Postoperative Blood Pressure Control Research Articles

Nicardipine or Nitroprusside for Postoperative Blood Pressure Control in Infants After Surgery for Congenital Heart Disease: Single-Center Retrospective Noninferiority and Cost Analysis, 2016-2020.

Postoperative hypertension frequently occurs after surgery for congenital heart disease. Given safety concerns when using calcium channel blockers in infants along with the cost and side-effect profile of nitroprusside, we retrospectively assessed our experience of using nicardipine and nitroprusside for postoperative blood pressure control in infants who underwent surgery for congenital heart disease. We also investigated the cost difference between the medications. This study was a single-center retrospective, pre-post chart review of patients who had surgery for congenital heart disease between 2016 and 2020. The primary aim was a noninferiority comparison of achievement of blood pressure goal at 1-hour post-initiation of an antihypertensive agent. Secondary comparisons included achievement of blood pressure goal at 2 hours after medication initiation, Vasoactive-Inotropic Score (VIS), and blood transfusion, crystalloid volume, and calcium needs. Academic quaternary-care center. Infants under 1 year old who required treatment for hypertension with nitroprusside (n = 71) or nicardipine (n = 52) within 24 hours of surgery for congenital heart disease. None. We failed to identify any difference in proportion of patients that achieved blood pressure control at 1-hour after medication initiation (nitroprusside 52% vs. nicardipine 54%; p = 0.86), with nicardipine noninferior to nitroprusside within a 15% margin. Of patients who did not achieve control at 1-hour post-medication initiation, receiving nicardipine was associated with blood pressure control at 2 hours post-medication initiation (79% vs. 38%; p = 0.003). We also failed to identify an association between antihypertensive types and mean VIS scores, blood transfusion volumes, crystalloid volumes, and quantities of calcium administered. Index cost of using nitroprusside was 16 times higher than using nicardipine, primarily due to difference in wholesale cost. In our experience of achieving blood pressure control in infants after surgery for congenital heart disease (2016-2020), antihypertensive treatment with nicardipine was noninferior to nitroprusside. Furthermore, nicardipine use was significantly less expensive than nitroprusside. Our contemporary practice is therefore to use nicardipine in preference to nitroprusside.

Multiple recurrent aneurysms with angiitis of the central nervous system in a girl: A case report

Primary central nervous system (CNS) vasculitis is a rare immune inflammatory disease confined to the blood vessels of the brain and spinal cord. The total number reported in the world is about 500[1]. Most are negative in cerebral angiography or vascular stenosis and only 1 case of aortic aneurysms reported. A 12-year-old female experienced sudden headache and vomiting. Previous findings of vascular stenosis. Diagnosed as a ruptured aneurysm bleeding. The aneurysm recurred a short time after treatment. Multiple recurrent aneurysms with angiitis of the central nervous system. The patient underwent 2 aneurysm clipping operations, both of which completely clipped the aneurysm. The patient recovered well after surgery. Three months after discharge, DSA reexamination in our hospital showed that the aneurysm was completely clipped without recurrence. Subarachnoid hemorrhage after acute cerebral infarction is rare. In addition, the patient had recurrent aneurysms after the first aneurysm clipping, which emphasized the importance of postoperative drug therapy and blood pressure control.

Raised Blood Pressure as a Risk Factor of Post-Operative Seroma Formation in Patients of Modified Radical Mastectomy

Despite seroma is rarely potentially lethal and is typically harmless, it can cause considerable sequelae such as flap necrosis, wound dehiscence, predisposes to infection. The objective of the study was to determine the association of raised blood pressure as a risk factor of development of seroma after MRM in breast cancer patients. Material Methods: In this case control study, all women of age 30 to 70 years with MRM done for carcinoma of the breast of stage T2 and lymph nodes N2 were enrolled and followed for 3 days after MRM surgery for seroma formation. Out of total 122 patients, 64 patients were cases and 58 controls. Patients with disease upto N2 had level 2 clearances with upfront surgery. Age, history of essential hypertension, compression bandage applied, serum albumin level, seroma formation and volume of seroma on 3rd post-operative day was documented. Results: Mean age of the patients was 51.2 + 9.5 years and 53.5 + 10.8 years in case and control, respectively. Majority of the patients were of the age group 40 to 50 year’s age group. 56.3% (n=36) cases and 43.8% (n= 28) controls had history of essential hypertension. Seroma formation was seen in cases 51% (n=31) as compare to controls 13% (n= 8) with odd ratio OR 1.48. Drainage volume among two groups was analyzed as in case group, the drainage volume was 148.1 + 76.4 ml (range 50 to 290) while in control group the drainage volume was 130 + 56.9 ml (60 to 250) and was statistically significant with p-value <0.001. Conclusion: Although the pathogenesis of seroma remains controversial, hypertension is the most consistent significant risk factor for seroma formation subsequent to modified radical mastectomy for carcinoma breast. Good pre, peri and post-operative blood pressure control can reduce the risk of seroma formation and the associated morbidity. Keywords: MRM, Seroma, nodal clearance, breast cancer,

