cardiovascular-agents and Postoperative-Complications

Treatment of ischemic mitral regurgitation (IMR) is in evolution, as percutaneous procedures and complex surgical repair have been recently investigated in randomized clinical trials and matched studies. This study aims to review and compare the current treatment options for IMR.. A comprehensive literature search was conducted using electronic databases. The primary outcome was all-cause long-term mortality. The secondary outcomes were perioperative mortality, unplanned rehospitalization, reoperation, and composite end points as defined in the original articles.. A total of 12 articles met the inclusion criteria and were included in the final meta-analysis. The MitraClip procedure did not confer a significant benefit in mortality and repeated hospitalization compared with medical therapy alone. In patients with moderate IMR, the adjunct of mitral procedure over coronary artery bypass graft is not associated with clinical improvements. When evaluating mitral valve (MV) replacement versus repair, hospital mortality was greater among patients undergoing replacement (odds ratio [OR], 1.91; P = .009), but both reoperation and readmission rates were lower (OR, 0.60, P = .05; and OR, 0.45, P < .02, respectively). Comparing restrictive annuloplasty alone with adjunctive subvalvular repair, subvalvular procedures resulted in fewer readmissions (OR, 0.50; P = .06) and adverse composite end points (P = .009).. MitraClip procedure is not associated with improved outcomes compared with medical therapy. MV replacement is associated with increased early mortality but reduced reoperation rate and readmission rate compared with MV repair using annuloplasty in moderate-to-severe IMR. Despite no significant benefit in isolated outcomes comparing annular and adjunct subvalvular procedures, the adjunct of subvalvular procedures reduces the risk of major postoperative adverse events.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hospital Mortality; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Annuloplasty; Mitral Valve Insufficiency; Myocardial Ischemia; Patient Readmission; Postoperative Complications; Prosthesis Design; Recovery of Function; Reoperation; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome

Topics: Acute Disease; Analgesics; Aortic Aneurysm; Aortic Dissection; Cardiovascular Agents; Clinical Decision-Making; Consensus; Delphi Technique; Humans; Patient Selection; Postoperative Complications; Risk Assessment; Risk Factors; Thoracic Surgery; Treatment Outcome; Vascular Surgical Procedures

The perioperative use of vasoactive drugs is ubiquitous in clinical anaesthesia; yet, the drugs, doses, and haemodynamic targets used are highly variable. Our objectives were to determine whether the perioperative administration of vasoactive drugs reduces mortality, morbidity, and length of stay in adult patients (aged 16 yr or older) undergoing major abdominal surgery.. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for peer-reviewed RCTs with no language or date restrictions. Studies that assessed the intraoperative use of vasoactive drugs were included. Title, abstract, and full-text screening was performed. Risk of bias for each outcome measure was conducted. We calculated the risk ratio (RR) using the Mantel-Haenszel random-effects model with corresponding 95% confidence interval (CI) for dichotomous outcomes, and mean difference using the inverse variance random-effects model with corresponding 95% CI for continuous outcomes.. Twenty-six studies (5561 participants) were included. There was no difference in mortality at the longest follow-up with an RR of 0.84 (95% CI: 0.63-1.12; P=0.23). The intervention significantly reduced the number of patients with one or more postoperative complications; RR: 0.76 (95% CI: 0.66-0.88; P=0.0002). Hospital length of stay was reduced by 0.91 days in the intervention group.. This review is limited by the quality and sample size of individual studies, and the heterogeneity of the settings, interventions, and outcome measures. Perioperative administration of vasoactive drugs may reduce postoperative complications and hospital length of stay in adult patients having major abdominal surgery.

Topics: Abdomen; Cardiovascular Agents; Drug Administration Schedule; Hemodynamics; Humans; Kidney; Length of Stay; Perioperative Care; Postoperative Complications; Vasodilator Agents

As an inodilator, milrinone is commonly used for patients who undergo coronary artery bypass graft (CABG) surgery because of its effectiveness in decreasing the cardiac index and mitral regurgitation. The aim of this study was to perform a systematic review and meta-analysis of existing studies from the past 20 years to evaluate the impact of milrinone on mortality in patients who undergo CABG surgery.. We performed a systematic literature search on the application of milrinone in patients who underwent CABG surgery in studies published between 1997 and 2017 in BioMed Central, PubMed, EMBASE, and the Cochrane Central Register. The included studies evaluated milrinone groups compared to groups receiving either placebo or standard treatment and further compared the systemic administration.. The network meta-analysis included 723 patients from 16 randomized clinical trials. Overall, there was no significant difference in mortality between the milrinone group and the placebo/standard care group when patients underwent CABG surgery. In addition, 9 trials (with 440 randomized patients), 4 trials (with 212 randomized patients), and 10 trials (with 470 randomized patients) reported that the occurrence of myocardial infarction (MI), myocardial ischemia, and arrhythmia was lower in the milrinone group than in the placebo/standard care group. Between the milrinone treatment and placebo/standard care groups, the occurrence of myocardial infarction, myocardial ischemia, and arrhythmia was significantly different. However, the occurrence of stroke and renal failure, the duration of inotropic support (h), the need for an intra-aortic balloon pump (IABP), and mechanical ventilation (h) between these two groups showed no differences.. Based on the current results, compared with placebo, milrinone might be unable to decrease mortality in adult CABG surgical patients but can significantly ameliorate the occurrence of MI, myocardial ischemia, and arrhythmia. These results provide evidence for the further clinical application of milrinone and of therapeutic strategies for CABG surgery. However, along with milrinone application in clinical use, sufficient data from randomized clinical trials need to be collected, and the potential benefits and adverse effects should be analyzed and reevaluated.

Topics: Adult; Aged; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Female; Humans; Male; Middle Aged; Milrinone; Postoperative Complications; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors; Treatment Outcome

Drug-coated balloon as a novel therapeutic strategy has been used to treat restenosis in cases of bare metal and drug-eluting stents. However, evidence of its safety and efficacy is scarce in de novo small coronary artery vessel disease. This meta-analysis aimed to compare the safety and efficacy of the drug-coated balloon and the drug-eluting stent.. The PubMed, EMBASE, Web of Science, and Cochrane library databases were searched for studies published up to October 17, 2018. Studies comparing the drug-coated balloon with the drug-eluting stent strategy in patients with de novo small coronary artery vessel disease (reference diameter, <3 mm) were identified. The clinical outcomes were nonfatal myocardial infarction, cardiac death, all-cause death, target lesion revascularization, and target-vessel revascularization. Data were analyzed using the statistical software RevMan (version 5.3). Fixed effects models were performed to calculate the pooled odds ratios (ORs) and 95% confidence intervals (95% CIs). Sensitivity analyses were used to detect potential sources of heterogeneity, while subgroup analyses were implemented to assess the differential effects.. Three randomized controlled trials and 3 nonrandomized controlled studies were identified. Six studies including a total of 1800 patients compared the differences between the drug-coated balloon and the drug-eluting stent strategies in patients with de novo small coronary artery vessel disease. The results indicated that the drug-coated balloon strategy was associated with a significant reduction in nonfatal myocardial infarction (OR 0.53, 95% CI 0.31-0.90, P = .02) compared with the drug-eluting stent strategy, while insignificant inter-strategy differences were observed in cardiac death (OR 1.56, 95% CI 0.73-3.33, P = .25), all-cause death (OR 0.56, 95% CI 0.25-1.23, P = .15), target lesion revascularization (OR 1.24, 95% CI 0.73-2.1, P = .43), and target-vessel revascularization (OR 0.95, 95% CI 0.59-1.52, P = .84).. This meta-analysis suggests that the drug-coated balloon strategy is noninferior to the drug-eluting stent strategy, delivering a good outcome in nonfatal myocardial infarction, and can be recommended as an optimal treatment strategy in patients with de novo small coronary artery vessel disease. Larger randomized controlled studies with longer follow-up periods are needed to further confirm the benefits of the drug-coated balloon strategy.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Disease; Coronary Vessels; Drug-Eluting Stents; Female; Humans; Male; Middle Aged; Myocardial Infarction; Non-Randomized Controlled Trials as Topic; Odds Ratio; Postoperative Complications; Prosthesis Design; Randomized Controlled Trials as Topic; Treatment Outcome

This study evaluated the clinical value of drug-coated balloons for patients with small-vessel coronary artery disease (SVD).. A computerized literature search was performed using the databases to conduct a meta-analysis and evaluate the clinical value of drug-coated balloons among patients with SVD.. This review enrolling 1545 patients receiving drug-coated balloons and 1010 patients receiving stents (including drug-eluting stents and bare-metal stents). The meta-analysis results showed that the incidence of major adverse cardiovascular events among patients with SVD did not significantly differ between the drug-coated balloon group and the stent group within 1 postoperative year (odds ratio = 0.81, P = .5). A subgroup analysis showed that the incidence of myocardial infarction among the drug-coated balloon group was significantly lower than that among the stent group (odds ratio = 0.58, P = .04). Nevertheless, the late lumen loss of the drug-coated balloon group was significantly lower than that of the stent group (mean difference = 0.31, P = .01).. Drug-coated balloons can be used to effectively reduce the incidence of myocardial infarction in patients with SVD within 1 year and decrease the extent of late lumen loss without increasing the incidence of major adverse cardiovascular events.

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Case-Control Studies; Coronary Artery Disease; Coronary Vessels; Drug-Eluting Stents; Female; Humans; Incidence; Male; Myocardial Infarction; Odds Ratio; Postoperative Complications; Randomized Controlled Trials as Topic; Self Expandable Metallic Stents; Treatment Outcome

Kidney transplants are the most common solid organ abdominal transplant and are occasionally performed simultaneously with pancreas transplants in diabetic patients. Preoperative evaluation of potential transplant recipients should focus on the potential for occult cardiovascular disease while also screening for other signs of end-organ dysfunction. Intraoperatively, it is of utmost importance to ensure adequate graft perfusion to limit the risk of postoperative graft dysfunction or rejection. Postoperative care of the kidney or pancreas transplant patient should focus on ensuring normalization of volume status, electrolyte concentrations, and glycemic control.

Topics: Anesthesia; Cardiovascular Agents; Diabetes Mellitus; Fluid Therapy; Heart Diseases; Humans; Kidney Transplantation; Pancreas Transplantation; Postoperative Complications; Renal Dialysis; Renal Insufficiency

Postoperative atrial fibrillation (POAF) is the most common complication following cardiac surgery, and randomised clinical trials (RCTs) and systematic reviews have been conducted to compare and evaluate different pharmacological interventions for preventing POAF. This study aimed to explore the effect of different pharmacological interventions for prophylaxis against POAF after cardiac surgery using network meta-analysis (NMA).. A systematic search will be performed in PubMed, EMBASE and the Cochrane Library to identify RCTs, systematic reviews, meta-analyses or NMA of different pharmacological interventions for POAF. We will evaluate the risk of bias of the included RCTs according to the Cochrane Handbook V.5.1.0, and use GRADE to assess the quality of evidence. Standard pairwise meta-analysis, trial sequential analysis and Bayesian network meta-analysis will be used to compare the efficacy of different pharmacological interventions.. Ethics approval and patient consent are not required as this study is a meta-analysis based on published studies. The results of this NMA and trial sequential analysis will be submitted to a peer-reviewed journal for publication.. CRD42017067492.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Atrial Fibrillation; Bayes Theorem; Cardiac Surgical Procedures; Cardiovascular Agents; Female; Humans; Male; Middle Aged; Network Meta-Analysis; Postoperative Complications; Postoperative Period; Research Design; Young Adult

Topics: Cardiovascular Agents; Drug Administration Schedule; Heart Diseases; Humans; Medication Adherence; Mortality; Postoperative Care; Postoperative Complications; Treatment Outcome

Theoretically, the everolimus-eluting bioresorbable vascular scaffold (BVS) could eliminate stent thrombosis and improve outcomes in patients having percutaneous coronary intervention.. To estimate the incidence of stent thrombosis after BVS implantation and to compare the efficacy and safety of BVSs versus everolimus-eluting metallic stents (EESs) in adults having percutaneous coronary intervention.. PubMed, EMBASE, Cochrane Central Register of Controlled Trials, conference proceedings, and relevant Web sites from inception through 20 January 2016.. 6 randomized, controlled trials and 38 observational studies, each involving at least 40 patients with BVS implantation.. Two reviewers independently extracted study data and evaluated study risk of bias.. The pooled incidence of definite or probable stent thrombosis after BVS implantation was 1.5 events per 100 patient-years (PYs) (95% CI, 1.2 to 2.0 events per 100 PYs) (126 events during 8508 PYs). Six randomized trials that directly compared BVSs with EESs showed a non-statistically significant increased risk for stent thrombosis (odds ratio [OR], 2.05 [CI, 0.95 to 4.43]; P = 0.067) and myocardial infarction (OR, 1.38 [CI, 0.98 to 1.95]; P = 0.064) with BVSs. The 6 observational studies that compared BVSs with EESs showed increased risk for stent thrombosis (OR, 2.32 [CI, 1.06 to 5.07]; P = 0.035) and myocardial infarction (OR, 2.09 [CI, 1.23 to 3.55]; P = 0.007) with BVSs. The relative rates of all-cause and cardiac death, revascularization, and target lesion failure were similar for BVSs and EESs.. Scarce comparative data, no published data from large trials with long-term follow-up, and limited quality and incomplete reporting of observational studies.. Compared with EESs, BVSs do not eliminate and might increase risks for stent thrombosis and myocardial infarction in adults having percutaneous coronary intervention. Results of large trials with long-term follow-up are critically needed to establish the safety or at least the noninferiority of BVSs compared with EESs.. None.

Topics: Absorbable Implants; Cardiovascular Agents; Cause of Death; Comparative Effectiveness Research; Coronary Artery Disease; Drug-Eluting Stents; Everolimus; Humans; Myocardial Infarction; Percutaneous Coronary Intervention; Postoperative Complications; Thrombosis; Tissue Scaffolds

Cardiac allograft vasculopathy (CAV) is a common complication following heart transplantation (HT), resulting in diminished graft survival. The preferred strategy for preventing CAV is optimal medical management; however, for patients who develop CAV, delaying disease progression through effective medication management is equally important. A review of the literature regarding medication management of CAV was conducted via a search of the MEDLINE database. Studies were included if they were published in English, conducted in humans ≥ 18 years of age or older, and used noninvestigational medications. Immunosuppressive medications such as the antiproliferative mycophenolate, the calcineurin inhibitor tacrolimus, and the proliferation signal inhibitors sirolimus and everolimus have been shown to prevent the development of CAV. Certain cardiovascular medications, such as HMG-CoA reductase inhibitors (statins), gemfibrozil, calcium channel blockers, and angiotensin-converting enzyme inhibitors, have also demonstrated efficacy in preventing this disease process. Prevention of CAV has also been observed with prophylaxis against cytomegalovirus infection and antioxidant medications. Despite being commonly used in HT patients, neither antiplatelet agents nor glycemic control have proved effective at preventing CAV. Only sirolimus has been shown to arrest the progress of existing CAV.

Topics: Allografts; Antioxidants; Calcineurin Inhibitors; Cardiovascular Agents; Cytomegalovirus Infections; Everolimus; Graft Occlusion, Vascular; Graft Rejection; Graft Survival; Heart Transplantation; Humans; Immunosuppressive Agents; Mycophenolic Acid; Postoperative Complications; Sirolimus; Tacrolimus

Atrial fibrillation is a frequent complication in the perioperative period. When it appears there is an increased risk of perioperative morbidity due to stroke, thromboembolism, cardiac arrest, myocardial infarction, anticoagulation haemorrhage, and hospital readmissions. The current article focuses on the recommendations for the management of perioperative atrial fibrillation based on the latest Clinical Practice Guidelines on atrial fibrillation by the European Society of Cardiology and the Spanish Society of Cardiology. This article pays special attention to the preoperative management, as well as to the acute perioperative episode. For this reason, the latest recommendations for the control of cardiac frequency, antiarrhythmic treatment and anticoagulation are included.

Topics: Anticoagulants; Atrial Fibrillation; Cardiovascular Agents; Electric Countershock; Female; Heart Conduction System; Heart Rate; Humans; Intraoperative Complications; Male; Perioperative Care; Postoperative Complications; Postoperative Hemorrhage; Practice Guidelines as Topic; Pregnancy; Pregnancy Complications, Cardiovascular; Premedication; Risk Factors; Thrombophilia

Atrial fibrillation is the most commonly encountered arrhythmia after cardiac surgery. Although usually self-limiting, it represents an important predictor of increased patient morbidity, mortality, and health care costs. Numerous studies have attempted to determine the underlying mechanisms of postoperative atrial fibrillation (POAF) with varied success. A multifactorial pathophysiology is hypothesized, with inflammation and postoperative β-adrenergic activation recognized as important contributing factors. The management of POAF is complicated by a paucity of data relating to the outcomes of different therapeutic interventions in this population. This article reviews the literature on epidemiology, mechanisms, and risk factors of POAF, with a subsequent focus on the therapeutic interventions and guidelines regarding management.

Topics: Anticoagulants; Atrial Fibrillation; Cardiovascular Agents; Humans; Incidence; Postoperative Complications; Prognosis; Risk Assessment; Risk Factors; Surgical Procedures, Operative; Thromboembolism

One of actual problems of modern cardiology is assessment and correction of risk of cardiac complications of noncardiac surgery. Recommendations on this issue propose reduction of preoperative examination and wide use of drug therapy, primarily statins and β-blockers. However, new data accumulated in recent years, as well as the recognition of scientific inconsistency of the DECREASE research series, force a new outlook at the problem. In this review in light of new facts the following important issues of perioperative medicine are discussed: administration of β-blockers and statins, volume of preoperative cardiac examination, value of preventive myocardial revascularization.

Topics: Cardiovascular Agents; Heart Diseases; Humans; Myocardial Revascularization; Perioperative Care; Postoperative Complications; Risk Adjustment; Risk Assessment; Surgical Procedures, Operative

Topics: Cardiac Resynchronization Therapy; Cardiovascular Agents; Combined Modality Therapy; Echocardiography, Transesophageal; Heart Failure; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Mitral Valve Insufficiency; Percutaneous Coronary Intervention; Postoperative Complications; Practice Guidelines as Topic; Prognosis; Risk Factors; Surgical Instruments; Survival Rate; Ventricular Dysfunction, Left

Perioperative cardiac complications are a common cause of death and major morbidity in patients undergoing non-cardiac surgery. Preoperative evaluation and medical optimisation can improve outcomes, although the evidence base is limited. Evidence of effectiveness is strongest for prophylactic use of β-blockers in high-risk patients and aspirin in patients with coronary artery disease. Particular challenges arise among patients with heart failure or valvular heart disease or those receiving antithrombotic therapy for coronary artery stents or atrial fibrillation. Close liaison between general practitioners, surgeons, anaesthetists and cardiologists is needed for optimising preoperative management and subsequent clinical outcomes in high-risk patients.

Topics: Cardiovascular Agents; Decision Support Techniques; Elective Surgical Procedures; Health Status Indicators; Heart Diseases; Humans; Percutaneous Coronary Intervention; Postoperative Complications; Preoperative Care; Risk Adjustment; Risk Assessment; Risk Factors

To avoid perioperative cardiac complications and deterioration of renal function in chronic kidney disease (CKD), anesthesiologists are required to manage respiration and circulation properly. Three mechanisms are considered to worsen renal function during inappropriate mechanical ventilation; first, hypercapnia or hypoxemia, second, unstable systemic hemodynamic, and third, systemic inflammatory mediators derived from pulmonary biotrauma. Many circulatory problems are present in CKD patients, for example, hypertension, cardiac hypertrophy, cardiomyopathy, ischemic heart disease, arterial sclerotic valve disease, salt and water retention etc. Blood pressure in CKD patients should be controlled properly before surgery. Renal blood flow and renal perfusion pressure should be maintained by aggressive fluid therapy to avoid perioperative acute kidney injury (AKI) on CKD, while cardiac congestion should also be avoided. Perioerative renal protective effects of human atrial natriuretic peptide (hANP) on CKD still needs further investigation. Appropriate hemodynamic monitoring, including direct arterial pressure, left ventricular preload, intravascular volume and cardiac output could be helpful for anesthesiologists to manage CKD patients safely. In the area of CKD and anesthesia, there is lack of evidence in respiratory and circulatory strategies. Prospective studies in these aspects are required in the future.

