Undergoing Heart Valve Surgery Research Articles

Development of Persistent Opioid Use After Cardiac Surgery

The overuse of opioids for acute pain management has led to an epidemic of persistent opioid use. To determine the proportion of opioid-naive patients who develop persistent opioid use after cardiac surgery and investigate the association between the initial amount of opioids prescribed at discharge and the likelihood of developing new persistent opioid use. This retrospective cohort study used data from a national administrative claims database from January 1, 2004, to December 31, 2016 and included 35 817 patients who underwent coronary artery bypass grafting (CABG) (25 673 [71.7%]) and heart valve (10 144 [28.3%]) procedures. All patients were opioid-naive within 180 days before the index procedure and filled an opioid prescription within 14 days after surgery. Opioid medications after cardiac surgery. The proportion of opioid-naive patients who developed new persistent opioid use within 90 to 180 days after surgery was determined. Oral morphine equivalents (OMEs) were calculated for the first opioid prescription filled after discharge. A multivariable logistic regression with cubic splines was used to analyze the association among the OMEs at discharge and likelihood of developing persistent opioid use. Of the 25 673 patients who underwent CABG, the mean (SD) age for those without (n = 23 064) vs with (n = 2609) persistent opioid use was 62.9 (9.8) years vs 61.6 (9.7) years, respectively, and the number who were men were 18 758 (81.3%) vs 1998 (76.6%). Of the 10 144 patients who underwent heart valve surgery, the mean (SD) age for those without (n = 9343) vs with (n = 821) persistent opioid use was 63.2 (12.4) years vs 61.2 (12.5) years, respectively, and the number who were men were 6378 (68.3%) vs 511 (62.2%). Persistent opioid use is a substantial concern after cardiac surgery and occurred in 2609 patients undergoing CABG (10.2%) and 821 valve surgery patients (8.1%; P = .001). The likelihood for developing persistent opioid use was decreased among heart valve surgery recipients (odds ratio [OR], 0.78; P < .001) and increased for patients who were women; younger; with preoperative congestive heart failure, chronic lung disease, diabetes, kidney failure, chronic pain, and alcoholism; and those taking preoperative benzodiazepines and muscle relaxants (women: OR, 1.15 [95% CI, 1.03-1.26]; younger age: OR, 1.02 [95% CI, 1.01-1.02]; congestive heart failure: OR, 1.17 [95% CI, 1.06-1.30]; chronic lung disease: OR, 1.32 [95% CI, 1.19-1.45]; diabetes: OR, 1.27 [95% CI, 1.15-1.40]; kidney failure: OR, 1.17 [95% CI, 1.00-1.37]; chronic pain: OR, 2.71 [95% CI, 2.10-3.56]; alcoholism: OR, 1.56 [95% CI, 1.23-2.00]; benzodiazepines: OR, 1.71 [95% CI, 1.52-1.91]; muscle relaxants: OR, 1.74 [95% CI, 1.51-2.02]; all P < .001). Furthermore, we found that when patients were prescribed more than approximately 300 mg of OMEs at discharge, they had a significantly increased risk of new persistent opioid use than with lower opioid prescriptions. Opioids are used extensively after cardiothoracic surgery and nearly 1 of 10 patients will continue to use opioids over 90 days after surgery. Furthermore, higher OMEs prescribed at discharge were significantly associated with developing persistent use. Centers must adopt protocols to increase patient education and limit opioid prescriptions after discharge.

Timing of peptide receptor radiotargeted therapy in relation to cardiac valve surgery for carcinoid heart disease in patients with neuroendocrine metastases and cardiac syndrome. A single-centre study from a centre of excellence.

Perioperative mortality of patients who undergo heart valve surgery for carcinoid heart valve disease has been observed to be high (5%-10%). We investigated whether peptide receptor radiotherapy with lutetium-177 dotatate can be used safely in patients with neuroendocrine neoplasm carcinoid heart valve disease and if there is associated survival advantage by reducing overall exposure of the valves to high doses of vasoactive peptides. Retrospective case notes review was performed on 18 neuroendocrine neoplasm patients (mean 60 years), who underwent heart valve surgery between 2003 and 2017 for carcinoid heart valve disease, 9 of whom received peptide receptor radiotherapy in addition to surgery. All patients were treated with somatostatin receptor antagonists and underwent cardiac valvular surgery (mean two valves replaced) and three benefitted from additional coronary bypass grafting. Nine patients underwent surgery alone: in this group, the time from surgery to progression was 14 months (mean; SD 13.5 months). Nine were treated with peptide receptor radiotherapy in addition to surgery. Six underwent surgery with peptide receptor radiotherapy on progression. Time to progression from surgery to first peptide receptor radiotherapy was mean 25.1 months (SD 23.6 months). No patients developed peritreatment cardiac complications. There were no deaths within the 30-day postoperative period. Average time from surgery to last follow-up/death was 41 months (6-79) in the surgery + lutetium group and in the surgery only group 17 months (1-24). Nine patients died, five in the surgery + lutetium group and four in the surgery only group, all at greater than 1-year postsurgery. Peptide receptor radiotherapy is safe in the setting of Carcinoid valvular heart disease in patients with controlled heart failure, PPRT can be use in the pre- and post-valve surgery period. There appears to be a survival benefit of having peptide receptor radiotherapy. Further evidence for peptide receptor radiotherapy in the neoadjuvant setting prior to cardiothoracic surgery is required.

