, and longer length of hospital stay. Unadjusted Kaplan-Meier survival estimates were significantly lower in the ARF group, compared to the group without ARF (p < .001, log-rank test). After multivariable adjustment, the development of postoperative ARF was significantly associated with an increased hazard of death over the study's follow-up time-period (hazard ratio: 2.74, 95% confidence interval: 1.95, 3.86, p < .001). ARF is a highly morbid postoperative event that may adversely impact long-term survival after aortic surgery.

The Effect of Low Preoperative Ejection Fraction on Mortality After Cardiac Surgery in Indonesia.

BackgroundAmong cardiac surgery patients, low preoperative left ventricular ejection fraction (LVEF) is common and has been associated with poor outcomes. The objective of this study was to assess the association between LVEF and postoperative mortality in patients undergoing open-heart surgery in several hospitals in Indonesia.MethodsWe conducted a multicenter study with the retrospective design using data from patients undergoing open-heart surgery in 4 institutions in Indonesia. Data regarding LVEF and other potential risk factors were extracted from medical records and compiled in one datasheet. Statistical analyses were performed to assess if low LVEF was associated with postoperative mortality and identify other potential risk factors.ResultsA total of 4789 patients underwent cardiac surgery in participating centers during the study period. Of these, 189 subjects (3.9%) had poor preoperative LVEF. Poor LVEF was associated with postoperative mortality (adjusted OR 2.761, 95% CI 1.763–4.323, p < 0.001). Based on types of surgery, LVEF had a significant association with mortality only in CABG patients, while there was no such association in valve surgery and inconclusive in congenital surgery patients. Other significant independent predictors of in-hospital mortality included age more than 65 years old, non-elective surgery, the complexity of procedures, history of cardiac surgery, organ failure, CARE score ≥ 3, NYHA class ≥ III, and poor right ventricular function.ConclusionPatients with low preoperative LVEF undergoing open-heart surgery had a higher risk of postoperative mortality. Cardiac surgery can be performed with acceptable mortality rates. Accurate selection of patients, risk/benefit evaluation, and planning of surgical and anesthesiological management are mandatory to improve outcomes.

Predictive value of left ventricular ejection fraction for the occurrence of postoperative myocardial infarction after coronary endarterectomy in patients with diffuse coronary artery disease

Objective: To investigate the predictive value of ejection fraction for the postoperative myocardial infarction after coronary endarterectomy (CE) in patients with diffuse coronary artery disease (DCAD). Methods: Patients who underwent cardiac artery bypass graft (CABG) surgery and CE in Beijing Anzhen Hospital affiliated to Capital Medical University from May 2018 to December 2020 were enrolled in this prospective observational study. Baseline features including age, sex and echocardiography parameters were obtained. Left ventricular ejection fraction(EF) was measured by echocardiography. The patients were divided into postoperative myocardial infarction (PMI) group and non-PMI group according to PMI occurrence. Linear regression analysis, logistic regression model, and receiver operating characteristic(ROC) curve were used to analyze the correlation between left ventricular ejection fraction and PMI and the influencing factors. Results: A total of 120 patients were enrolled in the study. There were 32 patients (27%) in the PMI group (male 27(84%), age (62±8)), inferior myocardial infarction occurred in 24 (75%) patients. There were 88 patients (73%) in the non-PMI group (male 70(80%), age (62±8)). EF (55% (49%, 64%) vs. 62% (55%, 67%), P=0.01) was significantly lower in the PMI group than in the non-PMI group. Perioperative TNI, IABP use and length of hospitalization were significantly higher in the PMI group than in the non-PMI group. Multivariate logistic regression showed that lower EF was an independent risk factor of PMI (OR=0.93, 95%CI: 0.89-0.98, P=0.01) after adjusting age, sex and body mass index. ROC curve analysis showed that EF<60% could sufficiently predict the occurrence of PMI (AUC= 0.67, sensitivity 64%, specificity 69%, P=0.01). Linear regression analysis showed that left ventricular end-diastolic diameter (OR=-0.52, 95%CI:-1.13-0.60, P<0.001), graft flow in left anterior descending (OR=-0.20, 95%CI:-0.15-0.01, P=0.02) and history of diabetes (OR=-0.28, 95%CI:-8.25-1.85, P=0.002) were negatively correlated with preoperative EF value. Conclusion: Lower preoperative EF is an independent risk factor for PMI after CABG and CE in DCAD patients, closely related to the left ventricular end-diastolic diameter, graft flow in left anterior descending artery and diabetes mellitus.