Topics: Acute Kidney Injury; Atrial Natriuretic Factor; Cardiovascular Agents; Cardiovascular Diseases; Fluid Therapy; Hemodynamics; Humans; Monitoring, Intraoperative; Perioperative Care; Positive-Pressure Respiration; Postoperative Complications; Renal Insufficiency, Chronic; Respiration, Artificial

Studies have suggested that increasing whole body blood flow and oxygen delivery around the time of surgery reduces mortality, morbidity and the expense of major operations.. To describe the effects of increasing perioperative blood flow using fluids with or without inotropes or vasoactive drugs. Outcomes were mortality, morbidity, resource utilization and health status.. We searched CENTRAL (The Cochrane Library 2012, Issue 1), MEDLINE (1966 to March 2012) and EMBASE (1982 to March 2012). We manually searched the proceedings of major conferences and personal reference databases up to December 2011. We contacted experts in the field and pharmaceutical companies for published and unpublished data.. We included randomized controlled trials with or without blinding. We included studies involving adult patients (aged 16 years or older) undergoing surgery (patients having a procedure in an operating room). The intervention met the following criteria. 'Perioperative' was defined as starting up to 24 hours before surgery and stopping up to six hours after surgery. 'Targeted to increase global blood flow' was defined by explicit measured goals that were greater than in controls, specifically one or more of cardiac index, oxygen delivery, oxygen consumption, stroke volume (and the respective derived indices), mixed venous oxygen saturation (SVO(2)), oxygen extraction ratio (0(2)ER) or lactate.. Two authors independently extracted the data. We contacted study authors for additional data. We used Review Manager software.. We included 31 studies of 5292 participants. There was no difference in mortality: 282/2615 (10.8%) died in the control group and 238/2677 (8.9%) in the treatment group, RR of 0.89 (95% CI 0.76 to 1.05, P = 0.18). However, the results were sensitive to analytical methods and the intervention was better than control when inverse variance or Mantel-Haenszel random-effects models were used, RR of 0.72 (95% CI 0.55 to 0.95, P = 0.02). The results were also sensitive to withdrawal of studies with methodological limitations. The rates of three morbidities were reduced by increasing global blood flow: renal failure, RR of 0.71 (95% CI 0.57 to 0.90); respiratory failure, RR of 0.51 (95% CI 0.28 to 0.93); and wound infections, RR of 0.65 (95% CI 0.51 to 0.84). There were no differences in the rates of nine other morbidities: arrhythmia, pneumonia, sepsis, abdominal infection, urinary tract infection, myocardial infarction, congestive cardiac failure or pulmonary oedema, or venous thrombosis. The number of patients with complications was reduced by the intervention, RR of 0.68 (95% CI 0.58 to 0.80). Hospital length of stay was reduced in the treatment group by a mean of 1.16 days (95% CI 0.43 to 1.89, P = 0.002). There was no difference in critical care length of stay. There were insufficient data to comment on quality of life and cost effectiveness.. It remains uncertain whether increasing blood flow using fluids, with or without inotropes or vasoactive drugs, reduces mortality in adults undergoing surgery. The primary analysis in this review (mortality at longest follow-up) showed no difference between the intervention and control, but this result was sensitive to the method of analysis, the withdrawal of studies with methodological limitations, and is dominated by a single large RCT. Overall, for every 100 patients in whom blood flow is increased perioperatively to defined goals, one can expect 13 in 100 patients (from 40/100 to 27/100) to avoid a complication, 2/100 to avoid renal impairment (from 8/100 to 6/100), 5/100 to avoid respiratory failure (from 10/100 to 5/100), and 4/100 to avoid postoperative wound infection (from 10/100 to 6/100). On average, patients receiving the intervention stay in hospital one day less. It is unlikely that the intervention causes harm. The balance of current evidence does not support widespread implementation of this approach to reduce mortality but does suggest that complications and duration of hospital stay are reduced.

Topics: Adult; Arrhythmias, Cardiac; Blood Circulation; Cardiovascular Agents; Humans; Length of Stay; Oxygen Consumption; Plasma Substitutes; Postoperative Complications; Randomized Controlled Trials as Topic; Renal Insufficiency; Respiratory Insufficiency; Surgical Procedures, Operative; Surgical Wound Infection

Preoperative cardiovascular management is an essential component of overall perioperative cardiovascular care. It involves preoperative detection and management of cardiovascular disease and prediction of both short- and long-term cardiovascular risk. It thereby not only affects anaesthetic perioperative management (e.g. choice of anaesthetic drug and method, type of monitoring, and postoperative care) but also surgical decision-making (e.g. postponement, modification, and cancellation of surgical procedure). The ultimate goal of preoperative cardiovascular management is to improve overall patient outcome. This requires individualized management. Although preoperative cardiac management has improved during the past decades, we are not yet in the situation where we can accurately predict individual perioperative risk. The individual stress response and the individual interactions between pharmacological intervention and intra- and postoperative risk factors are highly variable. More importantly, preoperative cardiac management is only one aspect of overall perioperative care. There are numerous intra- and postoperative factors which have been shown to affect overall outcome. However, not all of them can reliably be predicted or modified in a way to positively affect overall outcome. Recognition of such factors and aggressive attempts at appropriate intervention may reduce overall risk more than preoperative management in isolation. Without defining and subsequently targeting intra- and postoperative risk factors, the benefit of preoperative cardiac management will be limited.

Topics: Algorithms; Biomarkers; Cardiovascular Agents; Cardiovascular Diseases; Exercise Test; Humans; Myocardial Revascularization; Postoperative Complications; Preoperative Care; Risk Assessment

In an aging population, major surgery is often performed in patients with complex co-morbidities. These patients present new risk constellations so that cardiac and respiratory complications mainly contribute to perioperative morbidity.. We composed a narrative review on pharmacological approaches to cardiovascular protection in the perioperative period including effects of central neuraxial blocks and hypothermia on cardiovascular outcome. The single chapters are structured as follows: pathophysiology-early studies-recent evidence-recommendations.. In coping with this challenge, innovative concepts like fast track surgery and pharmacological treatment are being utilized with increasing frequency including perioperative cardioprotection, novel strategies of anticoagulation or antiplatelet therapy, and protocols for postoperative pain therapy.. All the concepts described require an interdisciplinary approach in collaboration between operative physicians and physicians working in non-surgical disciplines like internal medicine, cardiology, and clinical pharmacology. The perioperative continuation of a pre-existing therapy with beta-blockers and other potentially cardioprotective agents like α(2)-agonists and statines is recommended. In the management of patients presenting for major surgery stratification of the perioperative risk is essential which considers both, invasiveness of the surgical procedure and conditions of the patient. Otherwise, side-effects might outweigh benefits of a potentially effective therapy as recently shown for the perioperative administration of beta-blockers that should be restricted to high-risk patients.

Topics: Cardiovascular Agents; Comorbidity; Cooperative Behavior; Coronary Thrombosis; Death, Sudden, Cardiac; Drug Therapy, Combination; Evidence-Based Medicine; Hospital Mortality; Humans; Interdisciplinary Communication; Length of Stay; Myocardial Infarction; Perioperative Care; Postoperative Complications; Risk Factors

Acute aortic syndromes (AAS) comprise a group of potentially lethal conditions that require prompt recognition, diagnosis as well as acute medical stabilization and surgical intervention. The purpose of this article is to review the relevant variants of AAS presentation, as well as diagnostic and management issues, including adequate long-term medical therapy and follow-up imaging. In this context, the American College of Cardiology and the American Heart Association recently published guidelines on the management of thoracic aortic disease, drawing greater attention to these processes.

Topics: Acute Disease; Angioplasty; Aortic Aneurysm, Thoracic; Aortic Dissection; Aortic Rupture; Aortography; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Combined Modality Therapy; Echocardiography, Transesophageal; Follow-Up Studies; Humans; Image Processing, Computer-Assisted; Imaging, Three-Dimensional; Magnetic Resonance Angiography; Marfan Syndrome; Multidetector Computed Tomography; Postoperative Complications; Registries; Risk Factors; Stents; Survival Rate; Syndrome; Ulcer

Nowadays long-term outcome of heart transplantation is limited by a peculiar type of coronary atherosclerosis, known as cardiac allograft vasculopathy (CAV). Although the exact pathogenesis of CAV remains unclear, emerging evidence indicates that the endothelium plays a significant role in the onset and progression of this disease. Nitric oxide (NO) is the principal mediator of all endothelial protective effects, due to its antinflammatory, antiproliferative, immunomodulatory and vasorelaxant properties. CAV involves immunologic mechanisms operating in the context of common cardiovascular risk factors which lead to impaired endothelial function, mainly as a consequence of decreased NO bioavailability and excessive oxidative stress. Once dysfunctional, the endothelium promotes CAV lesion progression towards the diffuse narrowing of the coronary vasculature which characterizes advanced allograft vasculopathy. Recently, many studies showed the possibility to restore endothelial dysfunction with an associated potential improvement in clinical cardiovascular outcome. Therefore, growing interest deserves the possibility to exert an endothelial protective role shown by some currently used cardiovascular and immunosuppressive drugs, as well as the future development of new pharmacological compounds with selective endothelial protective properties as a target for successful prevention and therapy of CAV.

Topics: Animals; Cardiovascular Agents; Coronary Artery Disease; Disease Progression; Endothelium, Vascular; Heart Transplantation; Humans; Immunosuppressive Agents; Nitric Oxide; Oxidative Stress; Postoperative Complications; Risk Factors; Transplantation, Homologous

Protective effects of each cardiovascular drug on major organ functions are reviewed. Based on these effects, proper use of the drugs is presented. It is probable that norepinephrine and dobutamine have the most protective effect against major organ dysfunctions. It has been shown that perioperative beta-blocker administration reduces cardiovascular complications. Nicorandil is likely to have ischemic preconditioning properties. In case of hypotension, low doses of noradrenaline should be administered first, and then dobutamine should be added. In case of systolic dysfunction, low doses of dobutamine should be chosen first, and then noradrenaline, and finally olprinone could be added. In case of hypotension and systolic dysfunction, combination of norepinephrine and dobutamine is the first choice. Then adrenaline could be added. When ischemic heart disease exists, nicorandil should be given. When decreasing or stabilizing heart rate is required, an ultra-short acting beta-blocker, such as landiolol, is recommended. To maintain hypotension in a certain situation, prostaglandin E1 is better to use than nicardipine, diltiazem, and nitroglycerin. It is important to administer the drugs focusing on postoperative complications and outcome.

Topics: Anesthesia; Cardiovascular Agents; Cardiovascular Diseases; Cardiovascular Surgical Procedures; Catecholamines; Humans; Intraoperative Complications; Perioperative Care; Phosphodiesterase 3 Inhibitors; Phosphodiesterase Inhibitors; Postoperative Complications; Prognosis; Vasodilator Agents

Topics: Cardiovascular Agents; Child; Coronary Artery Bypass; Heart Defects, Congenital; Heart Failure; Humans; Intraoperative Care; Oxygen; Postoperative Complications; Pulmonary Circulation; Risk Factors

Topics: Cardiovascular Agents; Carotid Stenosis; Disease Management; Endarterectomy, Carotid; Humans; Postoperative Complications; Risk Factors

Topics: Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Vasospasm; Humans; Intra-Aortic Balloon Pumping; Intraoperative Complications; Perioperative Care; Postoperative Complications

Angiographic no reflow is a recognized phenomenon during percutaneous coronary intervention (PCI). It usually follows successful lesion dilation and, by definition, it represents a reduction in epicardial coronary blood flow in the absence of identifiable dissection, obstruction or distal vessel cut off (indicative of distal embolisation). No reflow appears to be more commonly associated with PCI for acute myocardial infarction and PCI for saphenous vein graft occlusions. While the exact mechanism of no reflow is unknown, theoretical causes include local humoral and microembolic effects leading to microcirculatory dysfunction. As the process is multifactorial, various therapeutic strategies are required in different situations. The present day pharmacological management involves the use of vasodilators including nitrates, verapamil, papaverine, adenosine, nicardipine and sodium nitroprusside, but interestingly a vasoconstrictor like epinephrine may also have a role. Glycoprotein IIb/IIIa platelet receptors antagonist have shown a powerful de-thrombotic effect, and the intracoronary administration appears to be particularly promising. We review the pathogenesis of a reduced epicardial flow during PCI and focus on those drugs that have been studied for the treatment of no reflow. Although no double blind, randomized trial has been conducted to assess any of these agents, or to determine the appropriate dosage, we try to identify some useful conclusions from the published evidence.

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Circulation; Coronary Disease; Humans; Postoperative Complications

The efficacy of magnesium administration in preventing the occurrence of atrial fibrillation after coronary artery bypass grafting surgery remains controversial. Optimal dose and timing of the administration also await clarification. The purpose of this study was to assess the effect of 3-day postoperative infusion of magnesium on postoperative atrial fibrillation and to find factors that can influence the efficacy of this treatment.. After institutional review board approval, a retrospective study was conducted reviewing 200 consecutive patients who underwent isolated, initial coronary artery bypass grafting operation. The first 100 patients did not receive the prophylactic treatment, whereas the next 100 patients were treated with magnesium postoperatively. Patients in the magnesium-treated group received 10 mmol (2.47 g) of magnesium sulfate (MgSO4 * 7H2O) infused daily for 3 days after surgery.. The incidence of postoperative atrial fibrillation was 35% in the untreated group compared with 16% in the magnesium-treated group (p = 0.002). Multivariate logistic regression analysis revealed that advanced age, decreased left ventricular ejection fraction, and absence of magnesium therapy were independent predictors of postoperative atrial fibrillation. For patients receiving the magnesium therapy, advanced age and decreased ejection fraction were the independent factors that predicted the arrhythmia.. Postoperative 3-day magnesium infusion is effective in reducing the incidence of atrial fibrillation occurring after coronary artery bypass grafting surgery. However, in older patients or in patients with reduced left ventricular function, magnesium treatment alone is insufficient for prophylaxis of postoperative atrial fibrillation.

Topics: Aged; Anesthesia, General; Anti-Arrhythmia Agents; Atrial Fibrillation; Cardiovascular Agents; Coronary Artery Bypass; Drug Administration Schedule; Drug Evaluation; Female; Humans; Incidence; Infusions, Intravenous; Magnesium Sulfate; Male; Middle Aged; Monitoring, Physiologic; Postoperative Complications; Prospective Studies; Research Design; Retrospective Studies; Stroke Volume; Treatment Outcome

Survival of patients with aortic coarctation has dramatically improved after surgical repair became available and the number of patients who were operated and reach adulthood is steadily increasing. However, life expectancy is still not as normal as in unaffected peers. Cardiovascular complications are frequent and require indefinite follow-up. Concern falls chiefly in seven categories: recoarctation, aortic aneurysm formation or aortic dissection, coexisting bicuspid aortic valve, endocarditis, premature coronary atherosclerosis, cerebrovascular accidents and systemic hypertension. In this review, these complications, with particular reference to late hypertension, are discussed and strategies for the clinical management of post-coarctectomy patients are described.

Topics: Aortic Coarctation; Blood Pressure Monitoring, Ambulatory; Cardiac Surgical Procedures; Cardiovascular Agents; Follow-Up Studies; Humans; Magnetic Resonance Angiography; Postoperative Complications; Reoperation; Risk Factors; Time Factors

The edge-to-edge mitral valve repair, first described by Alfieri in 1995 treats mitral regurgitation when standard reparative techniques are difficult, unlikely to succeed, or have failed. This study examines one institution's medium-term experience with this procedure.. This study involved patients undergoing edge-to-edge mitral valve repair at a single institution from 1997 to 2003. Preoperative and postoperative echocardiograms were compared. Postoperative morbidity was examined including need for reoperation and long-term medical management. Thirty-day survival and long-term actuarial survival were also determined.. Seventy-one patients comprised this study. Mitral regurgitation on echocardiogram went from 3.43 +/- 0.86 to 0.39 +/- 0.61 (p < 0.001) following repair. Thirty-day mortality was 3 of 71 (4.2%) patients. Actuarial survivals at 24 and 60 months were 84.5% and 58.3%, respectively; adjusted excluding noncardiac death they were 89.5% and 82.3%, respectively. Forty (56.3%) patients had concomitant ring placement and experienced similar survival to those repaired with the bow-tie stitch alone. Home telephone follow-up was conducted, and current medical therapy was determined on 51 patients; 59% were on a beta-blocker, 31% were on an angiotensin-converting enzyme (ACE) inhibitor, 27% were on a diuretic, and 22% were on digoxin. All were New York Heart Association (NYHA) class I or II. Three patients (4.2%) underwent mitral valve reoperation after a mean of 299 +/- 429 days. In no case did the bow-tie suture rupture.. Edge-to-edge mitral valve repair is a valuable tool in the armamentarium available to treat complex cases of mitral insufficiency or as an adjunct to standard repair techniques that fail to achieve an acceptable result.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cardiac Surgical Procedures; Cardiovascular Agents; Coronary Artery Bypass; Female; Follow-Up Studies; Heart Atria; Heart Septal Defects, Atrial; Heart Septal Defects, Ventricular; Humans; Life Tables; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; New York City; Postoperative Complications; Reoperation; Retrospective Studies; Survival Analysis; Treatment Outcome

Cardiac allograft vasculopathy is the most aggressive form of atherosclerosis in humans and is the leading cause of death after the first year of heart transplantation. Endothelial dysfunction is a major contributing factor to the acceleration of coronary vascular disease in these individuals. A reflection of this endothelial dysfunction is the severe impairment in endothelium-dependent vasodilation that occurs early after transplantation. The etiology of this allograft endothelial alteration is multifactorial and may include preexisting atherosclerosis of the graft vessels, reperfusion injury during transplantation, denervation, disruption of the lymphatic system, and acute and chronic immune injury, as well as traditional risk factors for coronary artery disease (hyperlipidemia, diabetes, hypertension, or hyperhomocysteinemia) and pathogens, such as cytomegalovirus. The alteration in endothelial function affects vasomotor tone of the coronary arteries. Evidence indicates that there may be an impairment of endothelial production and/or activity of NO. Because NO is a potent vasodilator, its deficiency would explain the abnormal vasomotor tone in these individuals. In addition, because NO inhibits key processes in vascular inflammation and atherosclerosis, its absence may contribute to the acceleration of transplant vascular disease. Recent studies from our group and others have shed light on the mechanisms of endothelial dysfunction and its importance in cardiac allograft vasculopathy. In addition, the alteration in endothelial function contributes to vascular inflammation and progression of the disease.

Topics: Animals; Arginine; Cardiovascular Agents; Coronary Artery Disease; Endothelium, Vascular; Graft Rejection; Heart Transplantation; Humans; Mice; Nitric Oxide; Nitric Oxide Synthase; Nitric Oxide Synthase Type II; Nitric Oxide Synthase Type III; Postoperative Complications; Rabbits; Transplantation, Homologous; Vasodilation; Vasomotor System

One of the aims of transplantation is to restore the potential for a full life to individuals with ESRD. To obtain this strategies that allow better and longer allograft function and a reduction in adverse events that lead to premature death are required. To this end, the recommendations below showed reduce cardiovascular disease and help present and future transplant recipients live a full life. Focusing on traditional risk factors (hypertension, hyperlipidemia, discontinuation of smoking, and prevention and treatment of diabetes mellitus) in patients at risk and striving for the recommended targets will have the greatest clinical benefit. These strategies should begin in the pre-dialysis and dialysis phases in order to reduce the cumulative burden of disease. Failing this, early and hopefully pre-emptive transplantation should be the goal.

Topics: Arteriosclerosis; Aspirin; Cardiovascular Agents; Cardiovascular Diseases; Comorbidity; Cost-Benefit Analysis; Diabetes Mellitus; Heart Function Tests; Humans; Hyperlipidemias; Hypertension; Hypertrophy, Left Ventricular; Hypoglycemic Agents; Hypolipidemic Agents; Immunosuppressive Agents; Kidney Failure, Chronic; Kidney Transplantation; Life Expectancy; Pancreas Transplantation; Postoperative Complications; Prevalence; Renal Dialysis; Risk Reduction Behavior; Smoking Cessation; Treatment Outcome

Many patients undergoing elective surgery will be taking medicines for cardiovascular disorders. Here, in the fourth and final article in our series on drug therapy in the peri-operative period, we review the management of patients taking certain antithrombotic, antihypertensive, anti-anginal or anti-arrhythmic drugs.

Topics: Cardiovascular Agents; Contraindications; Humans; Perioperative Care; Postoperative Complications; Thromboembolism

One of every four persons in the Western industrialised nations has cardiovascular disease. The perioperative setting in those patients is associated with the risk of myocardial ischaemia (PMI) and myocardial infarction, and also with the risk of perioperative stroke and dysfunction of the central nervous system (CNS). Perioperative cardiovascular morbidity represents a major healthcare challenge. The relevance of PMI is well documented. It has been demonstrated in early trials that both myocardial ischaemia and infarction are preventable in high-risk patients undergoing surgery, and that therapeutic agents such as adenosine-related agents, alpha 2-agonists, and other stress modulators can be safely administered to these patients. Regarding perioperative stroke, approximately 3 to 7% of patients undergoing cardiac surgery suffer stroke, with an additional 30% or more suffering in-hospital CNS dysfunction, and 10% suffering moderately severe long-term CNS dysfunction. Few data are available for noncardiac surgery. The number of outcome studies addressing prophylactic or therapeutic options in these patients is quite limited. In fact, only one recent study has established that perioperative stroke is preventable with the use of an adenosine-regulating agent. Thus, it appears that it may be possible to prevent stroke, even though these results require confirmation. Because of the aging of our population, and the medical, financial and social impact of cardiovascular disease, the development of anti-ischaemic therapy, particularly in the surgical patient, will be a critical area of medical research for the next several decades.

Topics: Anesthesia, General; Brain Damage, Chronic; Cardiovascular Agents; Cardiovascular Diseases; Cerebrovascular Disorders; Humans; Intraoperative Complications; Myocardial Infarction; Myocardial Ischemia; Postoperative Complications; Premedication; Risk Factors

Topics: Cardiovascular Agents; Combined Modality Therapy; Critical Care; Energy Metabolism; Heart Failure; Hemodynamics; Humans; Monitoring, Physiologic; Multiple Organ Failure; Postoperative Complications

Topics: Anesthesia, General; Anesthesia, Inhalation; Anesthesia, Spinal; Anesthetics; Cardiovascular Agents; Heart Failure; Hemodynamics; Humans; Hypotension, Orthostatic; Intraoperative Complications; Postoperative Complications; Shock, Cardiogenic

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Combined Modality Therapy; Coronary Disease; Hemodynamics; Humans; Myocardial Infarction; Myocardial Ischemia; Myocardial Revascularization; Postoperative Complications

Primary care physicians are often faced with follow-up care of patients who have had coronary artery bypass graft surgery. Familiarity with possible cardiac, pulmonary, neurologic, and infectious complications is important, and an open line of communication with the consulting cardiologist and the cardiac surgeon is essential. Modification of coronary risk factors is one of the greatest challenges after bypass surgery. The primary care physician plays the major role in directing and monitoring life-style changes that reduce the risk of progressive coronary atherosclerosis. Recurrent myocardial ischemia after bypass surgery should be evaluated fully and is often responsive to nonsurgical therapies, including percutaneous transluminal coronary angioplasty.

Topics: Activities of Daily Living; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Family Practice; Follow-Up Studies; Humans; Myocardial Ischemia; Platelet Aggregation Inhibitors; Postoperative Care; Postoperative Complications; Recurrence; Reoperation; Risk Factors; Time Factors

Patients with prostheses of the cardiac valve are, related to the total population, only a small part. But their number permanently increases. Alone in our clinic since 1973 3,250 patients have been provided with artificial cardiac valves. Thus more and more physicians are confronted with the problems of these patients. The long-term results after replacement of the cardiac valves are very essentially influenced by the prevention and well-timed recognition of complications, respectively. For this reason the medicamentous therapy is demonstrated on the basis of own experiences and modern literature. It is clearly pointed out that after replacement of the cardiac valve a permanent cardiologic control is necessary. In detail is reported on the therapy of cardiac insufficiency including disturbances of the cardiac rhythm, on the prophylaxis of thromboembolism as well as on the prophylaxis of endocarditis.