Recurrent infective endocarditis versus first-time infective endocarditis after heart valve surgery.

Infective endocarditis (IE) may require heart valve surgery. It is well known that heart valve surgery itself and previous IE predispose to IE. However, data are sparse on whether the risk of IE is different among patients undergoing valve surgery due to IE and other causes (i.e. recurrent vs. first-time IE). Using Danish nationwide registries, patients undergoing left-sided heart valve surgery in the course of an IE hospitalization (1996-2017) were identified and matched with controls undergoing left-sided heart valve surgery due to another cause than IE in a 1:1 ratio. Patients were stratified according to type of surgical valve intervention and affected valve. The comparative risk of recurrent vs. first-time IE was assessed by cumulative incidence curves and multivariable Cox regression analyses. The study population comprised 971 patients with a first-time admission for IE requiring heart valve surgery matched with 971 controls undergoing heart valve surgery due to other causes than IE. The risk of recurrent IE was significantly higher than the risk of first-time IE following heart valve surgery (5.5% and 3.0% by 10years, hazard ratio (HR) 1.66, 95% confidence interval (CI) 1.02-2.70). The risk of IE recurrence was not significantly different comparing valve replacement and valve repair (5.5% and 5.3%, respectively, HR 1.60, 95% CI 0.71-3.60). Yet, the risk of IE recurrence was significantly higher among patients with biological versus mechanical prostheses (6.3% and 4.6%, respectively, HR 2.00, 95% CI 1.02-3.70). Following heart valve surgery, the risk of recurrent IE was significantly higher than the risk of first-time IE.

Changes in Physical Performance and Their Association With Health-Related Quality of Life in a Mixed Nonischemic Cardiac Population That Participates in Rehabilitation.

Exercise-based cardiac rehabilitation improves physical performance and health-related quality of life (HRQoL). However, whether improvements in physical performance are associated with changes in HRQoL has not been adequately investigated in a nonischemic cardiac population. Patients who were ablated for atrial fibrillation, who underwent heart valve surgery or who were treated for infective endocarditis, and who participated in 1 of 3 randomized controlled rehabilitation trials were eligible for the current study. Change in physical performance and HRQoL were measured before and after a 12-wk exercise intervention. Physical performance was assessed using a cardiopulmonary exercise test, a 6-min walk test, and a sit-to-stand test. Health-related quality of life was assessed using the generic 36-Item Short Form Health Survey and the disease-specific HeartQoL questionnaire. Spearman correlation coefficient (ρ) and linear regressions quantified the association between changes in physical outcome measures and changes in HRQoL. A total of 344 patients were included (mean age: 60.8 ± 11.6 yr and 77% males). Associations between changes in physical outcome measures and HRQoL ranged from very weak to weak (ρ = -0.056 to 0.228). The observed associations were more dominant within physical dimensions of the HRQoL compared with mental or emotional dimensions. After adjusting for sex, age, and diagnosis, changes in physical performance explained no more than 20% of the variation in the HRQoL. The findings show that the positive improvement in HRQoL from exercise-based cardiac rehabilitation cannot simply be explained by an improvement in physical performance.

High-Sensitivity Troponin T Predicts Postoperative Cardiogenic Shock Requiring Mechanical Circulatory Support in Patients With Valve Disease.

Cardiogenic shock is a very serious postoperative complication in patients undergoing heart valve surgery. Mechanical circulatory support is a recognized method of treating patients with this complication. The aim of the presented study was to assess the usefulness of selected biomarkers in predicting the occurrence of postoperative cardiogenic shock requiring mechanical circulatory support. This prospective study was conducted on a group of 712 patients undergoing heart valve surgery. The primary end-point at the intrahospital follow-up was postoperative cardiogenic shock requiring mechanical circulatory support. The postoperative cardiogenic shock requiring mechanical circulatory support occurred in 20 patients. At multivariate analysis high-sensitivity Troponin T measured immediately after surgery (OR 1.006; 95% CI 1.002-1.013; P 0.009) remained independent predictor of the primary end point. The postoperative hs-TnT can be used to predict a postoperative cardiogenic shock requiring mechanical circulatory support.