The effects of levosimendan on renal functions in open-heart surgery patients with a low ejection fraction

Purpose. This study investigated the effects of levosimendan on renal functions in patients with a preoperative low ejection fraction undergoing open-heart surgery and cardiopulmonary bypass (CPB). Materials and Methods. The study retrospectively evaluated 64 patients with a diagnosis of mitral valve insufficiency and left ventricular dysfunction undergoing open-heart surgery with CPB. Patients were divided depending on the preoperative blood creatinine level less (Group 1) or more than 1.2 mg/dL (Group 2). A bolus dose of levosimendan was administered through the aortic arch at the end of the CPB, preceding an infusion of levosimendan intravenously in all patients. Demographic data, preoperative and 48-hour postoperative echocardiographic studies were done. The blood urea and creatinine levels were collected preoperatively and on postoperative days 1, 3, and 10. The use of inotropic support, intra-aortic balloon pump, and complications were recorded. Results. The demographic data were similar between groups (p&gt;0.05). Preoperative serum creatinine levels were higher in Group 1 in comparison to Group 2 (p=0.01, p&lt;0.001, respectively). The aortic cross-clamp and cardiopulmonary bypass times were similar between groups (p&gt;0.05). Preoperative serum creatinine levels were higher in Group 1 in comparison to Group 2 (p&lt;0.001). On postoperative day 1, serum creatinine levels of Group 1 were significantly lower than Group 2 (p&lt;0.001). On postoperative days 3 and 10, no differences were observed regarding serum creatinine levels between groups (p&gt;0.05). Complications were similar between groups (p&gt;0.05). Conclusions. In patients with low ejection fraction undergoing open-heart surgery, the use of levosimendan intraoperatively and 24 hours postoperatively prevents deterioration of renal functions in patients with or without preoperative disturbance in serum creatinine level.

Short-term outcomes of surgical myocardial revascularization on health-related quality of life: a validation of the Arabic MacNew heart disease questionnaire

BackgroundImpaired quality of life (QOL) is common in coronary heart disease and is the major indications for coronary artery bypass graft (CABG) operations. This study aims to compare the QOL of patients with coronary heart disease before and after CABG surgery.ResultsA translated Arabic version of the Mac-New health-related QOL questionnaire was used to evaluate QOL improvement in 446 patients who benefited from elective CABG at Nasser Institute for Research and Treatment. There was a statistically significant improvement in physical, emotional, social, and global domains of QOL, as evaluated 3 and 6 months after surgery. Follow-up was 90.4% complete. At 3 months, multiple linear regression has shown that male patients (β = 0.48, p ≤ 0.001) and rural residence (β = 0.39, p ≤ 0.001) were significant independent predictors of improvement in physical QOL domain. While hypercholesterolemia (β = −0.20, −0.49, −0.37, −0.46, p ≤ 0.001), hypertension (β = −0.29, −0.39, p ≤ 0.001, β = −0.35, −β = 0.35, p = 0.001), and smoking (β = −0.79, p ≤ 0.001, β = −0.33, p = 0.04, β = −0.69, p ≤ 0.001, β = −0.47, p = 0.005) were significant predictors of worsening in physical, emotional, social, and global domains, respectively. At 6 months, low preoperative ejection fraction (EF) ≤ 40% was the strongest predictor of improvement (β = 0.54, 0.49, 0.44, and 0.52, p ≤ 0.001) in physical, emotional, social, and global domains of QOL, respectively. But, peripheral vascular disease (PVD) (β = −0.53, p = 0.05, β = −0.81, p = 0.005, β = −0.62, p = 0.03, β = −0.76, p = 0.008) and smoking (β = −0.53, p = 0.001, β = −0.42, p = 0.01, β = −0.42, p = 0.01, β = −0.41, p = 0.02) were significant predictors of worsening in physical, emotional, social, and global domains of QOL, respectively.ConclusionsCABG surgery improved in all domains of QOL. Further studies are required to evaluate changes in QOL at longer period intervals.