Topics: Anti-Bacterial Agents; Arrhythmias, Cardiac; Cardiovascular Agents; Endocarditis; Heart Failure; Heart Valve Prosthesis; Humans; Postoperative Complications

Topics: Aged; Animals; Anti-Bacterial Agents; Anticonvulsants; Cardiovascular Agents; Chloroquine; Drug-Related Side Effects and Adverse Reactions; Hormones; Humans; Motor Endplate; Myasthenia Gravis; Neuromuscular Junction; Penicillamine; Postoperative Complications; Psychotropic Drugs; Respiratory Insufficiency; Synaptic Transmission; Syndrome

This study evaluated the 5-year clinical outcomes of the Genoss DES, the first Korean-made sirolimus-eluting coronary stent with abluminal biodegradable polymer.We previously conducted the first-in-patient prospective, multicenter, randomized trial with a 1:1 ratio of patients using the Genoss DES and Promus Element stents; the angiographic and clinical outcomes of the Genoss DES stent were comparable to those of the Promus Element stent. The primary endpoint was major adverse cardiac events (MACE), which was a composite of death, myocardial infarction (MI), and target lesion revascularization (TLR) at 5 years.We enrolled 38 patients in the Genoss DES group and 39 in the Promus Element group. Thirty-eight patients (100%) from the Genoss DES group and 38 (97.4%) from the Promus Element group were followed up at 5 years. The rates of MACE (5.3% vs 12.8%, P = .431), death (5.3% vs 10.3%, P = .675), TLR (2.6% vs 2.6%, P = 1.000), and target vessel revascularization (TVR) (7.9% vs 2.6%, P = .358) at 5 years did not differ significantly between the groups. No TLR or target vessel revascularization was reported from years 1 to 5 after the index procedure, and no MI or stent thrombosis occurred in either group during 5 years.The biodegradable polymer Genoss DES and durable polymer Promus Element stents showed comparable low rates of MACE at the 5-year clinical follow-up.

Topics: Absorbable Implants; Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Coronary Artery Disease; Drug-Eluting Stents; Female; Follow-Up Studies; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Percutaneous Coronary Intervention; Polymers; Postoperative Complications; Prospective Studies; Republic of Korea; Sirolimus; Treatment Outcome

Secondary preventive therapies play a key role in the prevention of adverse events after coronary artery bypass grafting (CABG). However, adherence to secondary preventive drugs after CABG is often poor. With the increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve medication adherence. We aimed to evaluate the effectiveness and feasibility of using a smartphone-based application to improve medication adherence in patients after CABG.. The Measurement and Improvement Studies of Surgical coronary revascularizatION: medication adherence (MISSION-2) study is a multicenter randomized controlled trial that planned to enroll over 1000 patients who underwent isolated CABG at one of four large teaching hospitals in China; all enrolled participants had access to a smartphone and were able to operate at least three smartphone applications. The investigators randomly assigned the participants to one of two groups: (1) the intervention group with an advanced smartphone application for 6 months which was designed specifically for this trial and did not exist before. Participants could receive medication reminders and cardiac health education by the smartphone application or (2) the control group with usual care. The primary outcome was CABG secondary preventive medication adherence as measured by the translated Chinese version of the 8-item Morisky Medication Adherence Scale (MMAS-8) at 6 months after randomization. The secondary outcomes were mortality, major adverse cardiovascular and cerebrovascular events (MACCE), cardiovascular rehospitalization, self-reported secondary preventive medication use after 6 months of follow-up, blood pressure (BP), body mass index (BMI), and self-reported smoking status. All analyses were conducted using the intention-to-treat principle.. A total of 1000 patients (mean age, 57.28 [SD, 9.09] years; 85.5% male) with coronary heart disease after CABG were enrolled between September 2015 and September 2016 and were randomly assigned to the intervention (n = 501) or control group (n = 499). At 6 months, the proportion of low-adherence participants, categorized by MMAS-8 scores, was 11.8% in the intervention group and 11.7% in the control group (RR = 1.005, 95% CI 0.682 to 1.480, P = 1.000). Similar results were found in sensitivity analyses that considered participants who withdrew from the study, or were lost to follow-up as nonadherent. There were no significant differences in the secondary clinical outcome measures, and there were no significant differences in the primary outcome across the subgroups tested. In the intervention group, the proportion of participants who used and operated the application during the first month after CABG was 88.1%; however, the use rate decreased sharply from 42.5% in the second month to 9.2% by the end of the study (6 months).. A smartphone-based application supporting secondary prevention among patients after CABG did not lead to a greater adherence to secondary preventive medications. The limited room for improvement in medication adherence and the low participants' engagement with the smartphone applications might account for these non-significant outcomes.

Topics: Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Female; Health Education; Humans; Male; Medication Adherence; Middle Aged; Outcome Assessment, Health Care; Postoperative Complications; Reminder Systems; Secondary Prevention; Smartphone; Software

Myocardial infarction (MI) in elderly patients is associated with unfavorable prognosis, and it is becoming an increasingly prevalent condition. The prognosis of elderly patients is equally impaired in ST-segment elevation (STE) or non-STE (NSTE), and it is markedly worsened by the common presence of multivessel disease (MVD). Given the limited evidence available for elderly patients, it has not yet been established whether, as for younger patients, a complete revascularization strategy in MI patients with MVD should be advocated. We present the design of a dedicated study that will address this research gap.. The FIRE trial is a prospective, randomized, international, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients aged 75 years and older, with MI (either STE or NSTE), MVD at coronary artery angiography, and a clear culprit lesion will be randomized to culprit-only treatment or to physiology-guided complete revascularization. The primary end point will be the patient-oriented composite end point of all-cause death, any MI, any stroke, and any revascularization at 1 year. The key secondary end point will be the composite of cardiovascular death and MI. Quality of life and physical performance will be evaluated as well. All components of the primary and key secondary outcome will be tested also at 3 and 5 years. The sample size for the study is 1,400 patients.. The FIRE trial will provide evidence on whether a specific revascularization strategy should be applied to elderly patients presenting MI and MVD to improve their clinical outcomes.

Topics: Aged; Cardiovascular Agents; Conservative Treatment; Coronary Angiography; Female; Functional Status; Humans; Male; Mortality; Multicenter Studies as Topic; Myocardial Revascularization; Non-ST Elevated Myocardial Infarction; Postoperative Complications; Prognosis; Randomized Controlled Trials as Topic; Severity of Illness Index; ST Elevation Myocardial Infarction

We carried out a pilot randomized controlled study to determine the feasibility of a large trial evaluating the impact of colchicine versus placebo on postoperative atrial fibrillation or atrial flutter (POAF) among patients undergoing lung resection surgery.. Patients ≥55 years of age undergoing lung resection surgery were randomly assigned to receive colchicine 0.6 mg or placebo starting a few hours before surgery. Postoperatively, patients received colchicine 0.6 mg or placebo twice daily for an additional 9 days. Our feasibility outcomes included the period of time required to recruit 100 patients, the completeness of follow-up and compliance with the study drug. The primary efficacy outcome was POAF within 30 days of randomization.. One hundred patients were randomized (49 to colchicine and 51 to placebo) over a period of 12 months at 2 centres in Canada. All patients completed the 30-day follow-up. The mean staff time required to recruit and to follow-up each patient was 165 min. In all, 71% of patients completed the study drug course without interruption. Patient refusal to continuing taking the study drug was the main reason for permanent drug discontinuation. New POAF occurred in 5 (10.2%) patients in the colchicine group and 7 (13.7%) patients in the placebo group (adjusted hazard ratio 0.69, 95% confidence interval 0.20-2.34).. These results show the feasibility of a trial evaluating Colchicine for the prevention of perioperative Atrial Fibrillation in patients undergoing lung resection surgery. This pilot study will serve as the foundation for the large multicentre COP-AF trial.

Topics: Aged; Atrial Fibrillation; Canada; Cardiovascular Agents; Colchicine; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Pilot Projects; Pneumonectomy; Postoperative Complications

Adenosine can reveal dormant pulmonary vein (PV) conduction after PV isolation (PVI) in patients with paroxysmal atrial fibrillation (AF). However, the impact of elimination of adenosine-provoked dormant PV conduction after PVI has not been formally evaluated.. The purpose of this study was to determine whether ablation of PV reconnections unmasked by adenosine improves outcomes.. Patients with paroxysmal AF (n = 129) were randomized to receive either adenosine (n = 61) or no adenosine (n = 68) after PVI. Dormant conduction revealed by adenosine after PVI was ablated until all adenosine-mediated reconnections were eliminated. Thereafter, both groups received isoproterenol.. Acute reconnection was seen in 23 patients (37%) in the adenosine group. There was a significant difference between the number of PVs reconnected if patients were given adenosine >60 minutes after initial PVI compared to those who received adenosine <60 minutes after initial PVI (3/32 [9.4%] vs 24/32 [75%], P <.0001). Patients who did not receive adenosine had more PV reconnections after isoproterenol infusion compared to patients in the adenosine group (17/68 [25.0%] vs 5/61 [8.2%], P = .018). There was no difference in the rate of AF recurrence in patients who received adenosine (24/61 [39%]) compared to control patients (23/68 [34%], log-rank P = .83).. Adenosine can reveal dormant conduction in more than one-third of patients with paroxysmal AF undergoing PVI. However, adenosine administration, and additional ablation of the resultant connections, does not improve long-term outcomes compared to a protocol that includes isoproterenol infusion.

Topics: Adenosine; Aged; Atrial Fibrillation; Cardiovascular Agents; Catheter Ablation; Female; Humans; Intraoperative Care; Isoproterenol; Male; Middle Aged; Postoperative Complications; Pulmonary Veins; Recurrence; Treatment Outcome

Topics: Acute Coronary Syndrome; Aged; Antibodies, Monoclonal; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Double-Blind Method; Female; Humans; Male; Middle Aged; P-Selectin; Postoperative Complications; Treatment Outcome

Low cardiac output syndrome is associated with increased mortality and occurs in 3% to 14% of patients undergoing cardiac surgery on cardiopulmonary bypass (CPB). Levosimendan, a novel calcium sensitizer and K. LEVO-CTS, a large randomized multicenter clinical trial, will evaluate the efficacy, safety, and cost-effectiveness of levosimendan in reducing adverse outcomes in high-risk patients undergoing cardiac surgery on CPB.. ClinicalTrials.gov (NCT02025621).

Topics: Administration, Intravenous; Adult; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Cardiovascular Agents; Dose-Response Relationship, Drug; Drug Monitoring; Female; Humans; Hydrazones; Male; Middle Aged; Postoperative Complications; Pyridazines; Simendan; Stroke Volume; Treatment Outcome; Ventricular Dysfunction, Left

Postoperative complications after cardiac surgery increase mortality. This study aimed to evaluate the efficacy of cardiopulmonary rehabilitation with adaptive servo-ventilation (ASV) in patients undergoing off-pump coronary artery bypass grafting (OPCAB).. A total of 66 patients undergoing OPCAB were enrolled and divided into 2 groups according to the use of ASV (ASV group, 30 patients; non-ASV group, 36 patients). During the perioperative period, all patients undertook cardiopulmonary rehabilitation. ASV was used from postoperative day (POD) 1 to POD5. Hemodynamics showed a different pattern in the 2 groups. Blood pressure (BP) on POD6 in the ASV group was significantly lower than that in the non-ASV group (systolic BP, 112.9±12.6 vs. 126.2±15.8 mmHg, P=0.0006; diastolic BP, 62.3±9.1 vs. 67.6±9.3 mmHg, P=0.0277). The incidence of postoperative atrial fibrillation (POAF) was lower in the ASV group than in the non-ASV group (10% vs. 33%, P=0.0377). The duration of oxygen inhalation in the ASV group was significantly shorter than that in the non-ASV group (5.1±2.2 vs. 7.6±6.0 days, P=0.0238). The duration of postoperative hospitalization was significantly shorter in the ASV group than in the non-ASV group (23.5±6.6 vs. 29.0±13.1 days, P=0.0392).. Cardiopulmonary rehabilitation with ASV after OPCAB reduces both POAF occurrence and the duration of hospitalization.

Topics: Adult; Aged; Aged, 80 and over; Atrial Fibrillation; Breathing Exercises; Cardiovascular Agents; Combined Modality Therapy; Comorbidity; Coronary Artery Bypass, Off-Pump; Coronary Disease; Exercise Test; Exercise Therapy; Female; Hemodynamics; Humans; Incidence; Male; Middle Aged; Oxygen Inhalation Therapy; Positive-Pressure Respiration; Postoperative Care; Postoperative Complications; Pulmonary Ventilation; Respiration Disorders; Ultrasonography

Recent studies have suggested that esmolol is the first choice for rate control in patients with postoperative atrial fibrillation (AF) after coronary artery bypass surgery, but side-effects of esmolol such as hypotension are problematic. To overcome this problem, landiolol, an ultra-short-acting β(1)-blocker with a less negative inotropic effect than esmolol, has been developed. The aim of the present study was to investigate whether landiolol was effective for both rate control and conversion to normal sinus rhythm (NSR).. A prospective, randomized, open-label comparison between i.v. landiolol and diltiazem in patients with postoperative AF was undertaken between January 2008 and June 2009 in Japan. Of 335 patients included in the analysis, 71 patients went into AF. Among these 71 patients, conversion to NSR within 8h after onset of AF occurred in 19 of 35 patients (54.3%) in the landiolol group vs. 11 of 36 patients (30.6%) in the diltiazem group (P<0.05). The incidence of hypotension was lower in the landiolol group (4/35, 11.4%) compared with the diltiazem group (11/36, 30.6%; P<0.05). The incidence of bradycardia was also lower in the landiolol group (0%) compared with the diltiazem group (4/36, 11.1%; P<0.05).. Landiolol is more effective and safer than diltiazem for patients with postoperative AF after open heart surgery.

Topics: Adrenergic beta-Antagonists; Adult; Aged; Aged, 80 and over; Atrial Fibrillation; Cardiac Surgical Procedures; Cardiovascular Agents; Diltiazem; Female; Humans; Male; Middle Aged; Morpholines; Postoperative Complications; Prospective Studies; Urea

The long-term benefits of the maze procedure in patients with chronic atrial fibrillation undergoing mechanical valve replacement who already require lifelong anticoagulation remain unclear.. We evaluated adverse outcomes (death; thromboembolic events; composite of death, heart failure, or valve-related complications) in 569 patients with atrial fibrillation-associated valvular heart disease who underwent mechanical valve replacement with (n=317) or without (n=252) a concomitant maze procedure between 1999 and 2010. After adjustment for differences in baseline risk profiles, patients who had undergone the maze procedure were at similar risks of death (hazard ratio, 1.15; 95% confidence interval, 0.65-2.03; P=0.63) and the composite outcomes (hazard ratio, 0.82; 95% confidence interval, 0.50-1.34; P=0.42) but a significantly lower risk of thromboembolic events (hazard ratio, 0.29; 95% confidence interval, 0.12-0.73; P=0.008) compared with those who underwent valve replacement alone at a median follow-up of 63.6 months (range, 0.2-149.9 months). The effect of superior event-free survival by the concomitant maze procedure was notable in a low-risk EuroSCORE (0-3) subgroup (P=0.049), but it was insignificant in a high-risk EuroSCORE (≥4) subgroup (P=0.65). Furthermore, the combination of the maze procedure resulted in superior left ventricular (P<0.001) and tricuspid valvular functions (P<0.001) compared with valve replacement alone on echocardiographic assessments performed at a median of 52.7 months (range, 6.0-146.8 months) after surgery.. Compared with valve replacement alone, the addition of the maze procedure was associated with a reduction in thromboembolic complications and improvements in hemodynamic performance in patients undergoing mechanical valve replacement, particularly in those with low risk of surgery.

Topics: Adult; Aged; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Cardiovascular Agents; Catheter Ablation; Combined Modality Therapy; Cryosurgery; Endocarditis; Female; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Kaplan-Meier Estimate; Male; Microwaves; Middle Aged; Mitral Valve Insufficiency; Postoperative Complications; Postoperative Hemorrhage; Prospective Studies; Thromboembolism; Treatment Outcome; Tricuspid Valve Insufficiency; Ultrasonography; Ventricular Dysfunction, Left

Volatile anesthetics protect the myocardium during coronary surgery. This study hypothesized that the use of a volatile agent in the anesthetic regimen would be associated with a shorter intensive care unit (ICU) and hospital length of stay (LOS), compared with a total intravenous anesthetic regimen.. Elective coronary surgery patients were randomly assigned to receive propofol (n = 80), midazolam (n = 80), sevoflurane (n = 80), or desflurane (n = 80) as part of a remifentanil-based anesthetic regimen. Multiple logistic regression analysis was used to identify the independent variables associated with a prolonged ICU LOS.. Patient characteristics were similar in all groups. ICU and hospital LOS were lower in the sevoflurane and desflurane groups (P < 0.01). The number of patients who needed a prolonged ICU stay (> 48 h) was also significantly lower (propofol: n = 31; midazolam: n = 34; sevoflurane: n = 10; desflurane: n = 15; P < 0.01). Occurrence of atrial fibrillation, a postoperative troponin I concentration greater than 4 ng/ml, and the need for prolonged inotropic support (> 12 h) were identified as the significant risk factors for prolonged ICU LOS. Postoperative troponin I concentrations and need for prolonged inotropic support were lower in the sevoflurane and desflurane group (P < 0.01). Postoperative cardiac function was also better preserved with the volatile anesthetics. The incidence of other postoperative complications was similar in all groups.. The use of sevoflurane and desflurane resulted in a shorter ICU and hospital LOS. This seemed to be related to a better preservation of early postoperative myocardial function.

Topics: Aged; Anesthesia, Inhalation; Anesthesia, Intravenous; Blood Transfusion; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Cardiotonic Agents; Cardiovascular Agents; Creatinine; Critical Care; Data Collection; Data Interpretation, Statistical; Female; Hemodynamics; Humans; Intubation, Intratracheal; Length of Stay; Male; Middle Aged; Monitoring, Intraoperative; Postoperative Complications; Troponin I

The effects of cardiac resynchronization therapy (CRT) in patients with mildly symptomatic heart failure have not been fully elucidated.. The Multicenter InSync ICD Randomized Clinical Evaluation II (MIRACLE ICD II) was a randomized, double-blind, parallel-controlled clinical trial of CRT in NYHA class II heart failure patients on optimal medical therapy with a left ventricular (LV) ejection fraction < or =35%, a QRS > or =130 ms, and a class I indication for an ICD. One hundred eighty-six patients were randomized: 101 to the control group (ICD activated, CRT off) and 85 to the CRT group (ICD activated, CRT on). End points included peak VO2, VE/CO2, NYHA class, quality of life, 6-minute walk distance, LV volumes and ejection fraction, and composite clinical response. Compared with the control group at 6 months, no significant improvement was noted in peak VO2, yet there were significant improvements in ventricular remodeling indexes, specifically LV diastolic and systolic volumes (P=0.04 and P=0.01, respectively), and LV ejection fraction (P=0.02). CRT patients showed statistically significant improvement in VE/CO2 (P=0.01), NYHA class (P=0.05), and clinical composite response (P=0.01). No significant differences were noted in 6-minute walk distance or quality of life scores.. In patients with mild heart failure symptoms on optimal medical therapy with a wide QRS complex and an ICD indication, CRT did not alter exercise capacity but did result in significant improvement in cardiac structure and function and composite clinical response over 6 months.

Topics: Aged; Cardiovascular Agents; Defibrillators, Implantable; Disease Progression; Double-Blind Method; Electric Countershock; Electrocardiography; Exercise Test; Exercise Tolerance; Heart Conduction System; Heart Failure; Humans; Male; Middle Aged; Postoperative Complications; Survival Rate; Tachycardia, Ventricular; Treatment Outcome; Ventricular Dysfunction, Left; Ventricular Fibrillation; Ventricular Remodeling

There are conflicting reports on the effects of diltiazem treatment on renal function in surgical patients. We sought to determine whether diltiazem treatment alters renal function in patients undergoing major thoracic surgery.. In a prospective study, 330 patients scheduled for elective thoracic surgery received either IV diltiazem (n = 167) or placebo (n = 163) immediately after the operation and orally thereafter for 14 days in an effort to prevent postoperative atrial arrhythmias. Serum creatinine and BUN levels were compared before and during the first postoperative week.. Patients treated with diltiazem were similar to control subjects in terms of age (mean +/-SD, 66 +/- 10 years vs 67 +/- 10 years, respectively), baseline serum creatinine or BUN levels, prevalence of comorbid conditions, and surgical characteristics. During the first 5 postoperative days, the two groups did not differ in terms of serum creatinine or BUN levels. The incidence of renal failure was 0.6% in the diltiazem group and 1.2% in the placebo group (difference was not significant). There was no difference in the length of hospitalization or mortality rate.. In patients without renal disease who are undergoing elective thoracic surgery, prophylactic diltiazem treatment did not alter postoperative renal function.