Nicardipine Is a Safe, Efficacious, and Cost-Effective Antihypertensive for Neonates and Young Infants Undergoing Cardiac Surgery.

The use of nicardipine in congenital cardiac surgery has been guarded given the calcium sensitivity of immature myocardium and paucity of clinical data. Reports of nicardipine use have excluded neonates with single ventricles. The goal of this study was to compare the use of nicardipine and sodium nitroprusside for postoperative blood pressure control in young patients recovering from cardiac surgery. All neonates (<30 days) and young infants (31-180 days) who received either sodium nitroprusside or nicardipine as first-line therapy for blood pressure control were retrospectively reviewed. Some patients had multiple index operations and each index operation was counted separately regarding treatment with sodium nitroprusside or nicardipine. A total of 59 patients underwent 70 procedures (24 as neonates and 46 as infants). Nicardipine was administered as initial therapy following 33 procedures (n = 28 patients), and sodium nitroprusside was administered as initial therapy following 37 index procedures (n = 31 patients). The duration of treatment was longer (P = .025) when sodium nitroprusside was the initial treatment. Five (15%) patients that received nicardipine required a second blood pressure management agent, and seven (19%) patients that received sodium nitroprusside required a second agent (P = .66). No adverse events related to titratable antihypertensive therapy were recorded in any treatment group. The use of nicardipine resulted in significant medication cost reduction. Based on average wholesale price, patient costs for sodium nitroprusside use were $182,952 ($5,544/pt), while costs for nicardipine were only $24,960 ($780/pt). Nicardipine can be safely used as a first-line antihypertensive in infants. The use of nicardipine as initial antihypertensive therapy rather than sodium nitroprusside can lead to a significant reduction in medication costs without jeopardizing clinical outcomes.

The ClearSight System for Postoperative Arterial Blood Pressure Monitoring After Carotid Endarterectomy: A Validation Study.

BACKGROUNDThe majority of postoperative events in patients undergoing carotid endarterectomy (CEA) are of hemodynamic origin, requiring preventive strict postoperative arterial blood pressure (BP) control. This study aimed to assess whether BP monitoring with noninvasive beat-to-beat ClearSight finger BP (BPCS) can replace invasive beat-to-beat radial artery BP (BPRAD) in the postoperative phase.METHODSThis study was a single-center clinical validation study using a prespecified study protocol. In 48 patients with symptomatic carotid artery stenosis, BPCS and BPRAD were monitored ipsilateral in a simultaneous manner during a 6-hour period on the recovery unit following CEA. Primary endpoints were accuracy and precision of BP derived by ClearSight (Edward Lifesciences, Irvine, CA) vs. the reference standard (Arbocath 20 G, Hospira, Lake Forest, IL) to investigate if BPCS is a reliable noninvasive alternative for BP monitoring postoperatively in CEA patients. Validation was guided by the standard set by the Association for Advancement of Medical Instrumentation (AAMI), considering a BP-monitor adequate when bias (precision) is <5 (8) mm Hg. Secondary endpoint was percentage under- and overtreatment, defined as exceedance of individual postoperative systolic BP threshold by BPRAD or BPCS in contrast to BPCS or BPRAD, respectively.RESULTSThe bias (precision) of BPCS compared to BPRAD was −10 (13.6), 8 (7.2) and 4 (7.8) mm Hg for systolic, diastolic and mean arterial pressure (MAP), respectively. Based on BPCS, undertreatment was 5.6% and overtreatment was 2.4%; however, percentages of undertreatment quadrupled for lower systolic BP thresholds.CONCLUSIONSNoninvasive MAP, but not systolic and diastolic BP, was similar to invasive BPRAD during postoperative observation following CEA, based on AAMI criteria. However, as systolic BP is currently leading in postoperative monitoring to adjust BP therapy on, BPCS is not a reliable alternative for BPRAD.