Coronary embolism causing myocardial infarction after heart valve surgery

Introduction. Coronary embolism can rarely be a cause of myocardial infarction. It is usually associated with atrial fibrillation, dilated cardiomyopathy, bacterial endocarditis and underlying hypercoagulable state, as well as heart surgery. Case report. We reported a case of a patient with severe mitral and tricuspid regurgitation, with no underlying coronary artery disease. The patient underwent heart valve surgery, and the immediate postoperative course was uneventful. Five days after the operation, the patient sustained cardiac arrest, which was followed by a successful cardiopulmonary resuscitation. Electrocardiography showed atrial fibrillation with a significant ST segment elevation in the inferior leads. Urgent coronary angiography revealed a total occlusion of the right coronary artery, thus percutaneous coronary intervention was performed, after which flow restoration through the artery was achieved. The patient was discharged with triple antithrombotic therapy on the 20th postoperative day. Conclusion. Heart surgery could be followed by unexpected and potentially fatal complications, coronary embolism being one of them. In such case, the prompt and adequate reaction by the whole medical team is crucial for a patient's survival and recovery.

Baseline and Outcome Characteristics of Multiple Valve Surgery Compared with Single Valve Procedures in Mainland China: A Multicenter Experience.

To compare baseline and outcome characteristics of multiple valve surgery with single-valve procedures in a multicenter patient population of mainland China. From January 2008 to December 2012, data from 14,322 consecutive patients older than 16 years who underwent heart valve surgery at five cardiac surgical centers (except pulmonary valve operations) were collected. The patients were divided into seven subgroups according to the type of valve procedures, and baseline characteristics and postoperative outcomes were contrasted between all seven combinations of single-valve and multiple-valve procedures involving aortic, mitral, and tricuspid valves. Two independent logistic regression analyses were performed and multivariable risk factors for mortality were compared, with emphasis on single-valve versus multiple-valve surgery. Baseline characteristics for MUV procedures (n = 8945) shared many differences to those for single-valve procedures (n = 5377). Proportion of females, chronic obstructive pulmonary disease, cerebrovascular disease, renal impairment, congestive heart failure, NHYA class III-IV, atrial fibrillation, pulmonary hypertension, and decreased ejection fraction were more common in MUV subgroups, and smoker, hypertension, dyslipidemia, active infectious endocarditis, and coronary bypass graft was less frequent. In-hospital mortality was higher for MUV as compared with single-valve procedures (2.4% versus 1.6%, P = .007). Preoperative independent predictors for mortality of patients undergoing MUV procedures were age, chronic obstructive pulmonary disease, diabetes mellitus, renal dysfunction, dialysis, congestive heart failure, cardiogenic shock, NYHA class III-IV, mitral stenosis, tricuspid regurgitation, mitral valve replacement, and concomitant CABG. However, risk factors for mortality were relatively different between single-valve and MUV procedures. Baseline characteristics and epidemiology were different between MUV and single-valve procedures. The in-hospital mortality and postoperative complications for MUV procedures remained considerably higher and determinants of mortality were relatively different across procedures types. These findings serve as a benchmark for further studies, as well as suggest a continued search for explanations of MUV outcomes.

Relationships between visceral/subcutaneous adipose tissue FABP4 expression and coronary atherosclerosis in patients with metabolic syndrome.

Cytoplasmic fatty acid-binding proteins facilitate the transport of lipids to specific compartments in cells. Fatty acid-binding protein 4 (FABP4), also known as aP2 or A-FABP, plays a key role in the development of atherosclerosis, insulin resistance, obesity, and metabolic syndrome (MS). The FABP4 polymorphisms are associated with protein expression changes invitro and metabolic and vascular alterations invivo. The aim of this study was to investigate the association between FABP4 messenger ribonucleic acid (mRNA) expression levels in epicardial (EAT), pericardial (PAT), and subcutaneous adipose tissues (SAT), and the extent of coronary atherosclerosis in coronary artery disease (CAD) patients with MS. Furthermore, the relationship between the extent of coronary atherosclerosis and epicardial adipose tissue volume (EATV) and FABP4 gene variations was evaluated. A total of 37 patients undergoing coronary artery bypass grafting because of CAD (MS CAD group) and 23 non-MS patients undergoing heart valve surgery (control group) were included. Coronary angiography was performed for all patients and the extent of coronary atherosclerosis was assessed using the Sullivan's scoring system. The mRNA expression levels of FABP4 gene in EAT, PAT, and SAT, and FABP4 polymorphisms were analyzed using the quantitative real-time polymerase chain reaction (qRT-PCR). An increased FABP4 expression was observed in EAT and PAT of MS CAD group compared to controls. In the MS CAD group, FABP4 mRNA expression levels in EAT was 2.8-fold highercompared to PAT. The expression of FABP4 in EAT was positively correlated with the extent of atherosclerosis and EATV in MS CAD group (r=0.588, P=0.001, r=0.174, P=0.001, respectively). There were no correlations between PAT and SAT versus the extent of atherosclerosis and EATV. The FABP4 EAT mRNA expression levels were found to significantly increase in mutant allele carriers of rs1054135, whereas they significantly decreased in mutant allele carriers of rs77878271 (T-87C) in MS CAD group (P<0.05). The extent of atherosclerosis was also found to be significantly associated with rs1054135 (P<0.05). A cut-off point of 57.5cm3 EATV was used indicating the presence of CAD with a significant area under the curve of 0.783%, 98% sensitivity, and 100% specificity (95% CI 0.620-0.880; P<0.05). Our study results suggest that FABP4 expression in EAT is strongly associated with the extent of atherosclerosis and EATV in MS CAD patients.