Topics: Aged; Cardiovascular Agents; Diltiazem; Female; Humans; Kidney Diseases; Male; Pneumonectomy; Postoperative Complications; Prospective Studies

Transmyocardial revascularization involves the creation of channels in the myocardium with a laser to relieve angina. We compared the safety and efficacy of transmyocardial revascularization performed with a holmium laser with those of medical therapy in patients with refractory class IV angina (according to the criteria of the Canadian Cardiovascular Society).. In a prospective study conducted between March 1996 and July 1998 at 18 centers, 275 patients with medically refractory class IV angina and coronary disease that could not be treated with percutaneous or surgical revascularization were randomly assigned to receive transmyocardial revascularization followed by continued medical therapy (132 patients) or medical therapy alone (143 patients).. After one year of follow-up, 76 percent of the patients who had undergone transmyocardial revascularization had improvement in angina (a reduction of two or more classes), as compared with 32 percent of the patients who received medical therapy alone (P<0.001). Kaplan-Meier survival estimates at one year (based on an intention-to-treat analysis) were similar for the patients assigned to undergo transmyocardial revascularization and those assigned to receive medical therapy alone (84 percent and 89 percent, respectively; P=0.23). At one year, the patients in the transmyocardial-revascularization group had a significantly higher rate of survival free of cardiac events (54 percent, vs. 31 percent in the medical-therapy group; P<0.001), a significantly higher rate of freedom from treatment failure (73 percent vs. 47 percent, P<0.001), and a significantly higher rate of freedom from cardiac-related rehospitalization (61 percent vs. 33 percent, P<0.001). Exercise tolerance and quality-of-life scores were also significantly higher in the transmyocardial-revascularization group than in the medical-therapy group (exercise tolerance, 5.0 MET [metabolic equivalent] vs. 3.9 MET; P=0.05); quality-of-life score, 21 vs. 12; P=0.003). However, there were no differences in myocardial perfusion between the two groups, as assessed by thallium scanning.. Patients with refractory angina who underwent transmyocardial revascularization and received continued medical therapy, as compared with similar patients who received medical therapy alone, had a significantly better outcome with respect to improvement in angina, survival free of cardiac events, freedom from treatment failure, and freedom from cardiac-related rehospitalization.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Combined Modality Therapy; Coronary Circulation; Disease-Free Survival; Exercise Tolerance; Female; Humans; Laser Therapy; Male; Middle Aged; Myocardial Revascularization; Postoperative Complications; Prospective Studies; Quality of Life; Severity of Illness Index; Survival Analysis

To examine the degree of success at maintaining patients randomized to epidural or general anesthesia for peripheral vascular surgery within predetermined blood pressure (BP) and heart rate (HR) limits. To investigate associations between such hemodynamic control and intraoperative myocardial ischemia and postoperative major cardiac morbidity.. Prospective randomized clinical trial.. University-affiliated hospital.. 100 patients undergoing elective lower extremity revascularization for atherosclerotic peripheral vascular disease.. Patients were randomized to receive either epidural anesthesia or general anesthesia. Blood pressure and HR limits were determined prior to randomization. Hemodynamic monitoring and management of anesthesia was standardized. Myocardial ischemia and major cardiac morbidity were diagnosed by a blinded cardiologist, based on continuous ambulatory ECG monitoring, cardiac enzymes, and 12 lead ECGs. Intraoperative BP and HR date were analyzed by investigators masked to the type of anesthesia given.. A greater percentage of patients randomized to general anesthesia had intraoperative BPs more above their limit (95% vs 72%, p = 0.002) and/or more rapid changes in HR (75% vs 48%, p = 0.008) or BP (100% vs 93%, p = 0.04) than those randomized to epidural anesthesia. Intraoperative ischemia and major cardiac morbidity were similar in the two anesthesia groups. Patients experiencing intraoperative ischemia, regardless of anesthetic type, more frequently had BPs greater than 10% above their upper limit (90% vs 60% p = 0.04) and/or more rapid HR changes (90% vs 58%, p = 0.03) compared with patients without ischemia. These vital sign abnormalities, however, were not necessarily temporally related to the ischemic episodes. Patients experiencing subsequent major cardiac morbidity were not different from other patients with respect to excursions out of BP on HR limits.. Prevention of elevated intraoperative BP and/on rapid changes in BP or HR may be more successful with epidural than with general anesthesia. Such vital sign abnormalities may occur more frequently in patients who have had intraoperative ischemia or are at risk for having it later in the procedure.

Topics: Aged; Anesthesia, Epidural; Anesthesia, General; Arteriosclerosis; Blood Pressure; Cardiovascular Agents; Elective Surgical Procedures; Electrocardiography, Ambulatory; Female; Heart Diseases; Heart Rate; Humans; Intraoperative Complications; Leg; Male; Middle Aged; Monitoring, Intraoperative; Myocardial Ischemia; Myocardium; Peripheral Vascular Diseases; Postoperative Complications; Prospective Studies; Risk Factors; Single-Blind Method

Accelerated coronary artery disease (TxCAD) in the long term heart transplant patient remains the major limitation to long term survival, with approximately 50% of patients developing an angiographic event of TxCAD by five years post-transplant. This accelerated vasculopathic process is believed to be due to chronic immune injury to the endothelium with coronary intimal proliferation developing rapidly. Subsequent lipid deposition develops in these proliferated areas, leading to a diffuse progressive occlusive CAD which can be seen on serial coronary arteriography as a progressive luminal narrowing. Based on multiple annual studies demonstrating a protective effect of calcium blockers in diet- or injury-induced vascular disease in animals, the authors undertook a randomized trial of diltiazem versus no calcium blocker begun early after heart transplantation in 1986. Serial quantitative coronary arteriographic measurements have demonstrated no significant change in the diltiazem group versus a decrease in mean coronary lumen diameter, from 2.41 +/- 0.27 to 2.19 +/- 0.28 mm, in the no calcium blocker group. These differences persisted at two and three years of follow-up. Freedom from CAD based on qualitative angiographic data confirmed this protective effect of diltiazem. These observations are supported by other reported retrospective studies of calcium blockers post-heart transplantation and in non-TxCAD. Therefore, calcium blockers appear to prevent the early coronary intimal proliferation in response to chronic immune injury, as well as the later lipid deposition. The cardiac transplant patient may serve as a useful model for study of antiatherosclerotic agents in humans.

Topics: Arteriosclerosis; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Diltiazem; Female; Heart Transplantation; Humans; Male; Postoperative Complications; Time Factors

Atrial fibrillation (AF) represents the most frequent arrhythmic disorder after thoracoabdominal esophageal resection and is associated with a significant increase in perioperative morbidity and mortality.. In this retrospective cohort study, 167 patients who underwent thoracoabdominal esophagectomy at a large university hospital were assessed. We compared patients who received a 14-day postoperative course of diltiazem with a control group of patients who did not undergo diltiazem prophylaxis. Diltiazem therapy started immediately upon admission to the intensive care unit (ICU) with a loading dose of 0.25 mg/kg bodyweight (i.v.) followed by continuous infusion (0.1 mg/kg bodyweight/h) for 40-48 h. Oral administration (Dilzem. A total of 117 patients were assessed. Twelve (10.3%) of all patients developed postoperative new-onset atrial fibrillation in the first 30 days after surgical intervention. Prevalence of new-onset AF showed no significant differences between the diltiazem group and control group (p = 0.74). The prevalence of bradycardia (14.7% vs. 3.6%; p = 0.03) and dose of norepinephrine required (0.09 vs. 0.04 µg/kg bodyweight/min; p = 0.04) were higher in the diltiazem group. There were no significant differences between the groups for the median postoperative duration of hospital/ICU stay or mortality.. A prophylactic 14-day postoperative course of diltiazem was not associated with a reduction in new-onset AF or 30-day mortality following thoracoabdominal esophagectomy. Prophylactic diltiazem therapy was associated with drug-related adverse effects such as bradycardia and increased requirement of norepinephrine. German Clinical Trial Registration Number: DKRS00016631.

Topics: Administration, Oral; Adolescent; Adult; Aged; Aged, 80 and over; Atrial Fibrillation; Cardiovascular Agents; Diltiazem; Drug Administration Schedule; Esophagectomy; Female; Follow-Up Studies; Humans; Infusions, Intravenous; Male; Middle Aged; Postoperative Care; Postoperative Complications; Retrospective Studies; Treatment Outcome; Young Adult

Topics: Acute Coronary Syndrome; Adult; Cardiac Catheterization; Cardiovascular Agents; Cardiovascular Diseases; Combined Modality Therapy; Coronavirus Infections; COVID-19; Diabetes Mellitus, Type 2; Diagnosis, Differential; Extracorporeal Membrane Oxygenation; Female; Heart Failure; Heart Transplantation; Humans; Hyperlipidemias; Hypertension; Hypertrophy, Left Ventricular; Immunosuppressive Agents; Intra-Aortic Balloon Pumping; Kidney Transplantation; Male; Middle Aged; Pandemics; Pericarditis; Pneumonia, Viral; Postoperative Complications; Respiration, Artificial; Respiratory Distress Syndrome; Shock, Cardiogenic

Dissection after plain balloon angioplasty is required to achieve adequate luminal area; however, it is associated with a high risk of vascular events. This study aimed to examine the relationship between non-flow limiting coronary dissections and subsequent lumen loss and long-term clinical outcomes following successful drug-coated balloon (DCB) treatment of de novo coronary lesions.. A total of 227 patients with good distal flow (Thrombolysis in Myocardial Infarction flow grade 3) following DCB treatment were retrospectively enrolled and stratified according to the presence or absence of a non-flow limiting dissection. The primary endpoint was late lumen loss (LLL) at 6-month angiography, and the secondary endpoint was target vessel failure (TVF, a composite of cardiac death, target vessel myocardial infarction, target vessel revascularization, and target vessel thrombosis).. The cohort consisted of 95 patients with and 132 patients without a dissection. There were no between-group differences in LLL (90.8%) returning for angiography at 6 months (0.05±0.19 mm in non-dissection and 0.05±0.30 mm in dissection group,. The presence of a dissection following successful DCB treatment of a de novo coronary lesion may not be associated with an increased risk of LLL or TVF (Impact of Drug-coated Balloon Treatment in de Novo Coronary Lesion; NCT04619277).

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Dissection; Drug-Eluting Stents; Female; Humans; Male; Middle Aged; Myocardial Infarction; Paclitaxel; Postoperative Complications; Retrospective Studies; Treatment Outcome

Junctional ectopic tachycardia (JET) is a relatively common narrow complex rhythm typically characterized by atrioventricular dissociation or retrograde atrial conduction in a 1:1 pattern. Junctional ectopic tachycardia can be a life-threatening disorder, causing severe hemodynamic compromise and increased morbidity and mortality. The treatment of refractory JET can be very difficult, even with multimodal therapeutic interventions. The purpose of this study was to assess the role of ivabradine in cases of JET refractory to amiodarone and esmolol.. A total of 480 congenital heart surgeries were carried out at our center in 2017. Twenty (4.16%) patients had postoperative JET. Among these, five infants, aged 7 to 12 months (median: 8 months), had refractory JET. These patients (three tetralogy of Fallot, one ventricular septal defect, one complete atrioventricular septal defect) were treated with oral ivabradine in the dose range of 0.1 to 0.2 mg/kg/12 h as an adjunct to amiodarone.. All five patients achieved rate reduction and eventual conversion to sinus rhythm. Mean duration to achieve heart rate of <140 bpm after initiation of ivabradine therapy was 16.8 hours (±7.2 hours), while mean duration to achieve sinus rhythm was 31.6 hours (±13.6 hours). No patient had any recurrence of JET. No patient exhibited any hemodynamic derangement nor side effects attributable to oral ivabradine.. Oral ivabradine has the potential to be used as an adjunct to amiodarone in the treatment of JET in infants after surgery for congenital heart disease.

Topics: Cardiac Surgical Procedures; Cardiovascular Agents; Electrocardiography; Female; Heart Defects, Congenital; Heart Rate; Humans; Infant; Ivabradine; Male; Postoperative Complications; Retrospective Studies; Tachycardia, Ectopic Junctional; Treatment Outcome

Common femoral artery (CFA) occlusive disease remains a debatable site for endovascular therapy, and the outcome of drug-eluting balloon (DEB) angioplasty in treating CFA occlusive disease is largely unknown. This study compared the efficacy, safety, and short-term patency rate of DEB angioplasty and femoral endarterectomy for treatment of CFA occlusive disease.. From March 2013 to June 2016, there were 100 patients with symptomatic CFA occlusive disease who were retrospectively reviewed. Forty patients were treated with DEB angioplasty and 60 were treated with femoral endarterectomy. Each patient received regular follow-up. Patency rate, ankle-brachial index, target lesion revascularization, and adverse events were assessed.. Technical success was 100% in all patients. The DEB group had a lower 1-year primary patency rate (75.0% vs 96.7%; P = .003), but the secondary patency rate was similar between the two groups (97.5% vs 98.3%; P = 1.000). At 2-year follow-up, the primary patency was lower in the DEB group (57.1%) than in the endarterectomy group (94.1%; P = .001), whereas the secondary patency rate had no significant difference (90.5% vs 97.1%; P = 1.000). Both groups had significant improvement in ankle-brachial index. Freedom from target lesion revascularization was lower in the DEB group both at 1 year (75.0% vs 96.7%; P = .003) and at 2 years (57.1% vs 94.1%; P = .001). There was no significant difference in the incidence of complications and adverse events.. Femoral endarterectomy has a better primary patency rate compared with DEB angioplasty in treating CFA occlusive disease without significant increase in complications. In patients not suitable for endarterectomy, DEB angioplasty provides a similar secondary patency rate and could be considered an alternative treatment.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon; Ankle Brachial Index; Cardiovascular Agents; Coated Materials, Biocompatible; Endarterectomy; Equipment Design; Female; Femoral Artery; Humans; Male; Middle Aged; Peripheral Arterial Disease; Postoperative Complications; Retrospective Studies; Risk Factors; Time Factors; Treatment Outcome; Vascular Access Devices; Vascular Patency

Managing patients with in-stent restenosis (ISR) remains an important clinical challenge. In particular, large, randomized trials assessing the effect of drug-eluting balloons (DEB) in patients with de novo lesions are warranted. We investigated the effect of DEB on procedural complications, target lesion revascularization (TLR), and major adverse cardiac and cerebrovascular events in patients with drug-eluting stent ISR and de novo lesions. The clinical profiles of 238 consecutive patients treated for coronary ISR (n = 174) and de novo lesions (n = 64) using SeQuent Please paclitaxel-coated balloon were analyzed. Study end points were major adverse cardiac events (MACEs). At 1-year follow-up, TLR and MACEs occurred with acceptably low rates (5.0% and 6.3%, respectively). At 2.00 (0.74) years of follow-up, there was a significant difference in the rates of TLR between the ISR and the de novo lesions groups (14.4% [ISR] vs 3.1% [de novo], P = .028), and the occurrence of MACEs distinctly increased in the ISR group compared to the de novo lesions group (21.8% vs 6.2%, P = .009). The long-term outcomes of the ISR group were inferior to those of the de novo group (TLR, log-rank P = .019; MACEs, log-rank P = .010). Drug-eluting balloon for ISR and de novo lesions of small coronary vessels is effective and safe.

Topics: Aged; Cardiac Catheters; Cardiovascular Agents; Coated Materials, Biocompatible; Coronary Artery Disease; Coronary Restenosis; Drug-Eluting Stents; Female; Humans; Male; Middle Aged; Paclitaxel; Percutaneous Coronary Intervention; Postoperative Complications; Retrospective Studies; Risk Factors; Time Factors; Treatment Outcome

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been shown to reduce angina and improve quality of life, but the frequency of new or residual angina after CTO PCI and its relationship with titration of anti-anginal medications (AAMs) has not been described.. Among consecutive CTO PCI patients treated at 12 US centres in the OPEN CTO registry, angina was assessed 6 months after the index PCI using the Seattle Angina Questionnaire (SAQ) Angina Frequency scale (a score <100 defined new or residual angina). We then compared the proportion of patients with AAM escalation (defined as an increase in the number or dosage of AAMs between discharge and follow-up) between those with and without 6-month angina. Of 901 patients who underwent CTO PCI, 197 (21.9%) reported angina at 6-months, of whom 80 (40.6%) had de-escalation, 66 (33.5%) had no change, and only 51 (25.9%) had escalation of their AAM by the 6-month follow-up. Rates of AAM escalation were similar when stratifying patients by the ultimate success of the CTO PCI, completeness of physiologic revascularization, presence or absence of angina at baseline, history of heart failure, and by degree of symptomatic improvement after CTO PCI.. One in five patients reported angina 6 months after CTO PCI. Although patients with new or residual angina were more likely to have escalation of AAMs in follow-up compared with those without residual symptoms, only one in four patients with residual angina had escalation of AAMs. Although it is unclear whether this finding reflects maximal tolerated therapy at baseline or therapeutic inertia, these findings suggest an important potential opportunity to further improve symptom control in patients with complex stable ischaemic heart disease.

Topics: Aged; Angina Pectoris; Cardiovascular Agents; Chronic Disease; Coronary Occlusion; Female; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Postoperative Complications; Prospective Studies; Registries; Time Factors

A multidisciplinary international working subgroup of the third Perioperative Quality Initiative consensus meeting appraised the evidence on the influence of preoperative arterial blood pressure and community cardiovascular medications on perioperative risk.. A modified Delphi technique was used, evaluating papers published in MEDLINE on associations between preoperative numerical arterial pressure values or cardiovascular medications and perioperative outcomes. The strength of the recommendations was graded by National Institute for Health and Care Excellence guidelines.. Significant heterogeneity in study design, including arterial pressure measures and perioperative outcomes, hampered the comparison of studies. Nonetheless, consensus recommendations were that (i) preoperative arterial pressure measures may be used to define targets for perioperative management; (ii) elective surgery should not be cancelled based solely upon a preoperative arterial pressure value; (iii) there is insufficient evidence to support lowering arterial pressure in the immediate preoperative period to minimise perioperative risk; and (iv) there is insufficient evidence that any one measure of arterial pressure (systolic, diastolic, mean, or pulse) is better than any other for risk prediction of adverse perioperative events.. Future research should define which preoperative arterial pressure values best correlate with adverse outcomes, and whether modifying arterial pressure in the preoperative setting will change the perioperative morbidity or mortality. Additional research should define optimum strategies for continuation or discontinuation of preoperative cardiovascular medications.

Topics: Blood Pressure; Cardiovascular Agents; Contraindications, Procedure; Delphi Technique; Elective Surgical Procedures; Humans; Hypertension; Perioperative Care; Postoperative Complications; Preoperative Period; Prognosis; Risk Assessment

The purpose of this observational study was to investigate the feasibility, initial safety, and efficacy of the SeQuent® Please DCB (B. Braun Melsungen, Germany) for patients with de novo coronary lesions in vessels exceeding 3.0 mm in a consecutive series of all comer percutaneous coronary intervention. A total of 120 patients (135 lesions) with de novo coronary lesions in vessels ≥ 3.0 mm treated with DCB were enrolled in this single-centre prospective observational study. The primary endpoint was target lesion failure (TLF), a composite endpoint of cardiac death, target vessel-myocardial infarction (TV-MI), and clinically driven target vessel revascularization (TLR) at 12 months. Safety endpoints included cardiac death, TV-MI, and definite target vessel thrombosis. 45.9% of the lesions were classified as complex (type B2/C). The reference vessel diameter was 3.09 ± 0.31 mm measured via quantitative coronary angiography analysis. Coronary dissections occurred in 42 patients (35.0%; Type A-B 14.1%; Type C 19.1%; Type D: 1.6%), two of which [1.6%; (type D dissection)] underwent bail-out stent implantation. 12-month follow-up was completed in 100% patients. The 12-month incidence of TLF was 3.4%. The clinically driven TLR occurred in four patients (3.4%). The incidence of TLR was low in patients without any detectable dissections, similar to those with dissections (3.8% vs. 2.5%; p = 0.146). No patient suffered cardiac death, TV-MI, or target vessel thrombosis. The study shows the feasibility, initial safety, and efficacy of coronary intervention using SeQuent® Please DCB for the treatment of patients with de novo lesion in vessels exceeding 3 mm. The study highlights that the coronary dissection (Type A-C) post DCB treatment occurs frequently but is safe at follow up.

Topics: Aged; Cardiac Catheters; Cardiovascular Agents; Coated Materials, Biocompatible; Coronary Angiography; Coronary Artery Disease; Coronary Stenosis; Equipment Design; Feasibility Studies; Female; Humans; Incidence; Male; Middle Aged; Paclitaxel; Percutaneous Coronary Intervention; Postoperative Complications; Prospective Studies; Risk Factors; Time Factors; Treatment Outcome

Most studies on gender difference of the in-hospital outcome of percutaneous coronary intervention (PCI) were performed in the pre-drug-eluting stents (DES) era. This study was performed to investigate whether gender influences the in-hospital outcome of PCI in the DES era.A total of 44,967 PCI procedure between January and December of 2014 from the nationwide PCI registry database in Korea were analyzed. The study population was male predominant (70.2%). We examined the association of gender with unadjusted and adjusted in-hospital mortality and composite events of PCI, including mortality, nonfatal myocardial infarction, stent thrombosis, stroke, urgent repeat PCI and bleeding requiring transfusion.Most of the study patients (91.3%) received DES. The incidence rates of in-hospital mortality (2.95% vs 1.99%, P <.001) and composite events (7.01% vs 5.48%, P <.001) were significantly higher in women compared to men. Unadjusted analyses showed that women had a 1.49 times higher risk of in-hospital mortality and a 1.30 times higher risk of composite events than men (P <.001 for each). After adjustment for potential confounders, female gender was not a risk factor for mortality (P = .258), but the risk of composite events remained 1.20 times higher in women than in men (P = .008).Among patients undergoing PCI in the contemporary DES era, female gender was associated with an increased risk of in-hospital composite events, but not in-hospital mortality. More careful attention should be emphasized to minimize procedure-related risks and to improve prognosis in women undergoing PCI.

Topics: Age Factors; Aged; Aged, 80 and over; Cardiovascular Agents; Comorbidity; Drug-Eluting Stents; Female; Hospital Mortality; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Postoperative Complications; Republic of Korea; Risk Factors; Sex Factors; Smoking; Stroke Volume

Junctional ectopic tachycardia (JET) is the commonest tachyarrhythmia in the early post-operative period in children undergoing open-heart surgery. It frequently leads to hemodynamic instability and needs to be managed aggressively. Amiodarone is the first-line agent along with non-pharmacological interventions. We report our initial experience with the use of Ivabradine in post-operative JET. A retrospective case records review of children with post-operative JET during the period from June 2018 to May 2019 was performed. Eight patients with post-operative JET were treated with Ivabradine during this period. The first patient was initially treated with Amiodarone. All eight patients responded to Ivabradine. The initial response was rate control permitting overdrive pacing. One patient had recurrence of JET 10 h after Ivabradine and after return to sinus rhythm. Amiodarone was administered along with the second dose of Ivabradine resulting in remission to sinus rhythm. Ivabradine appears to be an effective alternative to Amiodarone in children with post-operative JET based on our initial clinical experience.