Descending thoracic aorta\u2013abdominal aortic bypass and bilateral renal arterial blood circulation reconstruction are effective in atypical coarctation of the aorta with heart failure: a case report

BackgroundThere are a lot of reports of the renal failure and heart failure due to coarctation of the aorta. However, there are no case reports in which revascularization dramatically improved left ventricular function in patients with progressive decline in left ventricular function. Herein, we present a rare case in which the left ventricular function was dramatically improved by surgical treatment for progressive left ventricular dysfunction due to atypical coarctation of the aorta.Case presentationA 58-year-old man underwent left axillary artery-bilateral femoral artery bypass at another hospital for atypical coarctation of the aorta due to Takayasu’s arteritis. Approximately 10 years later, he was re-hospitalized for heart failure, and the left ventricular ejection fraction gradually decreased to 28%. Computed tomography showed severe calcification and stenosis at the same site from the peripheral thoracic descending aorta to the lower abdominal aorta of the renal artery, and aortography showed delayed bilateral renal artery blood flow. An increase in plasma renin activity was also observed. Despite the administration of multiple antihypertensive drugs, blood pressure control was insufficient. We decided to perform surgical treatment to improve progressive cardiac dysfunction due to increased afterload and activated plasma renin activity. Descending thoracic aorta-abdominal aorta bypass and revascularization of the bilateral renal arteries via the great saphenous vein grafts were performed. Postoperative blood pressure control was improved, and the dose of antihypertensive drugs could be reduced. Plasma renin activity decreased, and transthoracic echocardiography 1.5 years later showed an improvement in contractility with a left ventricular ejection fraction of 58%.ConclusionIn atypical coarctation of the aorta in patients with decreased bilateral renal blood flow, heart failure due to renal hypertension, and progressive decrease in left ventricular contractility, descending thoracic aorta-abdominal aortic bypass and bilateral renal artery recirculation can be extremely effective.

The Ross procedure is an excellent operation in non-repairable aortic regurgitation: insights and techniques.

The Ross procedure is the best operation to treat aortic stenosis (AS) in young and middle-aged adults. However, its role in non-repairable aortic regurgitation (AR) remains debated since many historical series have reported an increased risk of pulmonary autograft dilatation and subsequent need for reintervention in these patients. Some have attributed these findings to an unrecognized and poorly characterized inherited genetic defect that prevents adaptive remodelling of the pulmonary autograft. Herein, we review the contemporary evidence surrounding the use of the Ross procedure in young adults with AR and put forth the argument that with proper technical refinements, the Ross procedure may still be the best operation to treat these patients. We believe that by tailoring the operation to the patient's anatomy and ensuring strict postoperative blood pressure control, one can achieve excellent results with the Ross procedure, including in this challenging patient population.

The Impact of Perioperative Blood Pressure on Hematoma Development After Panniculectomy.

Hematoma affects 10% to 13% of patients undergoing panniculectomy. Although elevated perioperative blood pressure has been associated with hematoma after rhytidectomy, this has not been established for panniculectomy. We sought to determine the impact of perioperative blood pressure on hematoma development in patients undergoing panniculectomy. A retrospective review was performed on patients undergoing isolated panniculectomy procedures. Blood pressure parameters recorded included systolic blood pressures (SBPs), diastolic blood pressures (DBPs), and mean arterial pressure. The mean, peak, and trough blood pressure values were recorded. Preoperative, intraoperative, and postoperative blood pressures were recorded, and differences between phases were calculated. Univariate and multivariate logistic regressions were performed. One hundred forty-three patients were identified, which included 84% (n = 120) women and 17% (n = 23) men. A history of hypertension was present in 55% (n = 79) of patients, of which 91% (n = 72) were medically controlled. Preoperative antiplatelet or anticoagulation was used in 21% (n = 31) of patients. Seven patients (5%) developed a hematoma, of which 5 required operative drainage. Development of hematoma was not associated with patient, surgical, or postoperative pain variables. There was an association between hematoma and elevated postoperative blood pressures on univariate and multivariate analyses. The mean peak SBP in the hematoma group was 160 mm Hg in comparison to 141 mm Hg in the nonhematoma group. For each 10-mm Hg increase in postoperative peak SBP, the odds of a hematoma increased by 2.8 times. When comparing phases of care, hematoma patients had similar intraoperative and postoperative peak SBP, but their postoperative SBP was 19 mm Hg higher than preoperative baseline. Conversely, nonhematoma patients had a postoperative blood pressure that was similar to their preoperative baseline and 20 mm Hg lower than their intraoperative values. Hematoma is associated with elevated postoperative blood pressures. A postoperative mean peak SBP of 160 mm Hg was associated with hematoma, and for each 10 mm Hg, the risk of hematomsa increased by 2.8 times. The risk of hematoma may be reduced by strict postoperative blood pressure control. We recommend a postoperative peak SBP goal of 140 mm Hg or less, with a value equal to or less than their preoperative baseline and 20 mm Hg lower than their intraoperative pressure.