A Comparative Study of Hemodynamic Effects of Levosimendan and Milrinone in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

Background: Off-Pump CABG or “beating heart” surgery possess a challenge to the anesthesiologist. Main goals are provision of safe anesthesia with maximum myocardial protection and maintenance of hemodynamics with various manipulation of heart during in order to visualize and graft the coronary arteries. Anesthetic regimen and ionotropic support influences postoperative myocardial function and outcome in coronary bypass surgery patients.Objective: To compare and assess haemodynamic effects of Levosimendan and Milrinone in patient undergoing off pump coronary artery bypass grafting with compromised cardiac function (NYHA III,IV) and pre-operative, left ventricular ejection fraction (LVEF) &lt; 45%.Subjects and Methods:Patients were randomly allocated to 2 groups (64 patients in each group). Levosimendan Group (Group A) received infusion of Inj. Levosimendan 0.1µg/kg/min after loading dose of 12μg/kg over 10 mins. While Milrinone Group (Group B) received infusion of inj. Milrinone 0.5µg/kg/min after loading dose of 50 μg/kg over 10 mins. HR, MAP, CVP, CI, SVRI, lactate levels were monitored at baseline, after induction, after sternotomy, at 30mins ,thereafter 6, 12, and 24 hours using Flo-Trac sensor (Edwards Life sciences).Results:Heart Rate, CI was significantly higher in Levosimendan group while MAP, SVRI and lactate levels were lower in Levosimendan group as compared to Milrinone group. Need of other inotropic support is more in Milrinone group.Conclusion:Levosimendan maintained the haemodynamic parameters better as compared to Milrinone in off pump CABG patients with low preoperative ejection fraction and also better end organ perfusion represented by lower lactate levels.

Pre-, Intra-, and Post-Operative Factors for Kidney Injury of Patients Underwent Cardiac Surgery: A Retrospective Cohort Study.

BackgroundKidney injury is common in patients who have undergone cardiac surgery, and it has high morbidity and mortality. The objective of the study was to identify pre-, intra-, and post-operative risk factors responsible for kidney injury among patients who had undergone cardiac surgery.Material/MethodsPatients (n=1468) who had undergone cardiac surgery were stratified into those with kidney injury (n=488) and those without kidney injury (n=980) using the KDIGO (Kidney Disease: Improving Global Outcomes) criteria. Data of pre-, intra- and post-operative variables were collected and analyzed.ResultsAcute kidney injury occurred in 33.2% of study patients. Patients with post-operative acute kidney injury had older age, comorbidities, higher preoperative serum creatinine, coronary artery bypass grafting, longer operation time, high cardiopulmonary bypass and cross-clamping time, low central venous pressure, and prolonged mechanical ventilation as compared to patients without kidney injury (P<0.05 for all). Age >65 years (OR 1.4), preoperative hypertension (OR 2.0), preoperative anemia (OR 2.3), preoperative low ejection fraction (OR 3.7), Charlson comorbidity index >2 (OR 2.5), longer cardiopulmonary bypass time (OR 4.0), blood transfusions (OR 2.1), postoperative hypotension (OR 5.2), and low central venous pressure (OR 8.1) were responsible for kidney injury. Mortality of patients with kidney injury was significantly higher than those without acute kidney injury (52 versus 1, P<0.001).ConclusionsAppropriate and effective control of pre-, intra-, and post-operative variables can reduce the risk of kidney injury development in patients following cardiac surgeries.