Timing of peptide receptor radiotargeted therapy in relation to cardiac valve surgery for carcinoid heart disease in patients with neuroendocrine metastases and cardiac syndrome: a single centre study from a centre of excellence

Introduction Perioperative mortality of patients who undergo heart valve surgery for carcinoid heart valve disease has been observed to be high (5%-10%). We investigated whether peptide receptor radiotherapy with lutetium-177 dotatate can be used safely in patients with neuroendocrine neoplasm carcinoid heart valve disease and if there is associated survival advantage by reducing overall exposure of the valves to high doses of vasoactive peptides. Method Retrospective case notes review was performed on 18 neuroendocrine neoplasm patients (mean 60 years), who underwent heart valve surgery between 2003 and 2017 for carcinoid heart valve disease, 9 of whom received peptide receptor radiotherapy in addition to surgery. Results All patients were treated with somatostatin receptor antagonists and underwent cardiac valvular surgery (mean two valves replaced) and three benefitted from additional coronary bypass grafting. Nine patients underwent surgery alone: in this group, the time from surgery to progression was 14 months (mean; SD 13.5 months). Nine were treated with peptide receptor radiotherapy in addition to surgery. Six underwent surgery with peptide receptor radiotherapy on progression. Time to progression from surgery to first peptide receptor radiotherapy was mean 25.1 months (SD 23.6 months). No patients developed peritreatment cardiac complications. There were no deaths within the 30-day postoperative period. Average time from surgery to last follow-up/death was 41 months (6-79) in the surgery + lutetium group and in the surgery only group 17 months (1-24). Nine patients died, five in the surgery + lutetium group and four in the surgery only group, all at greater than 1-year postsurgery. Discussion Peptide receptor radiotherapy is safe in the setting of Carcinoid valvular heart disease in patients with controlled heart failure, PPRT can be use in the pre- and post-valve surgery period. There appears to be a survival benefit of having peptide receptor radiotherapy. Further evidence for peptide receptor radiotherapy in the neoadjuvant setting prior to cardiothoracic surgery is required.

Infective endocarditis according to type 2 diabetes mellitus status: an observational study in Spain, 2001\u20132015

BackgroundThe main aims of this study were to describe trends and outcomes during admission for infective endocarditis (IE) in people ≥ 40 years old with or without type 2 diabetes distributed in five time-periods (2001–2003; 2004–2006; 2007–2009; 2010–2012 and 2013–2015), using Spanish national hospital discharge data.MethodsWe estimated admission rates by diabetes status. We analyzed comorbidity, therapeutic procedures, and outcomes. We built Poisson regression models to compare the adjusted time-trends in admission rates. Type 2 diabetes cases were matched with controls using propensity score matching (PSM). We tested in-hospital mortality (IHM) in logistic regression analyses.ResultsWe identified 16,626 hospitalizations in patients aged ≥ 40 years for IE in Spain, 2001–2015. The incidence of IE increased significantly from 6.0/100,000 per year to 13.1/100,000 per year (p < 0.001) in the population with type 2 diabetes, and from 3.9/100,000 per year to 5.5/100,000 per year (p < 0.001) in the population without diabetes, over the study period. The adjusted incidence of IE was 2.2-times higher among patients with diabetes than among those without diabetes (IRR = 2.2; 95% CI 2.1–2.3). People with type 2 diabetes less often underwent heart valve surgery than people without diabetes (13.9% vs. 17.3%; p < 0.001). Although IHM decreased significantly in both groups over time, it represented 20.8% of IE cases among diabetes patients and 19.9% among PSM matched controls (p = 0.337). Type 2 diabetes was not associated with a higher IHM in people admitted to the hospital for IE (OR = 1.1; 95% CI 0.9–1.2).ConclusionIncidence rates of IE in Spain, among those with and without T2DM, have increased during the period 2001–2015 with significantly higher incidence rates in the T2DM population. In our population based study and after PSM we found that T2DM was not a predictor of IHM in IE.