Laparoscopic versus open surgery for pheochromocytoma: a meta-analysis

BackgroundSurgical resection is the main treatment for pheochromocytoma (PHEO). Although open surgery (OS) has been shown to be safe and feasible, the safety and efficacy of laparoscopic surgery (LS) for PHEO remain controversial due to the uncertain effects of pneumoperitoneum on haemodynamics and the complexity of the tumour itself. This study was performed to compare the treatment outcomes of OS with those of LS for patients with PHEO.MethodsA systematic search through November 11, 2019, was conducted. All studies comparing outcomes of LS and OS for PHEO were included according to eligibility criteria. This meta-analysis was conducted using Review Manager Software, version 5.3, and STATA software, version 12.0. The quality of the included studies was assessed using the Newcastle-Ottawa scale.ResultsFourteen studies involving 626 patients were included in this meta-analysis. LS was associated with lower rates of intraoperative haemodynamic instability (IHD) [odds ratio (OR) = 0.61, 95% CI: 0.37 to 1.00, P = 0.05], less intraoperative blood loss [weighted mean difference (WMD) = − 115.27 ml, 95% confidence interval (CI): − 128.54 to − 101.99, P < 0.00001], lower blood transfusion rates [OR = 0.33, 95% CI: 0.21 to 0.52, P < 0.00001], earlier ambulation (WMD = − 1.57 d, 95% CI: − 1.97 to − 1.16, P < 0.00001) and food intake (WMD = − 0.98 d, 95% CI: − 1.36 to − 0.59, P < 0.00001), shorter drainage tube indwelling time (WMD = − 0.51 d, 95% CI: − 0.96 to − 0.07, P = 0.02) and postoperative stay (WMD = − 3.17 d, 95% CI: − 4.76 to − 1.58, P < 0.0001), and lower overall complication rates (OR = 0.56, 95% CI: 0.35 to 0.88, P = 0.01). However, no significant differences in operative time, postoperative blood pressure control, rates of severe complications, postoperative hypotension or cardiovascular disease (CVD) were found between the two groups.ConclusionsLS is safe and effective for PHEO resection. Compared with OS, LS caused less IHD, providing an equal chance to cure hypertension while also yielding a faster and better postoperative recovery.

Early blood pressure management for endovascular therapy in acute ischemic stroke: A review of the literature.

The perioperative optimal blood pressure targets during mechanical thrombectomy for acute ischemic stroke are uncertain, and randomized controlled trials addressing this issue are lacking. There is still no consensus on the optimal target for perioperative blood pressure in acute ischemic stroke patients with large vessel occlusion. In addition, there are many confounding factors that can influence the outcome including the patient's clinical history and stroke characteristics. We review the factors that have an impact on perioperative blood pressure change and discuss the influence of perioperative blood pressure on functional outcome after mechanical thrombectomy. In conclusion, we suggest that blood pressure should be carefully and flexibly managed perioperatively in patient-received mechanical thrombectomy. Blood pressure changes during mechanical thrombectomy were independently correlated with poor prognosis, and blood pressure should be maintained in a normal range perioperatively. Postoperative blood pressure control is associated with recanalization status in which successful recanalization requires normal range blood pressure (systolic blood pressure 120-140mmHg), while non-recanalization requires higher blood pressure (systolic blood pressure 160-180mmHg). The preoperative blood pressure targets for mechanical thrombectomy should be tailored based on the patient's clinical history (systolic blood pressure ≤185mmHg). Blood pressure should be carefully and flexibly managed intraoperatively (systolic blood pressure 140-180mmHg) in patient-received endovascular therapy.

Incidence and Risk Factors of Intracranial Hemorrhage in Liver Transplant Recipients.