Anterior Pericardiectomy for Postinfective Constrictive Pericarditis: Intermediate-Term Outcomes

Posttubercular constrictive pericarditis is prevalent pericardial disease in developing countries. Pericardiectomy is the treatment of choice but considered a procedure of high morbidity and mortality. From January 2003 to December 2013 we performed 130 pericardiectomies. The patients' mean age was 22.95 ± 12.55 years, and there were 92 (71%) male patients. All patients were symptomatic; 118 (91%) were in New York Heart Association functional class III or IV. Almost all patients were diagnosed to be of tubercular origin: 14 (11%) were histopathologically proven, 77 (59%) had definitive history, 39 (30%) were suspected to be of tubercular origin, and 91 (70%) received prior antitubercular treatment. Anterior pericardiectomy was done without the use but with provision for cardiopulmonary bypass, which was required in 5 (3.8%) patients for repair of tear in right atrium. Following pericardiectomy central venous pressure dropped from 20.9 to 10.8 mm Hg. Early mortality was 10 (7.69%). Prolonged ventilation was required in 22 (16.92%) patients, 31 (23.84%) developed renal dysfunction, and there were 3 (3.12%) cases of new-onset atrial fibrillation. On analysis of univariate predictors for early mortality, low ejection fraction (p < 0.001) and preoperative atrial fibrillation (p < 0.001) were found to be significant. In a follow-up of 12 months, 85% patients were in New York Heart Association functional class I or II with mean ejection fraction of 52%. There was no recurrence of constriction from residual pericardium on 1-year follow-up. Anterior pericardiectomy is sufficient in patients with constrictive pericarditis of infective etiology. Preoperative low ejection fraction, atrial fibrillation, poor functional class, and constrictive effusive pericarditis results in poor surgical outcome.

New-Onset Ventricular Arrhythmias in Patients with Left Ventricular Dysfunction after Coronary Surgery: Incidence, Risk Factors, and Prognosis.

The incidence, risk factors, and long-term prognosis of new-onset ventricular tachycardia (VT) and ventricular fibrillation (VF) after coronary artery bypass graft surgery (CABG) in patients with impaired left ventricular function have not been thoroughly examined.Methods: This study enrolled 612 consecutive patients with impaired left ventricular function (ejection fraction <50%) undergoing CABG at a single institution between March, 1996, and September, 2015. Outcomes were analyzed and compared, including in-hospital mortality and long-term survival. After a propensity-score, matching was performed to adjust for differences between the two cohorts. Factors significantly associated with VT/VF were also investigated using multivariate logistic regression. Of the 600 patients included in the analyses, 92 (15.3%; 95% confidence interval [CI] 12.5-18.3%) had new-onset VT/VF postoperatively. Before propensity matching, patients with postoperative VT/VF were more likely to have renal failure, intra-aortic balloon pump support, lower preoperative ejection fraction (EF), and a larger left ventricle than those without VT/VF. Multivariate regression identified three preoperative risk factors and one protective factor that were independently associated with new-onset VT/VF: previous renal failure (odds ratio [OR] 4.42, P = .02), left ventricular end-diastolic dimension enlargement (OR 1.83, P = .03), ejection fraction (OR 1.88, P = .02 for EF ≥30 and <40% versus ≥40% and <50%; OR 5.46, P = .00 for EF <30% versus ≥40% and <50%), and preoperative β-blockers (OR 0.58, P = .03). The median follow-up time was 46.6 months. In the propensity-matched cohorts, survival for patients who had in-hospital VT/VF was lower than that of the non-VT/VF group (89.9% versus 97.6%; P < .05). This study shows a high incidence of new-onset VT/VF after CABG in patients with impaired left ventricular function. The early and long-term survival rates were significantly lower in the VT/VF group. Preoperative renal failure, left ventricular end-systolic dimension enlargement, and the severity of left ventricular function were independently associated with the development of new-onset VT/VF after CABG surgery. Preoperative use of beta-blocker was proved to be protective in reducing both VT/VF incidence and in-hospital mortality in CABG patients with impaired left ventricular function following CABG. When considering these data, a prescription of beta-blockers is prognostically indicated to CABG patients, especially those with new-onset VT/VF postoperatively.