Topics: Administration, Intranasal; Cardiac Surgical Procedures; Cardiovascular Agents; Child, Preschool; Female; Humans; Infant; Ivabradine; Male; Postoperative Complications; Retrospective Studies; Tachycardia, Ectopic Junctional; Treatment Outcome

The objective of this study was to compare the safety and efficacy of a polymer-free sirolimus coated, ultrathin strut drug eluting stent (PF-SES) to its uncoated bare-metal stent (BMS) platform of identical stent architecture.. Recently published randomized trials comparing BMS to DES with a focus on shortened dual-antiplatelet therapy reported incidences of stent thrombosis (ST) and bleeding complications (LEADERS FREE) in favor of drug eluting stents (DES).. Data of previously published large-sale, international, single-armed, multicenter, observational studies of ultra-thin PF-SES, and BMS were propensity score (PS) matched for selected lesion morphological and cardiovascular risk factors to compare target lesion revascularization (TLR), myocardial infarction, cardiac death, major adverse cardiac events (MACE), bleeding complications and ST rates. Primary endpoint in both studies was TLR at 9 months.. At 9 months the rates of TLR was significantly lower in the PF-SES group as compared with patients treated with the BMS analogue of identical stent design (1.4% vs. 4.6%, P = 0.005). Likewise the 9-month MACE rates were lower in the PF-SES group (3.2% vs. 8.7%, P = 0.001) whereas there were no differences in the accumulated ST rates (0.5% vs. 1.5%, P = 0.109). Overall accumulated bleeding incidences (BARC 1-5) were not significantly different between PF-SES and BMS patients (1.8% vs. 2.7%, p = 0.388).. PF-SES are superior over analogue BMS of identical stent architecture in daily clinical routine with lower rates of TLR and MACE in a PS-matched, unselected patient population without differences in accumulated ST rates and bleeding frequencies given the currently favored postprocedural comedication (ClinicalTrials.gov Identifier NCT02629575).

Topics: Aged; Aged, 80 and over; Asia; Cardiovascular Agents; Coronary Artery Disease; Drug-Eluting Stents; Europe; Female; Humans; Male; Metals; Middle Aged; Percutaneous Coronary Intervention; Postoperative Complications; Probucol; Propensity Score; Prospective Studies; Prosthesis Design; Registries; Risk Assessment; Risk Factors; Sirolimus; Time Factors; Treatment Outcome

: Major hepatectomy (MH) can lead to an increasing portal vein pressure (PVP) and to lesions of the hepatic parenchyma. Several reports have assessed the deleterious effect of a high posthepatectomy PVP on the postoperative course of MH. Thus, several surgical modalities of portal inflow modulation (PIM) have been described. As for pharmacological modalities, experimental studies showed a potential efficiency of Somatostatin to reduce PVP and flow. To our knowledge, no previous clinical reports of PIM using somatostatin are available. Herein, we report the results of PIM using somatostatin in 10 patients who underwent MH with post-hepatectomy PVP > 20 mmHg. Our results suggest Somatostatin could be considered as an efficient reversible PIM when PVP decrease is above 2.5 mmHg.

Topics: Cardiovascular Agents; Hepatectomy; Humans; Liver Failure; Pilot Projects; Portal Pressure; Portal Vein; Postoperative Complications; Regional Blood Flow; Somatostatin

Skin flap procedures are widely used to reconstruct skin and soft tissue defects. Skin flap necrosis is a serious postoperative complication. Many researchers have introduced pharmacological agents to improve flap ischemia in experimental studies. However, outcomes of these studies remain controversial. We previously demonstrated that transcutaneous CO. Six-week-old male Sprague-Dawley rats were divided into two equal groups: the control group (n = 6) and CO. A statistically significant difference was found in the percentage of the flap survival area between the two groups on postoperative days 3 and 5 (p < 0.05). Furthermore, the expression of VEGF and bFGF was significantly higher and that of HIF-1α was significantly lower in the CO. Transcutaneous CO

Topics: Administration, Cutaneous; Animals; Carbon Dioxide; Cardiovascular Agents; Graft Survival; Hypoxia; Ischemia; Male; Necrosis; Plastic Surgery Procedures; Postoperative Complications; Rats; Rats, Sprague-Dawley; Skin; Surgical Flaps; Treatment Outcome

Topics: Cardiovascular Agents; Diet Therapy; Humans; Myocardial Reperfusion Injury; Percutaneous Coronary Intervention; Postoperative Complications; ST Elevation Myocardial Infarction; Treatment Outcome

Patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are often managed conservatively. Clinical practice guidelines recommend treating these patients with the same pharmacological drugs as those who receive invasive treatment. We analyze the use of new antiplatelet drugs (NADs) and other recommended treatments in people discharged following an NSTE-ACS according to the treatment strategy used, comparing the medium-term prognosis between groups.. Prospective observational multicenter registry study in 1717 patients discharged from hospital following an ACS; 1143 patients had experienced an NSTE-ACS. We analyzed groups receiving the following treatment: No cardiac catheterization (NO CATH): n = 134; 11.7%; Cardiac catheterization without revascularization (CATH-NO REVASC): n = 256; 22.4%; percutaneous coronary intervention (PCI): n = 629; 55.0%; and coronary artery bypass graft (CABG): n = 124; 10.8%. We assessed major adverse cardiovascular events (MACE), all-cause mortality, and hemorrhagic complications at one year.. NO CATH was the oldest, had the most comorbidities, and was at the highest risk for ischemic and hemorrhagic events. Few patients who were not revascularized with PCI received NADs (NO CATH: 3.7%; CATH-NO REVASC: 10.6%; PCI: 43.2%; CABG: 3.2%; p<0.001). Non-revascularized patients also received fewer beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), and statins (p<0.001). At one year, MACE incidence in NO CATH group was three times that of the other groups (30.1%, p<0.001), and all-cause mortality was also much higher (26.3%, p<0.001). There were no significant differences in hemorrhagic events. Belonging to NO CATH group was an independent predictor for MACE at one year in the multivariate analysis (HR 2.72, 95% CI 1.29-5.73; p = 0.008).. Despite current invasive management of NSTE-ACS, patients not receiving catheterization are at very high risk for under treatment with recommended drugs, including NADs. Their medium-term prognosis is poor, with high mortality. Patients treated with PCI receive better pharmacological management, with high use of NADs.

Topics: Acute Coronary Syndrome; Aged; Cardiac Catheterization; Cardiovascular Agents; Comorbidity; Conservative Treatment; Coronary Artery Bypass; Female; Follow-Up Studies; Humans; Male; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Postoperative Complications; Prospective Studies; Risk Factors; Treatment Outcome

Topics: Adrenergic beta-Antagonists; Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Depression; Erectile Dysfunction; Humans; Male; Postoperative Complications

Cardiovascular complications, in particular perioperative myocardial infarctions, are central contributors to morbidity and mortality after non-cardiac surgery. We present a case of a 41-year-old male, smoker and dyslipidemic, who underwent bimaxillary orthognathic jaw surgery with the development of an acute coronary syndrome in the immediate postoperative period. We managed to early diagnose the myocardial infarction and promptly performed a percutaneous transluminal coronary angioplasty, resulting in a positive outcome.

Topics: Acute Coronary Syndrome; Adult; Anesthesia, General; Angioplasty; Anticoagulants; Atorvastatin; Cardiovascular Agents; Combined Modality Therapy; Disease Susceptibility; Drug-Eluting Stents; Dyslipidemias; Early Diagnosis; Elective Surgical Procedures; Humans; Male; Maxilla; Orthognathic Surgery; Postoperative Complications; Smoking; Surgery, Plastic

Topics: Cardiovascular Agents; Coronary Artery Bypass; Humans; Postoperative Complications; Preoperative Care; Risk Factors; Treatment Outcome

Topics: Cardiovascular Agents; Coronary Artery Bypass; Humans; Postoperative Complications; Preoperative Care; Risk Factors; Treatment Outcome

Cilostazol is effective in controlling pathophysiological pathways similar or identical to those involved in nonmaturation and failure of the arteriovenous access. This case-control study examined whether cilostazol would improve maturation rates and durability of vascular access for hemodialysis. The treatment group included 33 patients who received cilostazol for ≥30 days prior to creation of a dialysis access and continued with cilostazol therapy for ≥60 days after surgery. The matched (gender, age, race, diabetes, and the year of surgery) control group included 116 patients who underwent the same procedure but did not receive cilostazol prior to and at least 3 months after surgery. Primary outcomes were maturation and, for those that matured, time of functioning access, defined as the time from the first use to irreparable failure of the access. Secondary outcomes were time to maturation, complications, and time to first complication. Study group patients were 3.8 times more likely to experience fistula maturation compared to the controls (88% vs 66%, RR = 3.8, 95% confidence interval: 1.3-11.6, P = .016). Fewer patients in the study group had complications (76% vs 92%, P = .025), and the time from construction of the fistula to the first complication was longer (345.6 ± 441 days vs 198.3 ± 185.0 days, P = .025). Time to maturation was similar in both groups (119.3 ± 62.9 days vs 100.2 ± 61.7 days, P = .2). However, once matured, time to failure was significantly longer in the treatment group (903.7 ± 543.6 vs 381.6 ± 317.2 days, P = .001). Multivariate analysis confirmed that the likelihood of maturation was significantly higher in the treatment group patients. These results suggest that dialysis access patients may benefit from preoperative and postoperative cilostazol therapy. If confirmed by a randomized trial, this treatment will have a major beneficial impact on patients dependent on a well-functioning access for their hemodialysis.

Topics: Aged; Arteriovenous Shunt, Surgical; Cardiovascular Agents; Case-Control Studies; Cilostazol; Drug Administration Schedule; Female; Humans; Linear Models; Logistic Models; Male; Multivariate Analysis; Odds Ratio; Phosphodiesterase 3 Inhibitors; Postoperative Complications; Renal Dialysis; Risk Factors; Tetrazoles; Time Factors; Treatment Outcome

The internal mammary artery (IMA) is the preferred conduit for bypassing the left anterior descending (LAD) artery in patients undergoing coronary artery bypass grafting. Systematic evaluation of the frequency and predictors of IMA failure and long-term outcomes is lacking.. The Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV trial participants who underwent IMA-LAD revascularization and had 12- to 18-month angiographic follow-up (n=1539) were included. Logistic regression with fast false selection rate methods was used to identify characteristics associated with IMA failure (≥75% stenosis). The relationship between IMA failure and long-term outcomes, including death, myocardial infarction, and repeat revascularization, was assessed with Cox regression. IMA failure occurred in 132 participants (8.6%). Predictors of IMA graft failure were LAD stenosis <75% (odds ratio, 1.76; 95% confidence interval, 1.19-2.59), additional bypass graft to diagonal branch (odds ratio, 1.92; 95% confidence interval, 1.33-2.76), and not having diabetes mellitus (odds ratio, 1.82; 95% confidence interval, 1.20-2.78). LAD stenosis and additional diagonal graft remained predictive of IMA failure in an alternative model that included angiographic failure or death before angiography as the outcome. IMA failure was associated with a significantly higher incidence of subsequent acute (<14 days of angiography) clinical events, mostly as a result of a higher rate of repeat revascularization.. IMA failure was common and associated with higher rates of repeat revascularization, and patients with intermediate LAD stenosis or with an additional bypass graft to the diagonal branch had increased risk for IMA failure. These findings raise concerns about competitive flow and the benefit of coronary artery bypass grafting in intermediate LAD stenosis without functional evidence of ischemia.. URL: http:/www.clinicaltrials.gov. Unique identifier: NCT00042081.

Topics: Aged; Cardiac Catheterization; Cardiovascular Agents; Combined Modality Therapy; Comorbidity; Coronary Angiography; Coronary Disease; Coronary Restenosis; Diabetes Complications; Double-Blind Method; Female; Graft Occlusion, Vascular; Humans; Internal Mammary-Coronary Artery Anastomosis; Kaplan-Meier Estimate; Male; Middle Aged; Multicenter Studies as Topic; Myocardial Infarction; Postoperative Complications; Proportional Hazards Models; Randomized Controlled Trials as Topic; Reoperation; Treatment Failure

Topics: Aneurysm; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Combined Modality Therapy; Continuous Positive Airway Pressure; Echocardiography, Transesophageal; Enterobacteriaceae Infections; Epoprostenol; Female; Humans; Hypertension, Pulmonary; Marfan Syndrome; Middle Aged; Mitral Valve Insufficiency; Oxygen Inhalation Therapy; Postoperative Complications; Pulmonary Artery; Pulmonary Valve Insufficiency; Respiratory Insufficiency

To evaluate the role of routine troponin surveillance in patients undergoing major noncardiac surgery, unblinded screening with cardiac consultation per protocol was implemented at a tertiary care center. In this study, we evaluated 1-year mortality, causes of death, and consequences of cardiac consultation of this protocol.. This observational cohort included 3224 patients ≥60 years old undergoing major noncardiac surgery. Troponin I was measured routinely on the first 3 postoperative days. Myocardial injury was defined as troponin I >0.06 μg/L. Regression analysis was used to determine the association between myocardial injury and 1-year mortality. The causes of death, the diagnoses of the cardiologists, and interventions were determined for different levels of troponin elevation.. Postoperative myocardial injury was detected in 715 patients (22%) and was associated with 1-year all-cause mortality (relative risk [RR] 1.4, P = 0.004; RR 1.6, P < 0.001; and RR 2.2, P < 0.001 for minor, moderate, and major troponin elevation, respectively). Cardiac death within 1 year occurred in 3%, 5%, and 11% of patients, respectively, in comparison with 3% of the patients without myocardial injury (P = 0.059). A cardiac consultation was obtained in 290 of the 715 patients (41%). In 119 (41%) of these patients, the myocardial injury was considered to be attributable to a predisposing cardiac condition, and in 111 patients (38%), an intervention was initiated.. Postoperative myocardial injury was associated with an increased risk of 1-year all-cause but not cardiac mortality. A cardiac consultation with intervention was performed in less than half of these patients. The small number of interventions may be explained by a low suspicion of a cardiac etiology in most patients and lack of consensus for standardized treatment in these patients.

Topics: Aged; Aged, 80 and over; Biomarkers; Blood Transfusion; Cardiovascular Agents; Cause of Death; Chi-Square Distribution; Electrocardiography; Female; Heart Diseases; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Myocardial Revascularization; Odds Ratio; Postoperative Complications; Predictive Value of Tests; Referral and Consultation; Retreatment; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Troponin

Studies of the effects of postoperative atrial fibrillation (poAF) on long-term survival are conflicting, likely because of comorbidities that occur with poAF and the patient populations studied. Furthermore, the effects of poAF duration on long-term survival are poorly understood.. We utilized a prospectively collected database on outcomes of cardiac surgery at a large tertiary care institution between August 2001 and December 2010 with survival follow-up through June 2015 to analyze long-term survival of patients with poAF. In addition, we identified patient- and procedure-related variables associated with poAF, and estimated overall comorbidity burden using the Elixhauser comorbidity index. Survival was compared between patients with poAF (n = 513) and a propensity score matched control cohort, both for all patients and separately for subgroups of patients with poAF lasting less than 2 days (n = 218) and patients with prolonged poAF (n = 265).. Patients with poAF were older and had a higher burden of comorbidities. Survival was significantly worse for patients with poAF than for the matched control group (hazard ratio 1.43, 95% confidence interval: 1.11 to 1.86). That was driven by decreased survival among patients with prolonged poAF (hazard ratio 1.97, 95% confidence interval: 1.37 to 2.80), whereas survival of patients with poAF for less than 2 days was not significantly different from that of matched controls (hazard ratio 0.91, 95% confidence interval: 0.60 to 1.39).. After close matching based on comorbidity burden, prolonged poAF is still associated with decreased survival. Therefore, vigilance is warranted in monitoring and treating patients with prolonged poAF after cardiac surgery.

Topics: Age Factors; Aged; Aged, 80 and over; Atrial Fibrillation; Cardiac Surgical Procedures; Cardiovascular Agents; Comorbidity; Databases, Factual; Female; Follow-Up Studies; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Postoperative Complications; Prognosis; Propensity Score; Proportional Hazards Models; Prospective Studies; Risk Factors; Tertiary Care Centers; Time Factors

This study aimed to evaluate Fontan circulation which was observed over 30 years.. Forty patients who underwent a Fontan operation between 1974 and 1986 and survived (group S, n = 20) or died in the late period (group LD, n = 20) were evaluated. The median age at operation was 10 years (range 2-32 years). The diagnoses were tricuspid atresia in 21, single ventricle in 9, and others in 10. The Fontan procedure was a right atrium-pulmonary artery graft in 2, atriopulmonary connection in 28, and right atrium-right ventricle anastomosis in 10 (Björk in 4, graft in 6).. Causes of late death were congestive heart failure in 6, sudden death in 4, arrhythmia in 4, and others in 6. Sixteen patients underwent reoperation 23.3 ± 6.5 years after Fontan. Cardiac catheterization was performed at 1 month and 12 years. There were no significant differences in central venous pressure, ventricular ejection fraction, or pulmonary vascular resistance between the two groups. However, changes in ventricular end-diastolic volume suggested volume and pressure overload in group LD. In group S, the latest chest radiographs showed cardiothoracic ratio 51.3% ± 7.6%, oxygen saturation 94% ± 2%, brain natriuretic peptide 153 ± 111 pg ċ mL. For long-term Fontan survival, timely total cavopulmonary connection conversion and medication to decrease ventricular volume and pressure load might be important.

Topics: Adolescent; Adult; Cardiovascular Agents; Cause of Death; Child; Child, Preschool; Female; Fontan Procedure; Heart Defects, Congenital; Hemodynamics; Humans; Kaplan-Meier Estimate; Male; Postoperative Complications; Reoperation; Retrospective Studies; Risk Factors; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Young Adult

Uncomplicated Stanford B acute aortic dissection (AAD) is generally treated with medical management; whereas complicated dissections require surgery or thoracic endovascular aortic repair (TEVAR). Studies have demonstrated that long-term outcomes with medical management are suboptimal. Therefore, we sought to investigate the early and long-term clinical efficacy of TEVAR for Stanford B AAD.. From March 2004 to January 2008, 63 consecutive patients were treated and retrospectively placed into either one of the two groups, the TEVAR group (n = 42) and the medicine group (n = 21). All TEVAR procedures were performed in the acute phase. The changes of true and false lumen diameter were monitored with computed tomography angiography examinations in the thoracic aorta at the level of the stented segment at long-term follow-up.. As compared with the medicine group, the age at intervention in the TEVAR group was higher (p < 0.05), and they also had more patent false lumen in this group. Patients in the TEVAR group had significantly longer hospital stays than those in the medicine group (p < 0.01). The incidence of the early events was not significantly different between the two groups. The incidence of aortic-related late events and late death were significantly higher in the medicine group than those in the TEVAR group. Log-rank tests demonstrated that patients treated with medical management had significantly more late adverse events than did those treated with TEVAR (p < 0.01). At 1-year follow-up, the true lumen diameter in the thoracic aorta at the level of the stented segment increased significantly after TEVAR, and the mean reduction of false lumen diameter was highly significant. The remodeling was stable at 3 and 5 years after TEVAR.. Patients with Stanford B AAD treated with TEVAR experienced fewer late adverse events than those treated with medical management, TEVAR could be an effective treatment for Stanford B AAD.

Topics: Aged; Aortic Aneurysm, Thoracic; Aortic Dissection; Aortography; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; China; Endovascular Procedures; Female; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Risk Factors; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Vascular Remodeling

Predicting the occurrence of aortic insufficiency (AI) during left ventricular assist device (LVAD) support has remained unsolved.. We enrolled 52 patients who had received continuous flow LVAD (14 axial and 38 centrifugal pumps) and who been followed for ≥6 months between Jun 2006 and Dec 2013. Native aortic valve (AV) opening was observed in 18 patients (35%) with improved LV systolic function, and none of them had AI. On multivariate logistic regression analysis preoperative shorter heart failure duration was the only independent predictor of postoperative native AV opening (P=0.042; odds ratio [OR], 0.999). Of the remaining 34 patients (65%) with closed AV, 11 had AI with enlargement of the aortic root and narrow pulse pressure. Among those with closed AV, axial pump use (n=13) was the only significant predictor of the development of AI (P=0.042; OR, 4.950). Patients with AI had lower exercise capacity and a higher readmission rate than those without AI during 2-year LVAD support (55% vs. 8%; P<0.001).. Native AV opening during LVAD support is profoundly associated with reversal of LV systolic function, especially in patients with preoperative shorter heart failure duration. Among those in whom the native AV remains closed, low pulsatility of axial flow pump may facilitate aortic root remodeling and post-LVAD AI development that results in worse clinical outcome.

Topics: Adult; Aortic Valve; Aortic Valve Insufficiency; Cardiovascular Agents; Combined Modality Therapy; Equipment Design; Female; Heart Failure; Heart Valves; Heart-Assist Devices; Hemodynamics; Humans; Male; Middle Aged; Postoperative Complications; Radiography; Retrospective Studies; Ultrasonography; Ventricular Dysfunction, Left

Postoperative atrial fibrillation (AF) is a common complication following coronary artery bypass grafting (CABG). We investigated the risk factors for postoperative AF and analyzed the relationship between blood sugar concentration (BS) and AF after CABG.. A total of 199 consecutive patients who underwent isolated CABG were retrospectively examined and classified according to the presence (n=95) or absence (n=104) of postoperative AF. On univariate analysis mean postoperative BS (P<0.001), postoperative drainage volume (P<0.001), age (P=0.034), presence of diabetes mellitus (DM; P=0.004), and postoperative estimated glomerular filtration rate (P=0.032) were significant risk factors for postoperative AF. On multivariate analysis mean postoperative BS (OR, 1.041; 95% CI: 1.008-1.079; P<0.001), postoperative drainage volume (OR, 1.003; 95% CI: 1.001-1.006; P=0.001), and age (OR, 1.040; 95% CI: 1.002-1.083; P=0.041) were significant risk factors for postoperative AF. Postoperative AF often occurred in patients with high postoperative BS, irrespective of DM. The BS cut-off that predicted postoperative AF occurrence was 180 mg/dl. A strong positive correlation existed between the time of the maximum postoperative BS and AF onset time (ρ=0.746).. Mean postoperative BS and postoperative drainage volume are risk factors for AF after CABG. AF was strongly associated with maximum postoperative BS. Intensive glycemic control could reduce AF occurrence after CABG.