Intracranial hemorrhage after liver transplantation is an infrequently reported complication but one which can have devastating consequences. We performed a retrospective cross-sectional analysis of all liver transplants performed between January 2010 and June 2015 at a single high-volume institution using a prospectively maintained electronic database and query of the electronic medical record. Cases of intracranial hemorrhage were adjudicated as either spontaneous intraparenchymal hemorrhage(IPH) or extra-axial hemorrhage (EAH). Patients with confirmed intracranial hemorrhage were compared with all other liver transplant recipients. Risk factors were identified by univariate analysis and logistic regression models for IPH and EAH. Thirty-one (5.2%) of 595 liver transplant recipients developed an intracranial hemorrhage within 12 months of transplantation, 15 IPH and 16 EAH. The majority of intracranial hemorrhages were diagnosed within 1 month of transplantation. Eight (26%) intracranial hemorrhage patients died during hospitalization. Fourteen (45%) intracranial hemorrhage patients died within 1 year of transplantation and 1-year mortality was greater than in patients without intracranial hemorrhage (11.2%, P < 0.01). Female sex (adjusted odds ratio [OR], 3.291; 95% confidence interval [CI], 1.092-9.924; P = 0.034), higher pretransplant bilirubin (adjusted OR, 1.037; 95% CI, 1.006-1.070; P = 0.020), and greater increase in pretransplant to posttransplant systolic blood pressure (adjusted OR, 1.029; 95% CI, 1.006-1.052; P = 0.012) were associated with posttransplant IPH. Lower pretransplant serum fibrinogen level (adjusted OR, 0.988; 95% CI, 0.979-0.998; P = 0.017) was associated with posttransplant EAH. Postoperative blood pressure control and pretransplant fibrinogen levels may be modifiable risk factors for preventing posttransplant intracranial hemorrhage.

Invited commentary

Invited commentary

Cortical blindness as a rare presentation of hemorrhagic cerebral hyperperfusion syndrome following vertebral angioplasty

Cerebral hyperperfusion syndrome (CHS) is a well-documented complication after carotid endarterectomy or stenting. In contrast, CHS following vertebral revascularization is extremely rare. Here we present a case of a 77-year-old...

NP-59 test for preoperative localization of primary hyperaldosteronism.

Adrenal venous sampling is generally considered the gold standard to identify unilateral hormone production in cases of primary hyperaldosteronism. The aim of this study is to evaluate whether the iodine-131-6-β-iodomethyl-19-norcholesterol (NP-59) test may represent an alternative in selected cases. Patients submitted to laparoscopic adrenalectomy for suspected primary hyperaldosteronism (n=27) were retrospectively reviewed. When nuclear medicine tests were preoperatively performed, their results were compared with the histopathologic findings and clinical improvement. Nuclear medicine tests were realized in 13 patients. In 11 (84.6%), a planar anterior and posterior NP-59 scintigraphy was performed and a SPECT/TC in two (15.4%). Scintigraphy indicated a preoperative lateralization in 12 out of 13 patients (92.3%). When the value of NP-59 tests was based on pathologic results, it showed a sensitivity of 90.9% and a positive predictive value of 83.3%. When the nuclear medicine test's performance was based on postoperative blood pressure control, both sensitivity and positive predictive value were 91.6%. Nuclear medicine tests represent a useful tool in the preoperative localisation of primary hyperaldosteronism with a high sensitivity and positive predictive value. In patients with contraindications to adrenal venous sampling like contrast allergies, or when it is inconclusive, scintigraphy can represent a useful and non-invasive alternative.

Analysis of the causes of postoperative bleeding in hypertensive intracerebral hemorrhage patients

Objective To explore the reasons for rebleeding and its coping strategies. Methods To study the 19 hypertensive intracerebral hemorrhage patients' medical records who suffered postoperative rebleeding in our department from June 2011 to May 2015. Results Rebleeding time: within 6 hours: 11 cases, 6~24 hours: 5 cases, 2~3 weeks: 3 cases.Among 19 cases, hematoma puncture drainage in 2 cases, small bone window craniotomy surgery in 9 cases, craniotomy with big bone flap decompression in 8 cases, 6 cases with severely disabled and 7 cases died. Conclusion Intraoperative bleeding operation is not standardized, early postoperative blood pressure control failure in patients, preoperative instability function are the main causes of postoperative bleeding.Choosing a better operating time, the specification intraoperative hemostasis and controlling blood pressure to stable after surgery can reduce the membership of hypertensive intracerebral hemorrhage incidence of postoperative bleeding. Key words: Cerebral hemorrhage; High blood pressure; Department of Neurosurgery operation; Rebleeding

The Effects of Dexmedetomidine and Remifentanil on Hemodynamic Stability and Analgesic Requirement After Craniotomy: A Randomized Controlled Trial.