Urgent versus elective coronary artery bypass grafting in acute coronary artery syndrome

BackgroundIn this retrospective study, we aimed to evaluate the clinical outcomes, risk factors of mortality and prognosis after urgent coronary artery bypass grafting (CABG) in acute coronary syndrome (ACS) patients. MethodsOur study included 100 patients who underwent CABG for ACS (50 urgent and 50 elective). All patients were followed for 30 days after surgery, both clinically and echocardiographically. Data were analyzed using the SPSS software in accordance to the Society of Thoracic Surgeons (STS) National Cardiac Surgery Database guidelines. ResultsPatients in the urgent CABG group were of younger age (p = .03) and had a higher frequency of smoking (p = .04) and dyslipidemia (p = .004); otherwise, all baseline characteristics were comparable between the two groups. The cardiopulmonary bypass (CPB) (p = .003) and aortic cross-clamp times (p = .02) were significantly longer in the urgent CABG group compared to the elective CABG group. Although both groups had a relatively similar survival rate (p = .056), urgent CABG patients were more liable to postoperative myocardial infarction (p = .02), as well as prolonged ventilation time (p = .002) and hospital stay (p < .001). Our analysis showed that preoperative low ejection fraction (EF) (p = .03), use of inotropes (p = .002) and prolonged CPB time (p = .04) were independent risk factors for mortality after urgent CABG. ConclusionsUrgent CABG increased the risk of myocardial infarction and prolonged hospital stay in comparison to elective CABG. Moreover, preoperative low EF and prolonged CPB time were associated with a significant increase in the risk of mortality after urgent CABG.

A Retrospective Comparative Study between Levosimendan and Adrenaline as a Pharmacological Protocol for the Management of Coronary Artery Bypass Grafting Patients with Low Ejection Fraction: A Friend or Foe

Background: Left ventricular ejection fraction is an independent determinant of the outcome of coronary artery bypass surgery. Low preoperative ejection fraction requires special care in terms of pharmacological and mechanical inotropic support. Adrenaline is the most widely used inotropic drug, while levosimendan is a relatively new inotropic drug in the field of cardiac surgery. In this study, we aimed to evaluate the relative efficacy of levosimendan in low ejection fraction patients undergoing coronary artery bypass grafting (CABG). Methods: A retrospective comparative study was performed with 63 patients who underwent isolated on-pump elective CABG with a preoperative ejection fraction below 40%. Patients were allocated to the adrenaline group (n = 35) and levosimendan group (n = 28). Patients were further stratified according to ejection fraction above 30% and below or equal to 30%. The primary outcome was cardiac-related mortality, while other parameters were considered secondary endpoints. Results: EuroSCORE of the adrenaline group was 3.34 ± 1.26 and for the levosimendan group 3.15 ± 1.42 (p value 0.576). Nine patients of the adrenaline group had new postoperative atrial fibrillation compared to seven patients in the levosimendan group (p value 0.948). Two patients of the adrenaline group had postoperative ventricular arrhythmia compared to only one patient in the other group (p value 0.691). The adrenaline group had higher doses of inotropic support compared to the levosimendan group 210.84 ± 23.74 and 157.4 ± 22.69 ng/kg/min respectively (p value < 0.001). Longer ventilation hours and overall duration of ICU stay were also noticed in the adrenaline group 32.57 ± 7.23 hours, 8.84 ± 3.28 days in comparison to the levosimendan group 24.37 ± 5.09 hours, 6.23 ± 2.37 days (p values < 0.001 and 0.002 respectively). However, the primary endpoint was not significantly different between the two groups. Conclusions: The levosimendan-based protocol failed to improve overall mortality in low ejection fraction patients undergoing CABG. However, this protocol significantly reduced the dose of inotropic and vasoconstrictor support needed, ventilation hours and duration of ICU stay.