Topics: Aged; Aged, 80 and over; Atrial Fibrillation; Blood Glucose; Cardiovascular Agents; Case-Control Studies; Cerebral Infarction; Comorbidity; Coronary Artery Bypass; Diabetes Mellitus; Female; Humans; Hyperglycemia; Male; Odds Ratio; Postoperative Complications; Retrospective Studies; Risk Factors

Topics: Aged; Angiography; Arterial Occlusive Diseases; Cardiovascular Agents; Delayed Diagnosis; Diagnosis, Differential; Female; Heart Failure; Hemodiafiltration; Humans; Hypertension; Hypertension, Renovascular; Iliac Artery; Kidney Transplantation; Postoperative Complications; Renal Artery Obstruction; Reoperation; Stents; Ultrasonography, Doppler

Pulmonary hypertension is associated with diverse cardiac, pulmonary, and systemic diseases in neonates, infants, and older children and contributes to significant morbidity and mortality. However, current approaches to caring for pediatric patients with pulmonary hypertension have been limited by the lack of consensus guidelines from experts in the field. In a joint effort from the American Heart Association and American Thoracic Society, a panel of experienced clinicians and clinician-scientists was assembled to review the current literature and to make recommendations on the diagnosis, evaluation, and treatment of pediatric pulmonary hypertension. This publication presents the results of extensive literature reviews, discussions, and formal scoring of recommendations for the care of children with pulmonary hypertension.

Topics: Cardiovascular Agents; Child; Child, Preschool; Combined Modality Therapy; Diagnostic Imaging; Disease Management; Extracorporeal Membrane Oxygenation; Genetic Counseling; Heart Defects, Congenital; Hernias, Diaphragmatic, Congenital; Humans; Hypertension, Pulmonary; Infant; Infant, Newborn; Lung; Lung Transplantation; Nitric Oxide; Oxygen Inhalation Therapy; Persistent Fetal Circulation Syndrome; Postoperative Complications; Respiration, Artificial; Ventilator-Induced Lung Injury

We sought to evaluate the prognosis of different treatment strategies on patients with multivessel coronary disease and high SYNTAX score. 171 patients with multivessel coronary disease and SYNTAX score ε33, who underwent coronary angiography between July 2009 and July 2010 at our hospital were retrospectively selected and divided into incomplete and complete revascularization intervention groups (IR), a coronary artery bypass surgery group (CABG), a conservative drug therapy group according to treatment strategies chosen and agreed by the patients. These patients were followed up for 19.44 ± 5.73 months by telephone or outpatient service. We found the medical treatment group has a lower overall survival than the IR, CR group, and CABG group (P log-rank values are 0.03, 0.03, and 0.02, respectively). The medical treatment group also has a lower survival than the IR group, CR group, and CABG group in cerebral stroke and recurrent myocardial infarction (MI) (P log-rank values are 0.004, 0.03, and 0.001, respectively) and MACE events (P log-rank values are 0.003, 0.001 and P < 0.001, respectively). The medical treatment group and IR group have lower survival in recurrent angina pectoris than the CR group and CABG group (P log-rank values are 0.02, 0.02 and 0.03, 0.008, respectively). There are no significant differences between the CR group and the CABG group in number of deaths, strokes and recurrent MIs, MACE events, angina pectoris (P log-rank values are 0.69, 0.53, and 0.86, respectively). The IR group shows a lower survival than the CR group and CABG group only in angina pectoris (P log-rank values are 0.03 and 0.008, respectively). For the patients with a high SYNTAX score, medical treatment is still inferior to revascularization therapy (interventional therapy or coronary artery bypass surgery). It appears that the CABG is not obviously superior to the coronary intervention therapy. Complete revascularization and coronary artery bypass grafting treatments simply have better survival in angina pectoris compared to the incomplete revascularization. Therefore, individual treatment strategies are recommended and more trials are required to study these effects.

Topics: Adult; Aged; Angina Pectoris; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Female; Humans; Male; Middle Aged; Myocardial Infarction; Postoperative Complications; Stroke; Survival Analysis

Takotsubo cardiomyopathy consists of a transient dysfunction of the left ventricle. It is characterised by an impaired left ventricular segmentary contractility, without significant coronary lesions in the coronary angiography. It usually occurs after an episode of physical or emotional stress. We present the case of a 70 year-old woman, who, in the postoperative period of an ankle osteosynthesis, developed a Takotsubo cardiomyopathy in the context of a sepsis caused by Staphylococcus aureus. She presented with acute lung oedema and a clinical picture of low cardiac output. The echocardiogram showed left ventricular medioapical akinesia. Coronary angiography was normal. She was treated with supportive measures with good progress. At 33 days from onset she was able to be discharged from hospital to home with normal systolic function on echocardiography.

Topics: Aged; Ankle Fractures; Atrial Fibrillation; Bacteremia; Cardiovascular Agents; Female; Fracture Fixation, Internal; Humans; Postoperative Complications; Staphylococcal Infections; Takotsubo Cardiomyopathy

Heart rate variability (HRV), as an index of autonomic nervous system (ANS) functioning, is reduced by depression after cardiac surgery, but the underlying mechanisms of this relationship are poorly understood. Poor emotion regulation as a core symptom of depression has also been associated with altered ANS functioning. The present study aimed to examine whether emotion dysregulation could be a mediator of the depression-reduced HRV relationship observed after cardiac surgery.. Self-reported emotion regulation and four-minute HRV were measured in 25 depressed and 43 nondepressed patients after cardiac surgery. Mediation analysis was conducted to evaluate emotion regulation as a mediator of the depression-reduced HRV relationship.. Compared to nondepressed patients, those with depression showed lower standard deviation of normal-to-normal (NN) intervals (p<.05), root mean square successive difference of NN intervals (p<.004), and number of interval differences of successive NN intervals greater than 50ms (NN50) (p<.05). Increased low frequency (LF) in normalized units (n.u.) and reduced high frequency (HF) n.u. were also found in depressed compared to nondepressed patients (p's<.01). Mediation analysis revealed that suppression of emotion-expressive behavior partially mediated the effect of depression on LF n.u. and HF n.u.. Results confirmed previous findings showing that depression is associated with reduced HRV, especially a reduced vagal tone and a sympathovagal imbalance, after cardiac surgery. This study also provides preliminary evidence that increased trait levels of suppression of emotion-expressive behavior may mediate the depression-related sympathovagal imbalance after cardiac surgery.

Topics: Adaptation, Psychological; Aged; Anticoagulants; Autonomic Nervous System; Cardiovascular Agents; Coronary Artery Bypass; Depression; Emotions; Female; Heart Conduction System; Heart Rate; Heart Valve Prosthesis Implantation; Humans; Interview, Psychological; Male; Middle Aged; Postoperative Complications; Surveys and Questionnaires; Vagus Nerve

Topics: Arrhythmias, Cardiac; Cardiac Surgical Procedures; Cardiovascular Agents; Cyanosis; Diagnostic Techniques, Cardiovascular; Female; Humans; Hypoxia; Infant, Newborn; Male; Pacemaker, Artificial; Postoperative Complications; Pulmonary Valve Insufficiency; Respiration, Artificial; Tetralogy of Fallot

Topics: Adrenergic beta-Antagonists; Anticoagulants; Biomarkers; Cardiovascular Agents; Cardiovascular Diseases; Diagnostic Imaging; Drug Therapy, Combination; Evidence-Based Medicine; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Intraoperative Complications; Laparoscopy; Myocardial Revascularization; Perioperative Care; Postoperative Complications; Preoperative Care; Risk Assessment

Topics: Benzazepines; Bisoprolol; Cardiovascular Agents; Comparative Effectiveness Research; Drug Monitoring; Drug Therapy, Combination; Exercise Tolerance; Female; Heart Rate; Humans; Ivabradine; Male; Middle Aged; Myocardial Ischemia; Myocardial Revascularization; Postoperative Complications; Tachycardia; Treatment Outcome

To assess the role of percutaneous coronary intervention (PCI) for in-hospital and one-year prognosis of ST elevation (STE) myocardial infarction (MI) patients with impaired glucose tolerance (IGT) or type 2 diabetes mellitus (T2DM).. This registry study included 601 STEMI patients admitted to hospital within 24 hours after STEMI onset during one year. According to medical history, dynamics of glycemia and results of oral glucose tolerance test patients were divided into 3 groups: (1) without disturbances of carbohydrate metabolism (DCM), (2) with IGT and (3) with T2DM. Primary PCI was performed in 373 (62.06%) patients while 228 (37.94%) received pharmacological treatment only. The following events were registered during one year after PCI: recurrent MI, stroke, admission for decompensated chronic heart failure (CHF), repeat emergency PCI.. Patients with IGT and DM compared with those without DCM had similarly more severe course of the index MI and worse one-year prognosis. PCI significantly improved one-year prognosis in patients with and without DCM.. Use of urgent PCI in STEMI patients with both DM and IGT is prognostically more beneficial in terms of lowering rate of adverse events during one year after MI.

Topics: Carbohydrate Metabolism; Cardiovascular Agents; Diabetes Mellitus, Type 2; Electrocardiography; Female; Follow-Up Studies; Glucose Intolerance; Humans; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Postoperative Complications; Prognosis; Registries; Risk Factors; Russia; Severity of Illness Index; Treatment Outcome

This study sought to compare the survival of asymptomatic patients with previous revascularization and ischemia, who subsequently underwent repeat revascularization or medical therapy (MT).. Coronary artery disease is progressive and recurring; thus, stress myocardial perfusion scintigraphy (MPS) is widely used to identify ischemia in patients with previous revascularization.. Of 6,750 patients with previous revascularization undergoing MPS between January 1, 2005, and December 31, 2007, we identified 769 patients (age 67.7 ± 9.5 years; 85% men) who had ischemia and were asymptomatic. A propensity score was developed to express the associations of revascularization. Patients were followed up over a median of 5.7 years (interquartile range: 4.7 to 6.4 years) for all-cause death. A Cox proportional hazards model was used to identify the association of revascularization with all-cause death, with and without adjustment for the propensity score. The model was repeated in propensity-matched groups undergoing MT versus revascularization.. Among 769 patients, 115 (15%) underwent revascularization a median of 13 days (interquartile range: 6 to 31 days) after MPS. There were 142 deaths; mortality with MT and revascularization were 18.3% and 19.1% (p = 0.84). In a Cox proportional hazards model (chi-square test = 89.4) adjusting for baseline characteristics, type of previous revascularization, MPS data, and propensity scores, only age and hypercholesterolemia but not revascularization were associated with mortality. This result was confirmed in a propensity-matched group.. Asymptomatic patients with previous revascularization and inducible ischemia on MPS realize no survival benefit from repeat revascularization. In this group of post-revascularization patients, an ischemia-based treatment strategy did not alter mortality.

Topics: Age Factors; Aged; Asymptomatic Diseases; Cardiovascular Agents; Cause of Death; Coronary Artery Disease; Disease Progression; Female; Humans; Hypercholesterolemia; Male; Middle Aged; Myocardial Ischemia; Myocardial Perfusion Imaging; Myocardial Revascularization; Outcome Assessment, Health Care; Postoperative Complications; Proportional Hazards Models; Reoperation; Risk Assessment

Topics: Arteriovenous Fistula; Cardiac Catheterization; Cardiovascular Agents; Female; Hand; Humans; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Postoperative Complications; Radial Artery; Regional Blood Flow; Treatment Outcome; Ultrasonography, Doppler; Vascular Surgical Procedures; Veins

To study effect of age and presence of personality type D on quality of life (QL) of patients in one year after coronary bypass surgery (CBS).. Assessment of QL before and after surgery was carried out in 408 patients. Two groups were formed: patients younger than 60 years (n=233) and older than 60 years (n=175). Quality of life and presence of personality type D was assessed by questionnaires SF-36 and DS-14, respectively.. In a year after CBS improvement of physical and psychological components of QL (p<0.05) was noted in both groups. Personality type D was more frequent among patients older than 60 years (p<0.01). Patients with personality type D had worse parameters of irrespective of age (p<0.01). Personality type D correlated directly with age QL (p=0.003) and inversely with parameters of QL (p<0.01). Presence of personality type D was an independent predictor of low level of physical (together with index of atherogenecity prior to surgery) and psychological components of QL at multiple logistic regression analysis.. Assessment of personality traits of patients before CBS can be helpful for targeted measures aimed at improvement of QL what is especially important for older age groups.

Topics: Adult; Age Factors; Aged; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Female; Humans; Male; Middle Aged; Outcome Assessment, Health Care; Perioperative Period; Personality Assessment; Postoperative Complications; Quality of Life; Risk Factors; Severity of Illness Index; Statistics as Topic; Treatment Outcome; Type D Personality

We sought to evaluate patients' adherence to optimal pharmacotherapy as recommendedby the European Society of Cardiology, together with the assessment of potential clinical determinants of medical non-compliance in a large cohort of patients after endoscopic atraumatic coronary artery bypassing (EACAB).. This cross sectional study was conducted in a group of 706 individuals who underwent EACAB between April 1998 and December 2010. Data covering current pharmacological treatment with antiplatelet agents, beta-blockers (BB) (or heart rate lowering calcium channel blockers [CCB] in case of intolerance and/or poor efficacy of beta-blockade), angiotensin-converting enzyme (ACE) inhibitors (or angiotensin receptor blockers [ARB]) and statins was acquired. Mean duration of observation after the surgery was 2132 ± 1313 days.. Complete follow-up data has been obtained from 415 living patients (341 males). Amongst them, 353 (85%) received antiplatelet agents, while BB or CCB were routinely ingested by 349 (84%) patients. Statins were used by 310 (74.7%) individuals and 274 (66%) subjects took ACE inhibitors or ARB. Baseline demographic and clinical features, including major co-morbidities had no impact on patients' compliance with all investigated medications. There was no clear association between adherence to treatment and risk of rehospitalization or occurrence of major cerebral and cardiovascular events.. EACAB patients' compliance with pharmacotherapy guidelines is insufficient and is unrelated to demographic and clinical features of the subjects. Multidisciplinary approach involving health education, enhancement in prescription drug affordability and a better rapport between doctors and patients should be incorporated into clinical practice to overcome therapeutic disobedience.

Topics: Aged; Cardiovascular Agents; Coronary Artery Bypass; Cross-Sectional Studies; Drug Therapy, Combination; Endoscopy; Female; Humans; Male; Medication Adherence; Middle Aged; Patient Readmission; Postoperative Complications; Prospective Studies; Time Factors; Treatment Outcome

We present here analysis of surgical treatment of 24 patients (5 women, 19 men, age 20-75, mean age 50.7 +/- 2.5 years) with dilated cardiomyopathy (DCM) operated during the period from 2008 to 2013. Duration of the disease ranged from 4 months to 12 years (mean 49.4 +/- 7.5 months). According to symptoms and results of 6-minute walk test 3 patients (13%) had heart failure NYHA class III and 21 patients (87%)--NYHA class IV. Average end-diastolic left ventricular size was 7.4 +/- 0.18 cm (6.0-9.2 cm), ejection fraction--26.7 +/- 2.1% (13-47%), mean pulmonary artery pressure 54.9 +/- 2.9 mm Hg (35-80 mmHg). All patients underwent organ-conserving surgery aimed at reverse remodeling of the heart. Surgery was accompanied with implantation of implantable cardioverter defibrillator in 3 patients and/or cardiac resynchronization therapy device in 6 patients. Two patients (8.3%) died during hospitalization of hemodynamically significant ventricular arrhythmias; seven patients (29.2%) died in the late postoperative period. The results of the analysis indicate that reverse-remodeling surgery may be effective in patients with DCM of any age group with preserved reserves of the liver, kidney, and lung function in the absence of active myocarditis. Further observations are needed to determine the place of this operation in the protocol of treatment of patients with DCM.

Topics: Arrhythmias, Cardiac; Cardiac Resynchronization Therapy; Cardiac Surgical Procedures; Cardiomyopathy, Dilated; Cardiovascular Agents; Defibrillators, Implantable; Female; Follow-Up Studies; Heart Function Tests; Humans; Male; Middle Aged; Moscow; Organ Sparing Treatments; Postoperative Complications; Postoperative Period; Survival Analysis; Treatment Outcome

The vast majority of reports describing beating heart robotic myocardial revascularization (total endoscopic coronary artery bypass) contain very small numbers of patients undergoing single-vessel bypass. We present a large series of patients undergoing multivessel total endoscopic coronary artery bypass.. We performed a retrospective clinical review of 106 patients undergoing total endoscopic coronary artery bypass (72% multivessel) at 1 institution by 1 experienced cardiac surgeon/physician assistant team. These results were compared with the expected clinical outcomes from conventional coronary artery bypass grafting calculated using the Society of Thoracic Surgeons risk calculator.. Of the 106 patients, 1% underwent quadruple total endoscopic coronary artery bypass, 8% triple, 63% double, and 28% single. The emergent conversion rate for hemodynamic instability was 6.6%. The postoperative renal failure rate (doubling of baseline serum creatinine or dialysis required) was 7.5%. Overall, 23 patients (21.7%) exhibited at least 1 major morbidity/mortality (4 deaths). The number of vessels bypassed (single/double/triple/quadruple) correlated positively with the surgical/operating room time, the lung separation time, vasoactive medication use, blood use, a postoperative ventilation time longer than 24 hours, intensive care unit length of stay, and hospital length of stay. An increased surgical time was significantly associated with major morbidity (P = .011) and mortality (P = .043). A comparison with the Society for Thoracic Surgeons expected outcomes revealed a similar hospital length of stay but an increased incidence of prolonged ventilation (P = .003), renal failure (P < .001), morbidity (P = .045), and mortality (P = .049).. Our results suggest that addressing multivessel coronary artery disease using total endoscopic coronary artery bypass offers no obvious clinical benefits and might increase the morbidity and mortality.

Topics: Adult; Aged; Aged, 80 and over; Biomarkers; Blood Transfusion; Cardiovascular Agents; Chi-Square Distribution; Chicago; Coronary Artery Bypass; Coronary Artery Disease; Creatinine; Endoscopy; Female; Hemodynamics; Hospital Mortality; Humans; Intensive Care Units; Length of Stay; Logistic Models; Male; Middle Aged; Postoperative Complications; Renal Dialysis; Renal Insufficiency; Respiration, Artificial; Risk Assessment; Risk Factors; Robotics; Stroke; Surgery, Computer-Assisted; Time Factors; Treatment Outcome

Coronary artery bypass grafting (CABG) is the operation most commonly performed by cardiac surgeons. There are few contemporary data examining evolving patient characteristics and surgical outcomes of isolated CABG. We used the Society of Thoracic Surgeons adult cardiac surgery database to characterize trends in patient characteristics and outcomes after CABG over the past decade.. From 2000 to 2009, 1,497,254 patients underwent isolated primary CABG at Society of Thoracic Surgeons participating institutions. Demographics, operative characteristics, and postoperative outcomes were assessed, and risk-adjusted outcomes were calculated.. Compared with the year 2000, patients undergoing isolated primary CABG in 2009 were more likely to have diabetes mellitus (33% vs 40%) and hypertension (71% vs 85%). There were clinically insignificant differences in age, gender, and body surface area. Between 2000 and 2009, there has been a 6.3% and 19.5% increase in the preoperative use of aspirin and beta-blockers, respectively. Between 2004 and 2009, there was a 7.8% increase in the use of angiotension-converting enzyme inhibitors preoperatively. Furthermore, between 2005 and 2009 there was a 3.8% increase in the use of statins preoperatively. The median number of distal anastomoses performed was unchanged between 2000 and 2009 (3; interquartile range, 2-4). There was a significant increase in the use of the internal thoracic artery (88% in 2000 vs 95% in 2009). The predicted mortality rates of 2.3% were consistent between 2000 and 2009. The observed mortality rate over this period declined from 2.4% in 2000 to 1.9% in 2009 representing a relative risk reduction of 24.4%. The incidence of postoperative stroke decreased significantly from 1.6% to 1.2%, representing a risk reduction of 26.4%. There was also a 9.2% relative reduction in the risk of reoperation for bleeding and a 32.9% relative risk reduction in the incidence of sternal wound infection.. Over the past decade, the risk profile of patients undergoing CABG has changed, with fewer smokers, more diabetic patients, and better medical therapy characterizing patients referred for surgical coronary revascularization. The left internal thoracic artery is nearly universally used and outcomes have improved substantially, with a significant decline in postoperative mortality and morbidity.

Topics: Aged; Cardiovascular Agents; Chi-Square Distribution; Comorbidity; Coronary Artery Bypass; Coronary Artery Disease; Databases as Topic; Female; Humans; Logistic Models; Male; Middle Aged; Outcome and Process Assessment, Health Care; Postoperative Complications; Retrospective Studies; Risk Assessment; Risk Factors; Societies, Medical; Time Factors; Treatment Outcome; United States

The development of acute kidney injury (AKI) after adult cardiac surgery is associated with increased morbidity and mortality. Our aim was to assess the risk factors for postoperative AKI and whether the addition of perioperative management variables can improve AKI prediction.. We studied 3,219 patients operated from January 2006 to December 2009. The AKI was defined as proposed by the Acute Kidney Injury Network. Patient preoperative characteristics, as well as intraoperative, cardiopulmonary bypass (CPB), and postoperative management variables, were evaluated for association with AKI with logistic regression analysis. The model including all variables was assessed first, then separate models including only preoperative variables followed by the sequential addition of intraoperative, CPB, and postoperative management variables were tested; receiver operating characteristic analysis was used to evaluate and compare models' discriminatory power.. The AKI occurred in 288 of 3,219 patients (8.9%). Logistic regression analysis identified 15 predictors of AKI; 4 were preoperative (age, diabetes, smoking, and serum creatinine), 4 intraoperative (inotropes, erythrocytes transfusion, cross-clamp time, and need of a new pump run), 2 CPB-related (urine output and furosemide administration during CPB), and 5 postoperative (erythrocytes transfusion, administration of vasoconstrictors, inotropes, diuretics, and antiarrhythmics). Model-discrimination performance improved from an area under the curve of 0.830 (95% confidence interval 0.807 to 0.854) for the model including only preoperative variables to an area under the curve of 0.904 (95% confidence interval 0.886 to 0.921) for the model including all variables (p<0.001).. Several factors influence AKI development after cardiac surgery and perioperative patient management significantly affects AKI occurrence. Predictive models can be sensibly improved by the addition of these variables.

