Significance In Cardiac Surgery Research Articles

A Morphometric Study of Adult Human Sterna from the Galloway Osteological Collection

Background: Morphometric knowledge of the sternum is of great significance in cardiac surgery as variations in sternal dimensions have been considered a risk factor for translocation of suture material during median sternotomy, leading to poor outcomes. Fatalities attributed to subnor- mal sternal thickness have also been reported during sternal biopsies. Fractures of the sternum secondary to chest injury or cardio-pulmonary resuscitation may also be influenced by sternal thickness. Elongated xiphoid process can be mistaken for an epigastric mass which can be painful on palpation. Morphometric studies of African sterna are rare. The objective is to the study sought to describe the morphometry of adult sterna from the Galloway bone collection, Makerere University, Kampala, Uganda. Subjects and Methods: This study employed a descriptive cross sectional design to collect and analyze quantitative data. Eighty five dry adult sterna (75 males and 10 females) were examined at the Department of Human Anatomy, Makerere University. Data analysis at univariate and bivariate levels were performed using SPSS version 21.0 statistical software. Results:A significant difference in the average length of the mesosternum was found between males at 94.6 mm (SD 11.2) and females at 82.2 mm (SD 15.2) (P=0.002). Two cases (9.5%) presented with elongated xiphoid process and one (1.2%) with subnormal mesosternal thickness. Conclusions: Our study highlights the importance of knowledge of the sternal morphometry in sex identification, physical examination, sternal puncture and other thoracic procedures, calling for increased awareness of the findings.

The systemic immune-inflammation index is associated with early postoperative morbidity and mortality following cardiac surgery

Abstract Background The pathogenesis of cardiovascular diseases (CVD) is sustained by persistent low-grade systemic inflammation. Lipid deposition, atherosclerotic plaque formation, toll-like receptor activation, leukocyte infiltration and secretion of pro-inflammatory mediators collectively promote chronic low-grade inflammation which drives CVD-progression. Despite the well-described inflammatory processes in CVD, its perioperative clinical significance in cardiac surgery is ill-defined. Aim To evaluate the association between the preoperative chronic inflammation and postoperative outcome. We hypothesized that an elevated systemic inflammation predisposes patients to adverse postoperative outcome. Methods A retrospective analysis of 1251 consecutive adults undergoing cardiac surgery between July 2018 and Dec 2019. We used the systemic-immune-inflammation index (SII) as a marker for chronic inflammation and was calculated as follows: “platelet counts x (Neutrophil/Lymphocyte ratio)”. A Receiver Operating Characteristic (ROC) curve was generated by plotting the SII values for in-hospital mortality cases vs successfully discharged patients, the Wilcoxon estimate of area under ROC curve = 0.67; an optimum cut-off point of 647 (sensitivity = 0.72, specificity = 0.59) was chosen to classify patients with an elevated inflammatory status. We used the Fisher's exact test to assess whether the preoperative SII was related with adverse outcome. Finally, we included the SII in a multivariable logistic regression controlling for 11 established cardiac surgery mortality risk-factors. Results The median age was 65 years (range 18–88), 361 (29%) were females. The mean ACEF II operative mortality was 3.49%. The median SII before surgery was 576 (IQR 402 - 855). In comparison, the SII of a healthy control non-surgical cohort (N=60) was 434 (IQR 290–559), median difference = 142 [CI95% 84 to 223), p<0.0001. Sub-group analysis revealed that patients who passed away during hospitalisation were admitted with a significantly higher preoperative SII (= 824), median difference 255 [CI95% 143–388], p<0.0001, compared to those patients who were successfully discharged, SII = 569. Contrary to patients with low-grade systemic inflammation (= SII <647), we observed that patients with an elevated SII (≥647) were more likely to have difficulties coming off-pump, Odds Ratio (OR) 1.73, p=0.007; to experience an infection, OR 1.94, p<0.001, or death during postoperative hospitalisation, OR 3.46, p<0.0001. Multivariable logistic regression revealed that an SII ≥647 is an independent risk factor for in-hospital mortality, adjusted OR 2.67, p=0.004. Conclusion A high SII (≥647) is independently associated with postoperative morbidity and mortality following cardiac surgery. The SII may support clinical decision making and stratification of high-risk patients undergoing cardiac surgery. Funding Acknowledgement Type of funding source: None

Late Postoperative Troponin and its Significance in Cardiac Surgery

Late Postoperative Troponin and its Significance in Cardiac Surgery

N-terminal pro-Brain natriuretic peptide as a useful biomarker for monitoring prognosis in patients with cardiac valve replacement