Effect of levosimendan on prognosis in adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials

BackgroundSmall trials suggest that levosimendan is associated with a favorable outcome in patients undergoing cardiac surgery. However, recently published larger-scale trials did not provide evidence for a similar benefit from levosimendan. We performed a meta-analysis to assess the survival benefits of levosimendan in patients undergoing cardiac surgery and to investigate its effects in subgroups of patients with preoperative low-ejection fraction (EF).MethodsWe identified randomized clinical trials through 20 April 2017 that investigated levosimendan therapy versus control in patients undergoing cardiac surgery. Individual patient data from each study were compiled. Meta-analyses were performed for primary outcomes, secondary outcomes and serious adverse events, and subgroup analyses according to the preoperative EF of enrolled patients were also conducted. The risk of bias was assessed using the Cochrane risk-of-bias tool.ResultsSeventeen studies involving a total of 2756 patients were included. Levosimendan therapy was associated with a significant reduction in 30-day mortality (RR 0.67; 95% CI, 0.49 to 0.93; p = 0.02) and reduced the risk of death in single-center trials (RR 0.49; 95% CI, 0.30 to 0.79; p = 0.004) and in subgroup trials of inferior quality (RR 0.39; 95% CI, 0.17 to 0.92; p = 0.02); however, in multicenter and in high-quality subgroup-analysis trials, no significant difference in mortality was observed between patients who received levosimendan therapy and controls (p > 0.05). However, in high-quality subgroup trials, levosimendan therapy was associated with reduced mortality in patients in a preoperative low-EF subgroup (RR 0.58; 95% CI, 0.38 to 0.88; p = 0.01). Similarly, only patients in the preoperative low-EF subgroup benefited in terms of reduced risk of renal replacement therapy (RR 0.54; 95% CI, 0.34 to 0.85; p = 0.007). Furthermore, levosimendan therapy was associated with a significant reduction in intensive care unit (ICU) length of stay (MDR −17.19; 95% CI, −34.43 to −2.94; p = 0.02).ConclusionsIn patients undergoing cardiac surgery, the benefit of levosimendan in terms of survival was not shown in multicenter or in high-quality trials; however, levosimendan therapy was associated with reduced mortality in patients with preoperative ventricular systolic dysfunction.

Can Pre-Operative HbA1c Values in Coronary Surgery be a Predictor of Mortality?

One of the most frequently studied parameters in terms of outcome estimation in cardiac surgery is HbA1c. Several studies in literature suggest that high HbA1c value increases mortality and morbidity, but there is no relation between them. The primary aim of the present study is to investigate whether HbA1c value in diabetic patients undergoing coronary bypass graft surgery is an independent predictor for post-operative mortality and morbidity, and our secondary goal was to determine independent risk factors that cause mortality and morbidity in the same patient population. 380 diabetic patients diagnosed with diabetes who underwent coronary surgery with cardiopulmonary bypass in Mersin State hospital between July 2014 to December 2016 after the approval of the Mersin University Faculty of medicine ethics committee were included in this retrospective, observational, and cross-sectional study. Patient demographic and perioperative information were obtained from the electronic information operating system and from anesthesia-intensive care follow-up forms. The HbA1c threshold was accepted as 7%, which was reported to be more appropriate for evaluating high-risk groups. Three hundred and fifty-four patients with complete access to the data were included in the study. The mean age of the patients was 60.8±9.4 years. 37% of the patients (131 patients) were female. The number of patients with HbA1c≥7 was 194 (54,8%) in the entire patient population. In this study, high HbA1c (≥7) values in diabetic patients undergoing isolated coronary bypass graft surgery were not found to be independent predictors of post-operative mortality and morbidity. Mortality was seen in 28 patients (7.9%). Ejection fraction (EF) was found to be an independent predictor factor for pre-operative factors in logistic regression models constructed according to mortality predictors (OR:0.94; 95% CI: 0.90-0.99; p=0.016). Complications were seen in 50 patients (14.1%). In the models formed from the point of view of the complication predicators, only EF was found to be independent predictor (OR:0.95; 95% CI: 0.92-0.98; p=0.004). It was found that HbA1c was not predictive in all models for mortality and complication (p>0.05). There are reports in the literature that mortality increases 4-fold when HbA1c value is higher than 8.6% in coronary surgery. However, there is a view that HbA1c alone cannot predict mortality in coronary surgery if diabetes associated factors are excluded. In this study, high HbA1c (≥7) values in diabetic patients undergoing isolated coronary bypass graft surgery were not found to be independent predictors of post-operative mortality and morbidity. Pre-operative low ejection fraction was found as an independent risk factor for post-operative mortality and morbidity in the general patient population.