P3633Should we continue to routinely revascularize patients during valve surgery in optimal medical therapy era?

Abstract Background Optimal management of stable obstructive coronary artery disease (CAD) in patients (pts) undergoing heart valve surgery remains controversial. The aim of the present study is to evaluate the effective prognostic role of CABG in pts undergoing valve surgery who had concomitant CAD. Methods We conducted a retrospective multicenter survival analysis using multivariable Cox models and Kaplan-Meier curves of consecutive pts undergoing valve surgery with or without concomitant CABG between January 2015 and February 2017. Results From 1196 consecutive pts undergoing valvular surgery in 3 portuguese centers, 257 (21.5%) were found to have obstructive CAD (55.6% male, mean age 74±8 y.o., mean follow-up time 16±8 months, aortic valve disease 78.8%). No coronary revascularization (R) was attempted in 177 pts, complete R was achieved in 40 and R was anatomically incomplete in the remaining 40 pts. Age (75 vs 77.3 y.o.; p=0.202), multivessel disease (46.3% vs 53.8%, p=0.270), aortic valve disease (91.0% vs 92.5%, p=0.683), left ventricular ejection fraction &lt;40% (11.8% vs 19.4%, p=0.272) were comparable between nonrevascularized and revascularized pts; SYNTAX score was low and also similar in both groups (7±12 vs 7±5, p=0.856). Left main disease (8.5% vs 17.5%, p=0.034) and EUROSCORE IIrisk score (2.3±2 vs 3.2±2, p=0.011) was higher for those with any revascularization. Non-revascularized pts had significantly lower all-cause mortality at follow up than those with any R (10.2% vs 21.2%, p=0.016). However, both in-hospital (4% vs 7.5%, p=0.230) and cardiovascular mortality (6.9% vs 7.1%, p=1.00) were similar. In a multivariate analysis, independent predictors for all-cause mortality were: any surgical R (HR 4.52, CI95% 2.09–9.78), baseline atrial fibrillation (HR 2.51, CI95% 1.07–5.90), left main disease (HR 3.153, CI95% 1.26–7.90) and peripheral artery disease (HR 2.95, CI95% 1.036–8.421). All-cause mortality for pts with obstructive CAD was higher than in pts with no CAD (13.6% vs 6.2, p&lt;0.001). Interestingly, however, after multivariable adjustment, complete R was not found to be protective as compared to no R (HR 0.79, IC 0.31–2.06, p=0.633) Kaplan-Meier Plots Conclusion Significant CAD is associated with worse outcomes in pts undergoing valve surgery. In this study, standard angiographically-guided R was not associated with improved results. Randomized controlled trials are needed to further assess risk stratification and the role of coronary R of stable CAD in this setting.

P3628Contemporary coronary artery disease prevalence in a valvular heart disease population undergoing surgery

Abstract Background Patients undergoing heart valve surgery are routinely evaluated for the presence of Coronary Artery Disease (CAD), with the standard practice of combining valve intervention with a revascularization procedure, notably Coronary Artery Bypass Graft (CABG). Older studies suggest rates as high as 50% prevalence of CAD in this population. However, CAD prevalence, its treatment and prognostic implication has been questioned recently. Objectives The goal of this study is to evaluate the baseline characteristics, prevalence of CAD and treatment strategies in a contemporary population with valvular heart disease (VHD) referred for valve surgery. Methods In a national multicentre registry, consecutive patients, from Jan 2015 to Dec 2016, with a formal indication for heart valve surgery referred for a pre-op routine coronary angiogram were systematically analysed. Baseline characteristics, valve pathology and CAD prevalence and patterns were determined. Obstructive CAD was defined as luminal angiographic stenosis ≥70% (≥50% for left main artery). The prognostic impact of the different valve disease and CAD treatment strategies were assessed. Results 1175 patients (mean age 72.5±10.1; male 49.2%) fulfilled the clinical or echocardiographic indication for valve surgery by European guidelines. Valvular disease prevalence was: aortic stenosis (66.7%), aortic regurgitation (6.6%), mitral stenosis (6%), mitral regurgitation (19.2%), tricuspid regurgitation (7.5%). Mean follow-up time was 29.06±18.46 months. Prevalence of comorbidities was: Diabetes Mellitus (DM) 26%, chronic obstructive pulmonary disease (COPD) 5.7% and chronic kidney disease (CKD) 23.4%. Mean Euroscore II was 2.6%. Obstructive CAD was present in 27.3% patients. Mean Syntax score was 10.2 (&lt;22 in 88%, 23–32 in 10.2% and &gt;33 in 1.8%). Left main artery and 3-vessel disease were found in 13.1% and 11.8% of patients with CAD, respectively. Valvular surgery was ultimately performed in 80.3%. In patients with CAD, 57.3% were revascularized. All-cause mortality rate during follow-up was 12.9%, with 7.8% from cardiovascular causes. In univariate analysis DM, COPD, CKD, NYHA class, obstructive CAD and no surgery (p&lt;0.05) were associate with mortality on follow up. In multivariate analysis obstructive CAD (OR 2.36, 95% CI 1.53–3.65, p&lt;0.01) and no surgery (OR 6.05, 95% CI 3.95–9.30, p&lt;0.01) persisted as independent all-cause mortality predictors. Conclusion In a contemporary cohort of patients with VHD and surgical indication, CAD prevalence is lower (27.3%) than described in literature. Mortality rates were higher in patients with obstructive CAD, worse NYHA functional class and in those who never underwent surgery.