Anesthesia for craniotomies should blunt responses to noxious stimuli, whereas subsequently leaving patients sufficiently alert for early neurological evaluation. The aim was to compare postoperative blood pressure control, pain, and opioid requirement after anesthesia with dexmedetomidine versus remifentanil. We therefore tested 2 primary hypotheses: (1) intraoperative administration of dexmedetomidine provides better control of postoperative blood pressure than remifentanil; and (2) patients given dexmedetomidine have less postoperative pain and use less opioid. Adults having elective brain tumor excisions under balanced general anesthesia with endotracheal intubation were randomized to an infusion of remifentanil (0.08 to 0.15 μg/kg/min, n=71) or dexmedetomidine (0.2 to 0.7 μg/kg/h, n=68). Patients also received propofol, rocuronium, fentanyl, and sevoflurane. The mean arterial pressure (MAP) and pain were recorded at 15, 30, 45, 60, and 90 postoperative minutes. Outcomes were assessed with joint hypothesis testing, evaluating noninferiority and superiority. Compared with remifentanil, the use of dexmedetomidine was associated with reduced postoperative MAP (88±12 vs. 98±11 mm Hg), with estimated mean difference (97.5% confidence interval) of -10 (-13, -4) mm Hg, P<0.001, and mean visual analog pain score (2.9±2.6 vs. 5.1±2.4 points), with estimated mean difference of -5 (-10, -3) points, P<0.001, and required less median opioid consumption (5 [0, 10] vs. 10 [7, 15] mg morphine equivalents), with estimated median difference of -5 (-10, -3) mg, P<0.001. Dexmedetomidine was both noninferior and superior to remifentanil in maintaining postoperative hemodynamics and providing improved pain control. Intraoperative dexmedetomidine better controlled postoperative MAP and provided superior analgesia in patients undergoing craniotomy.

Comparison of Clevidipine Versus Sodium Nitroprusside for the Treatment of Postoperative Hypertension in Cardiac Surgery Patients.

To evaluate the efficacy and safety of clevidipine (CLV) versus sodium nitroprusside (SNP) for the treatment of hypertension (HTN) in postoperative cardiac surgery patients at a community hospital. This single-center, retrospective, cohort study included cardiac surgery patients treated with CLV or SNP for postoperative systolic blood pressure (SBP) control. The primary efficacy outcome was defined as the mean number of times the SBP rose above 140 mm Hg. Secondary outcomes included a comparative cost analysis and a safety analysis. Forty patients were included in each arm. Patients who received CLV had a higher incidence of SBP readings greater than 140 mm Hg (p < .05). There were no differences in safety outcomes, number of patients who received as-needed (PRN) antihypertensives, or mean number of PRN antihypertensives required. There were differences in infusion duration (22.4 hours CLV vs 15.6 hours SNP; p = .035), number of infusions dispensed (2.8 CLV vs 1.3 SNP; p = .001), and length of hospital stay (12.33 days CLV vs 7.65 days SNP; p = .013). However, CLV was less expensive based on the AWP cost at the time of review. Although a difference in blood pressure control was seen between CLV and SNP, the safety profiles were similar between the 2 drugs. In addition, CLV remained less expensive than SNP for postoperative BP control.

Does postoperative blood pressure influence development of aortic regurgitation following continuous-flow left ventricular assist device implantation?†.