Topics: Acute Kidney Injury; Age Factors; Aged; Cardiac Surgical Procedures; Cardiovascular Agents; Comorbidity; Coronary Artery Bypass; Creatinine; Diabetes Mellitus; Diuretics; Erythrocyte Transfusion; Female; Humans; Intraoperative Complications; Italy; Male; Middle Aged; Models, Theoretical; Perioperative Care; Postoperative Complications; Retrospective Studies; Risk Factors; ROC Curve; Smoking; Statistics, Nonparametric

Topics: Adrenergic beta-Antagonists; Atrial Fibrillation; Cardiac Surgical Procedures; Cardiovascular Agents; Diltiazem; Female; Humans; Male; Morpholines; Postoperative Complications; Urea

The case is reported of a 28-year-old subject with a bioprosthesis (Shelhigh 31) in the aortic position, with symptoms of heart failure and possible prosthetic dysfunction. As the echocardiographic interrogation remained inconclusive, the patient underwent cardiovascular magnetic resonance (CMR) imaging, which revealed an impaired movement of the non-coronary cusp. In addition, computed tomography (CT) demonstrated severe calcification of the immobile prosthetic component. Hence, in selected patients, both CMR and CT can be used as complementary tools to evaluate the dysfunction and pathology of heart valve bioprostheses.

Topics: Adult; Aortic Valve; Bioprosthesis; Calcinosis; Cardiovascular Agents; Drug Therapy, Combination; Heart Failure; Heart Function Tests; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Magnetic Resonance Imaging; Male; Postoperative Complications; Prosthesis Failure; Stroke Volume; Tomography, X-Ray Computed; Treatment Outcome; Ventricular Remodeling

The aim of this study was to compare preoperative patient evaluation by a vascular physician with a standardized workup protocol prior to elective endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA), in terms of differences in patient medication and mortality.. Consecutive patients with infrarenal AAA treated with standard EVAR from 1998 to 2006 (group 2) and 2007 to 2011 (group 1) were compared. Patients in group 1 (N.=201) were investigated preoperatively by a vascular physician, evaluating comorbidities and medication. Patients in group 2 (N.=304) underwent a standardized preoperative work-up including spirometry and echocardiography. Median time of follow-up was 23 months in group 1 and 71 months in group 2.. The proportion of patients who had on-going medication with anti-platelet and lipid lowering medication at admission was higher in group 1 compared to group 2 (62% versus 51%; P=0.013 and 68% versus 35%; P<0.001). In group 1, the proportion of newly instituted or increased dosage of anti-hypertensive, anti-platelet or lipid lowering medication at preoperative evaluation was 40%, 24% and 31%, respectively. The total cost for preoperative assessment per patient was 272 € in group 1 and 293 € in group 2 (P<0.001). There was no difference in 30-day (P=0.29) or long-term (P=0.24) mortality between the two groups.. Preoperative assessment by a vascular physician resulted in lower costs and improvement of medication against atherosclerosis, uncontrolled hypertension and perioperative ischemic cardiac events, but mortality was unaffected.

Topics: Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Chi-Square Distribution; Comorbidity; Diagnostic Techniques and Procedures; Echocardiography; Elective Surgical Procedures; Electrocardiography; Endovascular Procedures; Female; Hospital Costs; Humans; Kaplan-Meier Estimate; Kidney Function Tests; Male; Postoperative Complications; Predictive Value of Tests; Preoperative Care; Risk Assessment; Risk Factors; Spirometry; Sweden; Time Factors; Treatment Outcome

Topics: Aftercare; Anticoagulants; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Combined Modality Therapy; Endovascular Procedures; Extremities; Humans; Ischemia; Meta-Analysis as Topic; Minimally Invasive Surgical Procedures; Multicenter Studies as Topic; Peripheral Arterial Disease; Postoperative Complications; Radiography, Interventional; Randomized Controlled Trials as Topic; Risk; Thrombophilia; Vascular Surgical Procedures

The Second Medicine, Angioplasty, or Surgery Study (MASS II) included patients with multivessel coronary artery disease and normal systolic ventricular function. Patients underwent coronary artery bypass graft surgery (CABG, n=203), percutaneous coronary intervention (PCI, n=205), or medical treatment alone (MT, n=203). This investigation compares the economic outcome at 5-year follow-up of the 3 therapeutic strategies.. We analyzed cumulative costs during a 5-year follow-up period. To analyze the cost-effectiveness, adjustment was made on the cumulative costs for average event-free time and angina-free proportion. Respectively, for event-free survival and event plus angina-free survival, MT presented 3.79 quality-adjusted life-years and 2.07 quality-adjusted life-years; PCI presented 3.59 and 2.77 quality-adjusted life-years; and CABG demonstrated 4.4 and 2.81 quality-adjusted life-years. The event-free costs were $9071.00 for MT; $19,967.00 for PCI; and $18,263.00 for CABG. The paired comparison of the event-free costs showed that there was a significant difference favoring MT versus PCI (P<0.01) and versus CABG (P<0.01) and CABG versus PCI (P=0.01). The event-free plus angina-free costs were $16,553.00, $25,831.00, and $24,614.00, respectively. The paired comparison of the event-free plus angina-free costs showed that there was a significant difference favoring MT versus PCI (P=0.04), and versus CABG (P<0.001); there was no difference between CABG and PCI (P>0.05).. In the long-term economic analysis, for the prevention of a composite primary end point, MT was more cost effective than CABG, and CABG was more cost-effective than PCI.. www.controlled-trials.com.. ISRCTN66068876.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Cost-Benefit Analysis; Diagnostic Techniques, Cardiovascular; Disease-Free Survival; Female; Follow-Up Studies; Health Resources; Hospitalization; Humans; Male; Middle Aged; Multicenter Studies as Topic; Office Visits; Postoperative Complications; Prospective Studies; Quality-Adjusted Life Years; Randomized Controlled Trials as Topic; Treatment Outcome

Conflicting evidence exists on sex-based outcomes after coronary stenting.. Data on 426 996 patients ≥65 years old (42.3% women) from the National Cardiovascular Data Registry CathPCI Registry (2004-2008) were linked to Medicare inpatient claims to compare in-hospital outcomes by sex and long-term outcomes by sex and stent type. In-hospital complications were more frequent in women than in men: death (3869 [2.2%] versus 3737 [1.6%]; adjusted odds ratio, 1.41; 95% confidence interval [CI], 1.33-1.49), myocardial infarction (2365 [1.3%] versus 2858 [1.2%]; odds ratio, 1.19; 95% CI, 1.11-1.27), bleeding (7860 [4.4%] versus 5627 [2.3%]; odds ratio, 1.86; 95% CI, 1.79-1.93), and vascular complications (2381 [1.3%] versus 1648 [0.7%]; odds ratio, 1.85; 95% CI, 1.73-1.99). At 20.4 months, women had a lower adjusted risk of death (hazard ratio [HR], 0.92; 95% CI, 0.90-0.94) but similar rates of myocardial infarction, revascularization, and bleeding. Relative to bare metal stent use, drug-eluting stent use was associated with similar improved long-term outcomes in both sexes: death (women: adjusted HR, 0.78; 95% CI, 0.76-0.81; men: HR, 0.77; 95% CI, 0.74-0.79), myocardial infarction (women: HR, 0.79; 95% CI, 0.74-0.84; men: HR, 0.81; 95% CI, 0.77-0.85), and revascularization (women: HR, 0.93; 95% CI, 0.90-0.97; men: HR, 0.91; 95% CI, 0.88-0.94). There was no interaction between sex and stent type for long-term outcomes.. In contemporary coronary stenting, women have a slightly higher procedural risk than men but have better long-term survival. In both sexes, use of a drug-eluting stent is associated with lower long-term likelihood for death, myocardial infarction, and revascularization.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Anticoagulants; Cardiovascular Agents; Combined Modality Therapy; Coronary Artery Bypass; Coronary Disease; Drug-Eluting Stents; Female; Follow-Up Studies; Humans; Inpatients; Kaplan-Meier Estimate; Male; Medicaid; Medicare; Odds Ratio; Postoperative Complications; Proportional Hazards Models; Registries; Risk; Sex Factors; Stents; Treatment Outcome; United States

BRIEF SUMMARY: We describe the use of adenosine-induced cardiac arrest to facilitate intracranial aneurysm clip ligation.. Cerebral aneurysms are highly variable which may result in difficult surgical exposure for clip ligation in select cases. Secure clip placement is often not feasible without temporarily decompressing the aneurysm. This can be accomplished with temporary clip ligation of proximal vessels, or with deep hypothermic circulatory arrest on cardiopulmonary bypass, although these methods have their own inherent risks. Here we describe an alternate method of decompressing the aneurysm via adenosine-induced transient asystole.. We examined the records of 27 patients who underwent craniotomy for cerebral aneurysm clipping in which adenosine was used to induce transient asystole to facilitate clip ligation. Duration of adenosine-induced bradycardia (heart rate <40) and hypotension (SBP < 60) recorded on the electronic anesthesia record and outcome data including incidence of successful clipping, intraoperative and postoperative complications, and mortality were recorded.. Satisfactory aneurysm decompression was achieved in all cases, and all aneurysms were clipped successfully. The median dose of intravenous adenosine resulting in bradycardia greater than 30 seconds was 30 mg. The median dose of adenosine resulting in hypotension greater than 30 seconds was 15 mg, and greater than 60 seconds was 30 mg. One case of prolonged hypotension after rapid redosing of adenosine required brief closed chest compressions before circulation was spontaneously restored. No other adverse events were observed.. Adenosine cardiac arrest is a relatively novel method for decompression of intracranial aneurysms to facilitate clip application. With appropriate safety precautions, it is a reasonable alternative method when temporary clipping of proximal vessels is not desirable or not possible.

Topics: Adenosine; Aged; Anesthesia, General; Antihypertensive Agents; Cardiovascular Agents; Dose-Response Relationship, Drug; Female; Heart Arrest, Induced; Humans; Intracranial Aneurysm; Intraoperative Care; Length of Stay; Male; Middle Aged; Neurosurgical Procedures; Nicardipine; Patient Selection; Postoperative Complications; Retrospective Studies; Treatment Outcome; Vasospasm, Intracranial

Our purpose was to investigate the clinical outcomes of Zotarolimus- and Paclitaxel-eluting stents in Turkish patients with coronary artery disease (CAD). In general, the outcome of drug-eluting stent (DES) placement has a proven efficacy in randomized trials. However, the difference in efficacy between the Zotarolimus and Paclitaxel-eluting stents in unselected Turkish patients is controversial. Therefore, we investigated the clinical outcomes of these two drug-eluting stents in the real-world.. We created a registry and prospectively analyzed data on a consecutive series of all patients who presented to our institution with symptomatic coronary artery disease between February 2005 and March 2007 and who were treated with the zotarolimus- or the paclitaxel-eluting stent. The follow-up period was approximately two years. The primary end-point was major cardiac events, and the secondary end-point was definite stent thrombosis. Informed consent was obtained from all subjects, and the study protocol was approved by the local ethical committee.. In total, 217 patients were treated with either the zotarolimus-eluting stent (n = 116) or the paclitaxel-eluting stent (n = 101). The lesions in the 2 arms of the study were treated similarly by conventional technique. At 24-month follow-up the paclitaxel-eluting stent group showed significantly higher non-Q wave myocardial infarction (2.6% vs 5.9%, p: 0.02), Q wave myocardial infarction (1.7% vs 5.9%, p: 0.049), coronary artery binding graft surgery (2.6% vs 6.9%, p: 0.002), and late stent thrombosis (1.7% vs 3.9%, p: 0.046).. Zotarolimus-eluting stents demonstrated better clinical outcomes than Paclitaxel-eluting stents in a daily routine practice of coronary intervention in an unselected Turkish population.

Topics: Aged; Cardiovascular Agents; Coronary Artery Disease; Drug-Eluting Stents; Follow-Up Studies; Humans; Middle Aged; Paclitaxel; Patient Selection; Postoperative Complications; Prospective Studies; Random Allocation; Registries; Retrospective Studies; Sirolimus; Thrombosis; Time Factors; Treatment Outcome; Turkey

Topics: Bias; Cardiac Resynchronization Therapy; Cardiovascular Agents; Defibrillators, Implantable; Humans; Pacemaker, Artificial; Postoperative Complications; Randomized Controlled Trials as Topic; Treatment Outcome

We examined factors affecting the choice of surgical versus medical treatment of severe aortic stenosis and evaluated associated patient survival.. We retrospectively reviewed data from all patients diagnosed with severe aortic stenosis at a Veterans Affairs medical facility between January 1997 and April 2008.. Of 345 patients with severe aortic stenosis, 260 (75%) underwent surgical evaluation, and 205 (59%) underwent aortic valve replacement (AVR). The patient's decision to decline surgical referral or AVR (n = 47) and severe comorbidities (n = 34) were the top two reasons for medical treatment rather than AVR. The AVR group was younger (69.5 +/- 9.6 years versus 75.7 +/- 8.6 years; p < 0.001) and had a higher prevalence of symptoms (96% versus 71%; p < 0.001) than the medical group. The medical group had a lower cardiac ejection fraction (0.42 +/- 0.15 versus 0.50 +/- 0.12; p < 0.001) and was less likely to be independent in activities of daily living (64% versus 74%). The AVR group had higher survival rates than the medical patients at 1 year (92% versus 65%), 3 years (85% versus 29%), and 5 years (73% versus 16%; log-rank test p < 0.0001). Valve replacement was independently associated with decreased mortality (hazard ratio, 0.17; 95% confidence interval, 0.10 to 0.27; p < 0.0001).. The management of severe aortic stenosis in veterans is sometimes limited to medical evaluation and treatment. Surgeons should be involved in the complex process of risk assessment, to select patients with severe aortic stenosis who would benefit from the survival advantage associated with AVR.

Topics: Activities of Daily Living; Aged; Aged, 80 and over; Aortic Valve Stenosis; Blood Vessel Prosthesis Implantation; Cardiac Output, Low; Cardiovascular Agents; Comorbidity; Echocardiography; Female; Health Status Indicators; Hospitals, Veterans; Humans; Male; Middle Aged; Postoperative Complications; Prognosis; Proportional Hazards Models; Retrospective Studies; Risk Assessment; Survival Rate; Treatment Refusal; Veterans

Topics: Aged; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass, Off-Pump; Coronary Vasospasm; Coronary Vessels; Diltiazem; Electrocardiography; Female; Follow-Up Studies; Humans; Postoperative Complications; Ultrasonography

Indomethacin is accepted therapy for patent ductus arteriosus (PDA) in ELBW infants (<1000 g). We hypothesize that surgical ligation may provide comparatively superior outcomes in select ELBW infants.. Predischarge outcomes of 298 ELBW infants with echocardiography-proven PDA were retrospectively compared by treatment provided: no treatment (group 1, n = 54), indomethacin (group 2, n = 140), ligation (group 3, n = 46), and ligation after indomethacin failure (group 4, n = 58). chi(2) and Wilcoxon rank sum tests were used to test for significance. Institutional review board approval was obtained (IRB/05-00395).. Group 3 had significantly lower gestational age (P < .001), birth weight (P = .006), and 5-minute Apgar scores (P = .03) compared with group 2. Group 3 and group 1 had a higher rate of pretreatment intraventricular hemorrhage (IVH) compared with group 2 (P < .001). By contrast, posttreatment complications including acute renal failure, necrotizing enterocolitis, thrombocytopenia, and IVH occurred more frequently in groups 2 (P = .004) and 4 (P = .001) compared with group 3. Survival was 57.7% in group 1 compared with groups 2, 3, and 4 (82.4%, 86.0%, and 92.7% respectively; P = .001). Preoperative conditions associated with nonsurvival include gestational age (P = .009), birth weight (P = .002), maternal preeclampsia (P = .015), 5-minute Apgar score (P = .013), and sepsis (P = .018). Posttreatment complications associated with nonsurvival include acute renal failure (P = .002), thrombocytopenia (P = .002), and necrotizing enterocolitis (P = .034). Survival was not influenced by any congenital comorbidity, pre- or posttreatment IVH, diameter of the PDA, or recurrence of the PDA after indomethacin therapy.. (1) Patent ductus arteriosis requires treatment in ELBW infants to maximize survival. (2) Indomethacin and surgical ligation permit equivalent survival in low-risk ELBW infants, but indomethacin results in a high failure and complication rate requiring operative salvage in a number of patients. (3) Surgical ligation permits survival of high-risk ELBW infants with a low complication rate and is preferable to indomethacin in ELBW infants with the above risk factors.

Topics: Cardiovascular Agents; Chi-Square Distribution; Ductus Arteriosus, Patent; Echocardiography; Female; Gestational Age; Humans; Indomethacin; Infant, Extremely Low Birth Weight; Infant, Newborn; Ligation; Male; Postoperative Complications; Retrospective Studies; Risk Factors; Statistics, Nonparametric; Treatment Outcome

The search to define new standards of patient care is of particular relevance for the anesthesiologists providing cardiovascular anesthesia. Because of conflicting results on multiple issues, however, it is often difficult to understand new standards of patient care especially for occasional cardiovascular anesthesiologists. The objective of this series of articles is to summarize evidence of clinical and basic research and introduce current understanding of new standards of patient care in cardiovascular anesthesia. The following topics are discussed in each article: use of cardiovascular drugs for cardiac surgery, myocardial preconditioning in anesthesia, hemostatic management for cardiac surgical patients, blood glucose control during cardiac surgery, cognitive dysfunction after cardiac surgery, spinal protection in aortic surgery, ventricular assist device and heart transplantation in Japan. Further investigations in this area are critical in order to provide optimal patient care.

Topics: Anesthesia; Anesthesiology; Cardiovascular Agents; Cardiovascular Surgical Procedures; Cognition Disorders; Heart Transplantation; Heart-Assist Devices; Hemostasis, Surgical; Humans; Ischemic Preconditioning, Myocardial; Patient Care; Perioperative Care; Postoperative Complications

Most studies that have reported on the progression of ipsilateral and/or contralateral internal carotid artery (ICA) stenosis are restricted to a few years.. Based on a single-center carotid endarterectomy (CEA) registry, we sought all patients with CEA for symptomatic high-grade ICA stenosis between 1970 and 2002. 361 CEA patients (mean age 66 years, 73% male) with annual carotid ultrasound and clinical follow-up were identified. Kaplan-Meier analysis was used to estimate the occurrence of (i) progressive ICA stenosis or restenosis of either the operated or contralateral side, and (ii) cerebrovascular events over time of either the operated or contralateral side.. Progressive ICA disease was more likely on the contralateral than on the ipsilateral ICA (hazard ratio 2.71; CI 1.8-4.1, p < 0.001). After 5 years, the probability for progressive ICA disease was 5.2% for the ipsilateral versus 15.8% for the contralateral ICA. After 15 years, the likelihood was 37% for both sides. In the presence of progressive restenosis of the ipsilateral ICA, the 20-year probability of further ischemic cerebrovascular events was 50% compared to 18% in patients without ICA disease progression. For the contralateral ICA, the probability of further ischemic events was 24.5% in patients with ICA disease progression compared to 9.6% without ICA disease progression (15 years).. 15 years after CEA, one third of the patients can be expected to develop progressive ICA disease. While ICA disease progression seems to be more prominent on the contralateral ICA within the first years, this difference fades out after 15 years. One out of 2 patients with ipsilateral ICA disease progression can be expected to have a recurrent cerebral ischemic event within 15 years. It remains to be determined whether consequent application of high-dose statins, optimal blood pressure management and antithrombotic therapy can reduce this rate.

Topics: Adult; Aged; Aged, 80 and over; Brain Ischemia; Cardiovascular Agents; Carotid Stenosis; Comorbidity; Disease Progression; Endarterectomy, Carotid; Female; Follow-Up Studies; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Postoperative Complications; Recurrence; Registries; Risk Factors; Switzerland; Time Factors; Ultrasonography, Doppler, Color

An increasing number of patients aged>or=70 years are presenting for elective non-cardiac surgery. We undertook this study to: (i) compare the nature and distribution of cardiovascular disease (CVD) risk factors in an at risk population of patients aged>or=70 years undergoing elective surgery compared with a younger at risk cohort; and (ii) identify the impact of age and other risk factors on 6-month survival. We conducted a prospective observational study of patients undergoing elective non-cardiac surgery. A total of 1622 patients aged>or=40 years with recognised surgical or patient-specific risk factors for CVD were identified. The patients were divided into two groups; group 1 (aged: 40-69 years) and group 2 (aged>or=70 years). Logistic regression was used to identify the factors associated with 6-month mortality. Odds ratios (OR) and 95% confidence interval (CI) are presented. In hospital, mortality was similar in both groups. However, 6-month mortality in those aged>or=70 years was significantly higher (p=0.001). Cardiovascular symptoms were significantly more common in group 2 (p<0.001) as were cardiovascular-related deaths (p=0.04) at 6 months follow-up. Preoperative cardiovascular preventative therapy was under prescribed in the elderly cohort. Factors independently associated with 6-month mortality were aged>or=70 (OR=3.57, 95% CI: 2.22-5.73), angina (OR=2.0, 95% CI: 1.26-3.20), renal impairment (OR=2.39, 95% CI: 1.17-4.89) also operation type and duration. Despite similar in-hospital mortality, those aged>or=70 years had significantly higher 6-month mortality than the younger surgical cohort. Cardiovascular deaths were significantly higher in patients aged>or=70 years. Effective identification and the management of cardiovascular risk factors may improve 6-month survival.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Cardiovascular Agents; Cardiovascular Diseases; Elective Surgical Procedures; Female; Humans; Male; Middle Aged; Postoperative Complications; Prognosis; Prospective Studies; Regression Analysis; Risk Factors

Topics: Aged; Cardiovascular Agents; Equipment Failure; Heart Failure; Heart Transplantation; Heart-Assist Devices; Hospitalization; Humans; Middle Aged; Postoperative Complications; Quality of Life; Randomized Controlled Trials as Topic; Sepsis; Survival Rate; Treatment Outcome

High-sensitivity C-reactive protein (hsCRP) adds important prognostic information, not reflected by traditional risk factors, to the prediction of both the development and outcome of cardiovascular pathology. HsCRP levels also correlate inversely with cardiorespiratory fitness, an important determinant of peri-operative outcome. We hypothesised that pre-operative hsCRP should be associated with excess peri-operative morbidity and longer length of stay. Pre-operative hsCRP was measured blinded to standardised postoperative outcomes in 129 elective orthopaedic patients. HsCRP levels were divided into high (> 3 mg x l(-1)) or low (< 3 mg x l(-1)) groups (Center for Disease Control stratification). High-CRP patients had significant cardiovascular history, received cardiac medication or steroid therapy (p < 0.05). Higher pre-operative hsCRP was associated with longer length of stay: mean 7.5 days (95% CI: 6.2-8.8) vs 6.0 days (95% CI: 5.5-6.5; p = 0.03; log rank test). In 21 patients with > 8 days length of stay, high pre-operative hsCRP patients were over-represented (p = 0.04). Pre-operative hsCRP is related to length of stay and delayed postoperative complications.