Effect of sevoflurane-based or propofol-based anaesthesia on the incidence of postoperative acute kidney injury: A retrospective propensity score-matched analysis.

Propofol may help to protect against ischaemic acute kidney injury (AKI); however, research on this topic is sparse. The current study aimed to investigate whether there were differences in the incidence of postoperative AKI after lung resection surgery between patients who received propofol-based total intravenous anaesthesia (TIVA) and those who received sevoflurane-based inhalational anaesthesia. A retrospective observational study. A single tertiary care hospital. Medical records of patients aged 19 years or older who underwent curative lung resection surgery for nonsmall cell lung cancer between January 2005 and February 2018 were examined. After propensity score matching, the incidence of AKI in the first 3 postoperative days was compared between patients who received propofol and those who received sevoflurane. Logistic regression analyses were also used to investigate whether propofol-based TIVA lowered the risk of postoperative AKI. The analysis included 2872 patients (1477 in the sevoflurane group and 1395 in the propofol group). After propensity score matching, 661 patients were included in each group; 24 (3.6%) of the 661 patients in the sevoflurane group developed AKI compared with 23 (3.5%) of the 661 patients in the propofol group (95% confidence intervals of difference in incidence -0.019 to 0.022, P = 0.882). The logistic regression analyses revealed that the incidence of AKI was not different in the two groups (odds ratio 0.96, 95% confidence interval 0.53 to 1.71, P = 0.882). In this retrospective study, no significant difference was found in the incidence of postoperative AKI after lung resection surgery between patients who received propofol-based TIVA and those who received sevoflurane-based inhalational anaesthesia. Considering the methodological limitation of this retrospective study, further studies are required to confirm these results.

Genetic polymorphisms and dosing of vitamin K antagonist in Indian patients after heart valve surgery.

Vitamin K antagonists (VKAs), such as warfarin and acenocoumarol, exert their anti-coagulant effect by inhibiting the subunit 1 of vitamin K epoxide reductase complex (VKORC1). CYP2C9 is a hepatic drug-metabolizing enzyme in the CYP450 superfamily and is the primary metabolizing enzyme of warfarin. Three single nucleotide polymorphisms, two in the CYP2C9 gene, namely CYP2C9*2 and CYP2C9*3, and one in the VKORC1 gene (c.- 1639G > A, rs9923231), have been identified to reduce VKA metabolism and enhance their anti-coagulation effect. The purpose of this study is to evaluate the prevalence of CYP2C9 and VKORC1 polymorphism in Indians receiving VKA-based anti-coagulation after valve surgery and to evaluate the usefulness of genetic information in managing VKA-based anti-coagulation. In the current prospective observational study, 150 patients who underwent heart valve surgery and had stable INR were genotyped for VKORC1 (- 1639G > A), CYP2C9*2, and CYP2C9*3. The VKA dosage was estimated from published algorithms and compared to the clinically stabilized dosage. Out of 150 patients, 101 (67.33%) were on warfarin and 49 (32.66%) were on acenocoumarol. Majority of the patients, the 83 in warfarin group and the 40 in acenocoumarol group, had a wild CYP2C9 diplotype. The rest had a mutant (CYP2C9*2 or CYP2C9*3) diplotype. Similarly, 67 patients in the warfarin group and 35 patients in the acenocoumarol group had wild type (G/G) of VKORC1 genotype. The rest had a mutant (G/A or A/A) VKORC1 genotype. In the warfarin group, based on the genotype, 51.5% of the patients were extensive or normal metabolizers, and 47.4% of the patients were intermediate metabolizers of VKAs. In the acenocoumarol group, 61.2% of the patients were extensive or normal metabolizers, and 38.8% of the patients were intermediate metabolizers. Individually, alleles of VKORC1 (- 1639G > A), CYP2C9*2, and CYP2C9*3 had mean dosage reduction effect on VKA dosage, which co-related to the clinically stabilized dosages (P < 0.0001). Among the VKORC1 (- 1639G > A) cohort, the reduction in warfarin mean weekly dosage was 13.48mg as compared to the wild-type category (P < 0.0001) and similarly, the reduction in the mean weekly acenocoumarol dose was 6.07mg (P < 0.03) as compared to the wild type after adjusting for age, gender, and body mass index. Single nucleotide polymorphism in the CYP2C9 gene and in the VKORC1 gene is present in nearly 40% of Indian patients. VKORC1 (- 1639G > A), CYP2C9*2, and CYP2C9*3 genotypes have significant dosage-lowering effects on VKA-based anti-coagulation therapy. The trend in estimated dosages of VKAs co-related to that of observed the clinically stabilized dosage in the cohort. The pharmacogenomic calculators used in this study tend to overestimate the VKA dosages as compared to clinical dosage due to the limitations in the algorithms and in our study. A new algorithm based on a larger dataset capturing the vast genetic variability across the Indian population and relevant clinical factors could provide better results.