The true impact of postoperative blood pressure (BP) control on development of aortic regurgitation (AR) following continuous-flow left ventricular assist device (CF-LVAD) implantation remains uncertain. This study examines the influence of BP in patients with de novo AR following CF-LVAD implantation. All patients with no or <mild AR who underwent CF-LVAD implantation from July 2006 to July 2012 at our institute and with subsequent device-support of ≥3months (n = 90) were studied. Serial echocardiograms and BP readings were obtained preoperatively, postoperatively at 1, 3 and 6 months, and then at a minimum of 4-monthly intervals. BP readings were compared between patients who developed mild AR (AR group) versus those who did not (non-AR group). Logistic regression analysis was used to define independent predictors of ≥mild AR following CF-LVAD implantation. Median duration of CF-LVAD support was 575 days (range: 98-2433 days). Forty-eight patients (53.3%) developed mild AR over a median duration of 126 days. BP readings (median values, mmHg) between AR and non-AR groups showed statistically significant differences: at 3 months-systolic 99.5 vs 92.5 (P = 0.038), diastolic 81.5 vs 66 (P < 0.001), mean 86.5 vs 74 (P < 0.001) and at 6 months-diastolic 73 vs 62 (P = 0.044), mean 83 vs 74.5 (P = 0.049), respectively. Systolic BP at 3 months (P = 0.047, 95% CI 0.453-0.994, OR 0.671), aortic valve (AoV) closure (P = 0.01, 95% CI 0.002-0.429, OR 0.029) and duration of support (P = 0.04, 95% CI 1.000-1.009, OR 1.004) were found to be independent predictors of AR following CF-LVAD implantation. BP readings at 3 months and 6 months showed a statistically significant association with ≥mild AR following CF-LVAD implantation, with systolic blood pressure at 3 months, aortic valve closure and longer support duration being independent predictors. Clinical implications of these data may warrant consideration of aggressive early control of BP to protect against the development/progress of AR following CF-LVAD implantation.

Factors that determine the length of stay after carotid endarterectomy represent opportunities to avoid financial losses

A postoperative length of stay (LOS) >1day after elective surgery incurs financial losses for hospitals, given fixed diagnosis-related group-based reimbursement. We sought to identify factors leading to a prolonged LOS (>1 postoperative day) after carotid endarterectomy (CEA). Patients undergoing CEA in 23 centers of the Vascular Study Group of New England between 2003 and 2011 (n= 8860) were analyzed. Only elective, primary CEAs were analyzed, leaving a study cohort of 7108 procedures. Hierarchical multivariable logistic regression analysis was performed to identify predictors of a postoperative LOS >1day. A Knaus-Wagner chi-pie analysis was performed to determine the relative contributions of each significant covariate to a postoperative LOS >1day. A postoperative LOS >1day occurred in 17.5% of the sample (n= 1244). The average LOS was 1.4days (range, 1-91days; median, 1). There was significant variation in rates of postoperative LOS >1day across centers (range, 5%-100%; P< .001). Factors independently associated with a postoperative LOS >1day and their percentage contribution to the prediction model included the need for postoperative intravenous medications for hypertension or hypotension (26%), any major adverse event (MAE) postoperatively (21%), low-volume (<15 CEAs per year) surgeons (28%), increasing age (7%), female gender (4%), positive result on a preoperative stress test (3%), preoperative major stroke ≤30days (2%), medication-dependent diabetes (1%), severe chronic obstructive pulmonary disease (1%), history of congestive heart failure (1%), and CEA performed on Friday (2%). Certain patient characteristics predispose to a postoperative LOS >1day after elective CEA. However, patient characteristics play only a modest (17%) role in determining LOS. The need for postoperative blood pressure control and MAEs are the biggest drivers of postoperative LOS >1day, but system factors, such as low operative volume, contribute substantially to postoperative LOS >1day, independent of MAEs. These findings can be used to guide quality improvement efforts designed to reduce LOS after elective CEA.

Clinical Effect of Endovascular Treatment on Blood Pressure and Kidney Function for Hypertensive Patients with Renal Artery Stenosis

The objective of this study was to evaluate the clinical effect of endovascular treatment on postoperative blood pressure (BP) control and kidney function of hypertensive patients with renal artery stenosis (RAS). Between January 2004 and December 2011, RAS was diagnosed in 120 renal arteries from 115 hypertensive patients. Preoperative and postoperative BPs and glomerular filtration rate (GFR) were monitored. Postoperative oral antiplatelet and antihypertensive agents were administered. Clinical follow-up was available for all patients for at least 6 months. Balloon angioplasty was performed successfully in 110 patients, and stents were deployed in 94 renal arteries from 89 patients. Hypertension was cured and lessened in 19 and 61 patients, respectively. Blood pressure was stable and worsened in 26 and 9 patients, respectively. The renal function was improved and stable in 23 patients and 57 patients, respectively. Deterioration of renal function was observed in 11 patients. Doppler ultrasound after discharge revealed 87 patent renal arteries and fixed stents in 82 patients 6 months after procedure. Balloon angioplasty and stent deployment are effective and feasible procedures for patients with RAS that help in controlling BP and improving renal function moderately.