N-terminal pro-Brain natriuretic peptide (NT-proBNP) is an important biomarker to indicate cardiac function, but its significance in cardiac surgery is still unclear. To explore clinical significance of serum NT-proBNP and their dynamic characteristics in patients with cardiac valve replacement (CVR). Dynamically detecting pre-operative and postoperative serum NT-proBNP on Elecsys 2010 in 60 CVR patients. (1) There was a good relationship between pre-operative NT-proBNP and pre-operative NYHA classification, ejection fraction, fractional shortening, or between postoperative 1 day log [NT-proBNP] and postoperative ICU time, correlation coefficients were respectively 0.426 (P=0.001), -0.465 (P=0.001), -0.463 (P=0.002), and 0.453 (P=0.006). (2) Pre-operative NT-proBNP would be higher in multivalves damage or mitral lesions patients than that in single valve damage or aortic lesions. It indicated NT-proBNP>1,352 pg/ml could discriminate multivalves damage in Rheumatic Heart Diseases (RHD) patients (sensitivity: 0.742; specificity: 0.64); and NT-proBNP>549.12 pg/ml could differentiate mitral lesions and aortic lesions (sensitivity: 0.92; specificity: 0.75). However, pre-operative serum NT-proBNP for differentiating atrial fibrillation and sinus arrhythmia was not most efficient (AUC=0.655; P=0.044). (3) Perioperative NT-proBNP in CVR patients was characterized by early postoperative NT-proBNP increasing and late postoperative NT-proBNP decreasing. The peak of postoperation NT-proBNP was at postoperative 7 days. Serum NT-proBNP was not only a good biomarker to effectively evaluate heart function but also to evaluate the cardiac valve damage in RHD patients, and postoperative NT-proBNP dynamic determination, especially detecting postoperative 1 day, 7 days and 14 days NT-proBNP would be more useful to evaluate prognosis of CVR patients.

Incidence and Predictors of Postoperative Deep Vein Thrombosis in Cardiac Surgery in the Era of Aggressive Thromboprophylaxis

Deep venous thrombosis (DVT) is a well-known complication of surgery but its significance in cardiac surgery is not well defined. We reviewed the results of a prospective observational protocol for repeated postoperative lower extremity duplex venous scans (DVS) screening starting on postoperative day 3-4 through hospital discharge. A total of 1,070 (88%) of the 1,219 overall unique adult cardiac surgery patients at our institution (August 2005 to December 2007) underwent DVS screening. The 149 exclusions included 15 due to early death (1.2%); 39 with a history of preoperative DVT (3.2%) and 93 missed patients (7.6%). All patients underwent maximally aggressive thromboprophylaxis as stipulated by the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition), and complemented with postoperative clopidogrel in coronary artery bypass grafting patients. A positive DVS (within 30 days of surgery) for at least 1 lower extremity DVT was observed in 139 of 1,070 eligible patients (DVT: 13.0%). Incidence of DVT was similar in coronary artery bypass grafting (118 of 948; 12.4%) and valve (33 of 237; 13.9%) patients. Hemorrhagic complication requiring reexploration occurred in only 19 patients (1.8%) despite thromboprophylaxis. The DVT cohort showed significantly worse operative (in-hospital or <30 days) mortality (DVT: 9 [6.5% vs no DVT: 16 [1.7%];] p < 0.003), postoperative hospital stay (14.4 +/- 12.9 vs 8.3 +/- 7.3 days; p < 0.001), and 30-day hospital readmissions (20.9% vs 10.3%; p = 0.001). Multivariate logistic regression predictors for developing DVT were increased age (odds ratio [OR; 95% confidence interval = 1.24 (1.07 to 1.41) per 10-year increments]), blood transfusion (OR = 2.24 [1.49 to 3.39]), initial time on the ventilator/prolonged mechanical ventilation (OR = 1.02 [1.01 to 1.04] per 10-hour increments), and need for reintubation (OR = 2.57 [1.48 to 4.47]). A considerable number (13%) of cardiac surgery patients develop otherwise silent DVT despite maximal thromboprophylaxis. Aggressive mechanical and pharmacologic thromboprophylaxis in this population appears safe and indicated. Whether routine postoperative DVS screening alters patients' outcomes and is cost effective remains undefined, but should be considered in case of a complicated-prolonged postoperative course.

Morphological comparison of the cardiac autonomic nervous system between normal and abnormal great arterial branching pattern with a brief review of the literature

Information on the topological relationship between arterial and peripheral autonomic nervous systems is insufficient for application to other research fields as each system has been analyzed separately during a long anatomical history. In the present study, we scrutinized the topological changes in the cardiac autonomic nervous system (CANS) in cadavers with a normal great arterial branching pattern of the aortic arch and in those with an anomalous left vertebral artery. These results were then compared with our previous report on cadavers with a retroesophageal right subclavian artery, and we attempted to consider the possible morphological causal principles of the changes. This report would be useful not only for morphological research but also to improve cardiac treatment and animal experiments. Although the CANS shift was considered when a great arterial branching anomaly appeared, additional cardiac nerves along the anomalous artery were found in addition to the normal CANS composition, based on our present and previous anomalous reports. From both developmental and anatomical viewpoints, CANS may depend on the surrounding arterial system. Therefore, a detailed analysis of the peripheral autonomic nervous system with its surrounding structures, especially the arterial system, has filled the gap between morphological and molecular embryological research in addition to the clinical significance in cardiac surgery, the understanding of experimental results, and the application to cardiac functions.