Postoperative atrial fibrillation is associated with delayed early rehabilitation after heart valve surgery: a multicenter study.

Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery. The aim of this multicenter study was to determine the relationship between POAF and patients' progress in early rehabilitation after heart valve surgery. We enrolled 302 patients (mean age, 69±10 years) who had undergone heart valve surgery. POAF was monitored using continuous electrocardiogram telemetry, and the Short Physical Performance Battery (SPPB) was used to assess lower-extremity function before surgery and at the time of discharge. Progress in early rehabilitation was evaluated by the duration from the surgery to independent walking. We determined factors associated delayed early rehabilitation and evaluated the interplay of POAF and delayed early rehabilitation in increasing the risk of decline in lower-extremity function from preoperatively to hospital discharge. Multivariate analysis determined POAF to be independent predictors of delayed early rehabilitation after heart valve surgery (OR: 3.906, P = .01). The association between delayed early rehabilitation and decline in lower extremity function was stronger in patients with POAF (OR: 2.73, P = .041) than in those without (OR: 2.22, P = .052). POAF was clinical predictors of delayed early rehabilitation in patients undergoing heart valve surgery. The combination of POAF with delayed early rehabilitation conferred a high risk of decline in lower-extremity function during hospitalization.

Reduction of plasma angiopoietin-like 2 after cardiac surgery is related to tissue inflammation and senescence status of patients

ObjectivesA strong relationship between high circulating angiopoietin-like 2 (ANGPTL2) levels, a proinflammatory adipokine, and cardiovascular diseases has been reported. Our objective was to determine whether plasma ANGPTL2 and high-sensitivity C-reactive protein (hs-CRP) levels change postoperatively in patients who underwent heart valve surgery and/or coronary artery bypass grafting. We hypothesized that a corrective cardiac surgery would decrease ANGPTL2 levels. MethodsIn 47 prospectively recruited patients who underwent coronary artery bypass grafting (n = 16), valve replacement (n = 16), or both (n = 15), we measured plasma ANGPTL2 and hs-CRP levels preoperatively, at 24 hours, at 3 to 5 days (hospital discharge), and at 30 to 90 days (follow-up) after surgery. Mediastinal adipose tissue and distal fragments of the left internal mammary artery (IMA) were harvested during surgery and mRNA expression of inflammatory and senescence markers was assessed using real-time quantitative polymerase chain reaction. ResultsANGPTL2 and hs-CRP levels were elevated 24 hours after surgery and then returned to baseline levels. We noted, however, a dichotomy among patients: compared with baseline, plasma ANGPTL2 levels either significantly decreased (n = 21/47) or increased (n = 26/47) after surgery. In contrast, hs-CRP levels were identical between groups (P = .997). Patients in the increased group were older (P = .002) with a higher systolic blood pressure (P = .038) at baseline. Moreover, changes in ANGPTL2 levels (ΔANGPTL2 = final minus initial levels) positively correlated with mRNA expression of tumor necrosis factor α and interleukin 8 in mediastinal adipose tissue and IMA (P < .05) and with the senescence-associated marker cyclin-dependent kinase inhibitor 1 in IMA (P = .009). ConclusionsIn younger patients with lower levels of tissue inflammation and arterial senescence load, ANGPTL2, but not hs-CRP levels decreased after cardiac surgery, suggesting that circulating ANGPTL2 reflects tissue inflammation and senescence.

The usefulness of perioperative lactate blood levels in patients undergoing heart valve surgery.

AimThe aim of the study was to assess the usefulness of lactate blood levels in the perioperative period in patients undergoing heart valve surgery.Material and methodsA prospective study was conducted on a group of consecutive patients with significant valvular heart disease who underwent elective valve surgery. The primary endpoint was total mortality in a 30-day follow-up. Univariate analysis, followed by multivariate regression analysis, was performed.ResultsThe study included 801 patients. The primary end point occurred in 36 patients. At multivariate analysis lactate blood level measured one day after surgery and pH measured one day after surgery remained independent predictors of the primary end-point.ConclusionsElevated postoperative lactate blood level was associated with a higher risk of postoperative death.

Infective endocarditis as a morbidity predictor in patients who underwent mitral valve surgery

Infective endocarditis (IE) often develops into rheumatic heart disease (RHD) that has many perioperative complications during the evolution of the disease. Cardiac surgery in patients with IE is often followed by post-operative morbidities that can decrease the quality of life. This study aimed to investigate the correlations between preoperative IE and the emergence of various morbidities in patients undergoing heart valve surgery. This was a cross-sectional study with secondary data analysis of the medical record in 60 patients with mitral valve surgery at Dr. Sardjito General Hospital, Yogyakarta from 2012 to 2017. As much as 30 of 60 patients were suffered IE before mitral valve surgery. The most common valve disease in the IE group was mitral stenosis (60%). IE was significantly associated with arrhythmia and cardiac event with p=0.002 (PR: 6.91), prolonged ICU stay with p=0.011 (PR: 5.68), prolonged ventilator use with p=0.015 (PR: 12.43) and severe pulmonary arterial hypertension (PAH) with p=0.033 (PR: 0.192) post mitral valve surgery. As many as 26 (87%) and 29 (96.7%) of patients with IE had a prolonged ICU stay and prolonged ventilator after mitral valve surgery respectively. The incidence of severe PAH postoperatively in the IE group was lower than in the non-IE group (10% vs 36.7%). IE was significantly associated with the increased risk of arrhythmia, prolonged ventilator use and prolonged ICU stay after mitral valve surgery

Cognitive Outcomes After Heart Valve Surgery: A Systematic Review and Meta-Analysis.

To summarize evidence on cognitive outcomes after heart valve surgery; secondary aim, to examine whether aortic and mitral valve surgery are associated with different cognitive outcomes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review and meta-analysis. Cardiac surgery. Individuals undergoing heart valve surgery. We searched MEDLINE, EMBASE, and PsycINFO for peer-reviewed reports of individuals undergoing heart valve surgery who underwent pre- and postoperative cognitive assessment. Our initial search returned 1,475 articles, of which 12 were included. Postoperative cognitive results were divided into those from 1 week to 1 month (early outcomes, npooled = 450) and from 2 to 6 months (intermediate outcomes; npooled = 722). No studies with longer-term outcomes were identified. Subjects had moderate early cognitive decline from baseline (Becker mean gain effect size (ES)=-0.39 ± 0.27) that improved slightly by 2 to 6 months (ES=-0.25 ± 0.38). Individuals undergoing aortic valve surgery-who were older on average than those undergoing mitral valve surgery (68 vs 57)-had greater early cognitive decline than those undergoing mitral valve surgery (ES=-0.68 vs -0.12), but both cohorts had similar decline 2 to 6 months postoperatively (ES=-0.27 vs -0.20). Heart valve surgery is associated with cognitive decline over the 6 months after surgery, but outcomes beyond 6 months are unclear. These findings highlight the cognitive vulnerability of this population, especially older adults with aortic stenosis. © 2018 American Geriatrics Society and Wiley Periodicals, Inc. J Am Geriatr Soc 66:2327-2334, 2018.

Effect of Fast Cardioplegic Arrest Induced by Adenosine on Cardiac Troponin Levels After Heart Valve Surgery

Cellular injury is not avoidable with current cardioplegic solutions. The effect of adenosine on reducing cardiac injury post-surgery is controversial. The objective of the current study is to evaluate the effect of fast cardioplegic arrest induced by adenosine on high sensitive cardiac troponin I after heart valve surgery. Forty-five (45) patients with rheumatic heart diseases underwent heart valve surgery using conventional approach through median sternotomy. They were classified into two groups, group I (n=21) patients received 0.25mg/kg adenosine into the aortic root just after aortic cross-clamping and before infusion of the cold hyperkalaemic crystalloid cardioplegia via antegrade route and group II (n=24) who received cold crystalloid hyperkalaemic cardioplegia without adenosine. Cardiac troponin I was measured preoperatively and on postoperative days 0, 3 and 7. There was no significant difference between both groups in the demographic, preoperative and operative data. Adenosine significantly reduced arrest time. Postoperative high sensitive cardiac troponin I increased significantly in both groups compared to the preoperative levels and the rise continued till postoperative day 3. Troponin levels were significantly lower in the adenosine group compared to the control at all measurements. The clinical outcomes were non-significant different between groups. Using adenosine in inducing fast cardioplegic arrest in heart valve surgery after aortic cross clamp and prior to infusion of the cold cardioplegia had significantly decreased postoperative cardiac troponin levels which was used as a proxy for cellular injury compared to the control group.