Topics: Aged; Arthroplasty, Replacement; Biomarkers; C-Reactive Protein; Cardiovascular Agents; Elective Surgical Procedures; Epidemiologic Methods; Female; Glucocorticoids; Humans; Length of Stay; Male; Postoperative Complications; Preoperative Care; Prognosis

The population in the UK is growing older and the number of elderly patients cared for on intensive care units (ICU) is increasing. This study was designed to identify risk factors for mortality in critically ill patients of >80 yr of age after surgery.. We identified 275 patients, aged 80 yr or greater, admitted to the ICU after surgery. After exclusions, 255 were selected for further analysis. Multivariate analysis was then performed to determine the covariates associated with hospital mortality.. The overall ICU and hospital mortality was 20.4% and 33.3%, respectively. Patients who received i.v. vasoactive drugs on days 1 and 2 had hospital mortality of 54.4% and 60.5%, respectively. Multivariate analysis showed that requirement for i.v. vasoactive drugs within the first 24 h on ICU [odds ratio (OR) 4.29; 95% CI, 2.35-7.84, P<0.001] and requirement for i.v. vasoactive drugs for a further 24 h (OR 3.63; 95% CI, 1.58-8.37, P<0.01) were associated with hospital mortality. The requirement for i.v. vasoactive drugs was also strongly associated with hospital mortality in all the subgroups studied (elective surgery, emergency surgery, and emergency laparotomy).. For patients aged 80 yr and more, admitted to ICU after surgery, the requirement for i.v. vasoactive drugs in the first and second 24 h was the strongest predictor of hospital mortality.

Topics: Aged, 80 and over; Cardiovascular Agents; Critical Illness; Drug Administration Schedule; England; Epidemiologic Methods; Female; Humans; Intensive Care Units; Length of Stay; Male; Postoperative Care; Postoperative Complications; Prognosis; Treatment Outcome

Topics: Aged, 80 and over; Arrhythmias, Cardiac; Cardiovascular Agents; Colitis, Ischemic; Colonic Neoplasms; Colonic Polyps; Colonoscopy; Digoxin; Drug Therapy, Combination; Female; Humans; Hypertension; Intestinal Mucosa; Nicardipine; Postoperative Complications; Propranolol; Risk Factors; Sigmoid Neoplasms

The purpose of this study was to evaluate predictors of an adverse outcome after "crush" bifurcation stenting.. The "crush" technique is a recently introduced strategy with limited data regarding long-term outcomes.. We identified 231 consecutive patients treated with drug-eluting stent implantation with the "crush" technique for 241 de novo bifurcation lesions. Clinical follow-up was obtained in 99.6%.. The in-hospital major adverse cardiac event (MACE) rate was 5.2%. At 9 months, 10 (4.3%) patients had an event consistent with possible post-procedural stent thrombosis. Survival free of target lesion revascularization (TLR) was 90.3%; the only independent predictor of TLR was left main stem (LMS) therapy (odds ratio [OR] 4.97; 95% confidence interval [CI] 2.00 to 12.37, p = 0.001). Survival free of MACE was 83.5% and independent predictors of MACE were LMS therapy (OR 3.79; 95% CI 1.76 to 8.14, p = 0.001) and treatment of patients with multivessel disease (OR 4.21; 95% CI 0.95 to 18.56, p = 0.058). Angiographic follow-up was obtained in 77% of lesions at 8.3 +/- 3.7 months. The mean late loss of the main vessel and side branch were 0.30 +/- 0.64 mm and 0.41 +/- 0.67 mm, respectively, with binary restenosis rates of 9.1% and 25.3%. Kissing balloon post-dilation significantly reduced the side branch late lumen loss (0.24 +/- 0.50 mm vs. 0.58 +/- 0.77 mm, p < 0.001).. The crush technique of bifurcation stenting with drug-eluting stents is associated with favorable outcomes for most lesions; however, efficacy appears significantly reduced in LMS bifurcations, and further research is needed before the technique can be routinely recommended in this group. Furthermore, the incidence of possible stent thrombosis is of concern and requires further investigation. Kissing balloon post-dilatation is mandatory to reduce side branch restenosis.

Topics: Angina Pectoris; Angioplasty, Balloon, Coronary; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Coronary Angiography; Coronary Restenosis; Coronary Stenosis; Coronary Thrombosis; Delayed-Action Preparations; Female; Humans; Male; Middle Aged; Paclitaxel; Postoperative Complications; Prognosis; Sirolimus; Stents; Time Factors; Treatment Outcome

Earlier studies evaluating long-term survival in type A acute aortic dissection (TA-AAD) have been restricted to a small number of patients in single center experiences. We used data from a contemporary, multi-center international registry of TA-AAD patients to better understand factors associated with long-term survival.. We examined 303 consecutive patients with TA-AAD enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003. We included patients who were discharged alive and had documented clinical follow-up data. Kaplan-Meier survival curves were constructed to depict cumulative survival in patients from date of hospital discharge. Stepwise Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality. We found that 273 (90.1%) patients had been managed surgically and 30 (9.9%) were managed medically. Patients who were dead at follow-up were more likely to be older (63.9 versus 58.4 years, P=0.007) and to have had previous cardiac surgery (23.9% versus 10.6%, P=0.01). Survival for patients treated with surgery was 96.1%+/-2.4% and 90.5%+/-3.9% at 1 and 3 years versus 88.6%+/-12.2% and 68.7%+/-19.8% without surgery (mean follow-up overall, 2.8 years, log rank P=0.009). Multivariate analysis identified a history of atherosclerosis (relative risk (RR), 2.17; 95% confidence interval [CI], 1.08 to 4.37; P=0.03) and previous cardiac surgery (RR, 2.54; 95% CI, 1.16 to 5.57; P=0.02) as significant, independent predictors of follow-up mortality.. Contemporary 1- and 3-year survival in patients with TA-AAD treated surgically are excellent. Independent predictors of survival during the follow-up period do not appear to be influenced by in-hospital risks but rather preexisting comorbidities.

Topics: Acute Disease; Age Factors; Aged; Antihypertensive Agents; Aortic Aneurysm; Aortic Dissection; Atherosclerosis; Cardiac Surgical Procedures; Cardiovascular Agents; Case Management; Comorbidity; Europe; Female; Follow-Up Studies; Humans; Hypertension; Japan; Life Tables; Male; Middle Aged; Mortality; Patient Discharge; Postoperative Complications; Proportional Hazards Models; Registries; Risk Factors; Survival Analysis; Treatment Outcome; United States

The clinical profiles and outcomes of patients treated surgically for acute type B aortic dissection (ABAD) are often reported for those in small series or for those cared for at a single institution over a long time period, during which a continuous evolution in techniques has occurred. Accordingly, we sought to evaluate the clinical features and surgical results of patients enrolled in the International Registry of Acute Aortic Dissection by identifying primary factors that influenced surgical outcome and estimating average surgical mortality for ABAD in the current era.. A comprehensive analysis of 290 clinical variables and their relation to surgical outcomes for 82 patients who required surgery for ABAD (from a population of 1256 patients; mean+/-SD age, 60.6+/-15.0 years; 82.9% male) and who were enrolled in the International Registry of Acute Aortic Dissection was performed. The overall in-hospital mortality was 29.3%. Factors associated with increased surgical mortality based on univariate analysis were preoperative coma or altered consciousness, partial thrombosis of the false lumen, evidence of periaortic hematoma on diagnostic imaging, descending aortic diameter >6 cm, right ventricle dysfunction at surgery, and shorter time from the onset of symptoms to surgery. Factors associated with favorable outcomes included radiating pain, normotension at surgery (systolic blood pressure 100 to 149 mm Hg), and reduced hypothermic circulatory arrest time. The 2 independent predictors of surgical mortality were age >70 years (odds ratio, 4.32; 95% confidence interval, 1.30 to 14.34) and preoperative shock/hypotension (odds ratio, 6.05; 95% confidence interval, 1.12 to 32.49).. The present study provides insights into current-day clinical profiles and surgical outcomes of ABAD. Knowledge about different preoperative clinical conditions may help surgeons in making treatment decisions among these high-risk patients.

Topics: Acute Disease; Aged; Anastomosis, Surgical; Antihypertensive Agents; Aortic Aneurysm, Thoracic; Aortic Dissection; Aortic Rupture; Atherosclerosis; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Comorbidity; Disease Susceptibility; Europe; Female; Follow-Up Studies; Heart Diseases; Hemodynamics; Hospital Mortality; Humans; Hypertension; Japan; Male; Marfan Syndrome; Middle Aged; Paraplegia; Postoperative Complications; Registries; Spinal Cord Ischemia; Stents; Survival Analysis; Treatment Outcome; United States

In older patients who are known to be at greater risk for atrial fibrillation, we aimed to determine whether patients who develop atrial fibrillation-flutter (AF) after major thoracic surgery have an exaggerated white blood cell (WBC) count in response to surgical stress compared with those who do not develop AF.. Using a prospective database, 272 patients 60 years or older who were in sinus rhythm before surgery and had elective lobectomy, pneumonectomy, or esophagectomy were studied. Patients did not receive perioperative medications to prevent AF. Clinical characteristics and preoperative 12-lead electrocardiogram were examined and WBC counts were recorded for patients prior to and for up to five days after surgery.. Atrial fibrillation-flutter was observed in 74 of 272 (27%) patients a median of 3 days after surgery. The increase in WBC count from preoperative to postoperative day 1 and age were jointly significant predictors of AF by multiple logistic regression (area under the receiver operating characteristic curve = 0.69). Using this model, a twofold increase in WBC from presurgery to postoperative day 1 corresponded to a 3.3-fold increase in the odds of developing AF (95% confidence interval [CI] 2.0 to 8.3) and for each 10 year increase in age, a 1.8-fold increase in risk of AF (95% CI 1.1 to 2.8) was seen.. Increments in WBC were greater in patients with AF and coincided with the peak onset of AF. These prospective data support an important role for stress-mediated autonomic mechanisms in the pathogenesis of AF after major thoracic surgery. We aim to examine further whether WBC elevations on postoperative day one can help further risk stratify patients younger than 60 years or those with the highest risk who could benefit from one or more AF prevention strategies.

Topics: Age Factors; Aged; Anti-Inflammatory Agents; Atrial Fibrillation; Atrial Flutter; Autonomic Nervous System; Cardiovascular Agents; Disease Susceptibility; Esophagectomy; Female; Humans; Inflammation; Leukocyte Count; Leukocytosis; Male; Middle Aged; Odds Ratio; Pneumonectomy; Postoperative Complications; Postoperative Period; Prospective Studies; Risk Factors; Stress, Physiological

Secondary prevention is needed following coronary artery bypass graft (CABG) surgery to reduce the subsequent risk of unstable angina, myocardial infarction and death. However, little research exists on the use of cardiovascular medical therapy in CABG surgery patients. The objective of the present study is to describe the use of cardiovascular medical therapy among patients discharged after CABG surgery.. The use of acetylsalicylic acid, clopidogrel, warfarin, antilipid agents, beta-blockers, calcium channel blockers, nitrates and angiotensin-converting enzyme (ACE) inhibitors was examined among 320 patients enrolled in the Routine versus Selective Exercise Treadmill Testing After Coronary Artery Bypass Graft Surgery (ROSETTA-CABG) Registry. Logistic regression identified the determinants of medication use at 12 months following CABG surgery.. Most patients were male, hyperlipidemic and underwent CABG surgery for relief of angina symptoms. At admission, discharge and at 12 months, acetylsalicylic acid was used in 71%, 92% and 87% of cases, respectively, and some form of antiplatelet agent was used in 74%, 94% and 89% of cases, respectively. The use of antilipid agents remained constant, from 55% at admission to 57% at discharge. However, 24% of patients were not receiving antilipid agents at 12 months. The use of beta-blockers was 57% at admission, 71% at discharge and 64% at 12 months. The use of calcium channel blockers and nitrates decreased modestly from admission to discharge and remained stable at approximately 20% and 22%, respectively, at 12 months. ACE inhibitor use remained stable, from 33% at admission to 38% at 12-months. Hyperlipidemia, hypertension, obesity and pre-CABG surgery left ventricular ejection fraction less than 40% were all found to be important determinants of 12-month medication use. Importantly, the use at discharge was an important determinant of 12-month use of for each medication examined in the present study.. The use of antilipid agents, beta-blockers and ACE inhibitors was found to be too low among post-CABG surgery patients, who are known to benefit from their use, and the use of nitrates was too high. Discharge from hospital provides a unique opportunity for physicians to modify the use of cardiovascular medical therapy among patients undergoing CABG surgery.

Topics: Aged; Analysis of Variance; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Europe; Exercise Test; Female; Follow-Up Studies; Humans; Hypolipidemic Agents; Male; Middle Aged; Myocardial Ischemia; North America; Pakistan; Platelet Aggregation Inhibitors; Postoperative Complications; Prospective Studies; Registries; Stroke Volume; Treatment Outcome

We present real world experience from a single center registry comparing the 6-month outcome of percutaneous coronary intervention (PCI) in unselected high-risk individuals using either sirolimus-eluting (SES) or paclitaxel-eluting stents (PES).. We compared clinical outcome at 6 months follow-up in two cohorts of 156 consecutive patients (total n = 312) who underwent SES (June 2002-February 2003) and PES (march 2003-July 2003) implantation. The primary endpoint was a composite of major adverse cardiac events (MACE). Baseline clinical characteristics were well matched. The 6-month target vessel revascularization (TVR) rates were 1.9% (SES) and 2.6% (PES) and MACE rates were similar in the two groups (SES 4.5% vs. PES 3.2%, P = NS). In the PES group, intervention for multivessel disease, bifurcation lesions and in small vessels was more common, and for in-stent restenosis less common, reflecting the impact of drug eluting stents on indications for PCI. The incidence of sub-acute stent thrombosis, related to inadequate antiplatelet therapy in 3 of the 6 cases, was 0.95% with no difference between the two groups.. This study confirms the safety and efficacy of SES and PES in unselected high risk patients undergoing PCI. Clinical outcomes of both stents are equivalent at 6 months with low rates of MACE and TVR. These data provide important complementary information to forthcoming randomized studies.

Topics: Angioplasty, Balloon, Coronary; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Coated Materials, Biocompatible; Coronary Artery Disease; Coronary Restenosis; Female; Follow-Up Studies; Humans; Immunosuppressive Agents; Incidence; Male; Middle Aged; Paclitaxel; Postoperative Complications; Prospective Studies; Registries; Risk Factors; Sirolimus; Stents; Taxus; Treatment Outcome

Decisions about chronic treatments during the perioperative period must be made at the presurgical anesthesia consultation. It is increasingly rare to stop treatment during this period, because: This new rule is applied particularly to patients with cardiovascular disorders. Beta blockers have a special role in preventing the onset of postoperative cardiovascular events. The role of statins requires further precision but they appear to fit into the same preventive approach. Interruption of antiplatelet agents appears to be associated with a risk of arterial thrombosis in patients with coronary conditions, notably those with conventional stents and most especially those with drug-eluting stents.

Topics: Adrenergic beta-Antagonists; Anesthesia; Angioplasty, Balloon, Coronary; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Cardiovascular Diseases; Case-Control Studies; Clinical Trials as Topic; Cohort Studies; Drug Interactions; Humans; Hypolipidemic Agents; Multicenter Studies as Topic; Platelet Aggregation Inhibitors; Postoperative Complications; Prospective Studies; Receptors, Angiotensin; Retrospective Studies; Risk Factors; Stents; Surgical Procedures, Operative; Thrombosis

The rationale for the use of a biventricular assist device (BiVAD) for morbid congestive heart failure (MCHF) has been questioned because of historically unacceptable rates of postimplant and post-transplant mortality as well as perceived barriers to their outpatient management.. All patients who received a Thoratec BiVAD from January 1990 to December 2003 at the University of Pittsburgh were studied retrospectively. There were a total of 73 patients (32% ischemic, 21% idiopathic, and 47% other) who had a BiVAD implanted. Before implantation, 100% were on > or =1 inotropic agent, and 77% had an intra-aortic balloon pump. Overall survival was 69%; 42 patients (84%) received cardiac transplantation, 5 patients (10%) were weaned, and 3 (6%) remained supported on BiVAD. If the 14 patients with postcardiotomy failure and acute myocardial infarction with shock are excluded, the overall survival improves to 75%. Five-year actuarial survival after heart transplantation was 58%. Of the 29 patients implanted before 2000, the 4-month actuarial freedom from driveline infections, bloodstream infections, and neurological events was 10%, 54%, and 48%, respectively, whereas the rates of these events for the 44 patients implanted after 2000 improved to 70%, 79%, and 80%, respectively. Since 2000, 21 (48%) patients were discharged from the hospital, of whom 38% went to an outpatient residence, 33% to a skilled nursing facility, and 29% to home. Once discharged, > or =1 readmission occurred in 45% and > or =2 readmissions in 48%.. BiVAD support for MCHF has an acceptable overall mortality and survival to transplantation. Morbidity has been significantly reduced in the past 4 years, and management as an outpatient is achievable.

Topics: Adult; Ambulatory Care; Cardiovascular Agents; Combined Modality Therapy; Device Removal; Equipment Design; Female; Heart Failure; Heart Transplantation; Heart-Assist Devices; Hospitalization; Humans; Infections; Institutionalization; Intra-Aortic Balloon Pumping; Life Tables; Male; Middle Aged; Postoperative Complications; Prospective Studies; Retrospective Studies; Risk Factors; Skilled Nursing Facilities; Stroke; Survival Analysis; Treatment Outcome

Topics: Aged; Atrial Fibrillation; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Bypass, Off-Pump; Humans; Postoperative Complications

Few data exist on gender-related differences in clinical presentation, diagnostic findings, management, and outcomes in acute aortic dissection (AAD).. Accordingly, we evaluated 1078 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) to assess differences in clinical features, management, and in-hospital outcomes between men and women. Of the patients enrolled in IRAD (32.1%) with AAD, 346 were women. Although less frequently affected by AAD (32.1% of AAD), women were significantly older and had more often presented later than men (P=0.008); symptoms of coma/altered mental status were more common, whereas pulse deficit was less common. Diagnostic imaging suggestive of rupture, ie, periaortic hematoma, and pleural or pericardial effusion were more commonly observed in women. In-hospital complications of hypotension and tamponade occurred with greater frequency in women, resulting in higher in-hospital mortality compared with men. After adjustment for age and hypertension, women with aortic dissection die more frequently than men (OR, 1.4, P=0.04), predominantly in the 66- to 75-year age group. Moreover, surgical outcome was worse in women than men (P=0.013); type A dissection in women was associated with a higher surgical mortality of 32% versus 22% in men despite similar delay, surgical technique, and hemodynamics.. Our analysis provides insights into gender-related differences in AAD with regard to clinical characteristics, management, and outcomes; important diagnostic and therapeutic implications may help shed light on aortic dissection in women to improve their outcomes.

Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Aortic Aneurysm; Aortic Dissection; Cardiac Tamponade; Cardiovascular Agents; Case Management; Combined Modality Therapy; Consciousness Disorders; Europe; Female; Hospital Mortality; Humans; Hypotension; Life Tables; Male; Middle Aged; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Registries; Retrospective Studies; Risk Factors; Sex Factors; Survival Analysis; Treatment Outcome; United States

Topics: Anastomosis, Surgical; Antimanic Agents; Aorta; Ataxia; Carbamazepine; Cardiovascular Agents; Diltiazem; Drug Interactions; Female; Humans; Iliac Artery; Middle Aged; Ophthalmoplegia; Postoperative Complications

One of the consultant's roles is to make recommendations regarding the use of medications in the perioperative period. Unfortunately, the data in this area are often insufficient to provide evidence-based recommendations. In this article, we have provided advice considering the pharmacokinetics of the drug, the effect on the primary disease of stopping medications, and the effect of the medication on perioperative risk, including potential drug interactions with anesthetic agents.

Topics: Anti-HIV Agents; Antirheumatic Agents; Cardiovascular Agents; Drug Therapy; Drug-Related Side Effects and Adverse Reactions; Hematologic Agents; Hormones; Humans; Insulin; Intraoperative Complications; Pharmacokinetics; Phytotherapy; Postoperative Complications; Preoperative Care; Psychotropic Drugs; Respiratory System Agents

Topics: Aged; Atrial Fibrillation; Carcinoma, Squamous Cell; Cardiovascular Agents; Chylothorax; Combined Modality Therapy; Drainage; Hemodynamics; Humans; Hypotension; Laryngeal Neoplasms; Laryngectomy; Male; Neck Dissection; Parenteral Nutrition; Pleural Effusion; Postoperative Complications

Atrial fibrillation after cardiac surgery is still a frequent encountered complication and has been associated with increased hospital length of stay and numerous postoperative complications. The pathogenesis of atrial fibrillation involves an overall sequence of perioperative events, collectively termed as ischemia-reperfusion injury. Heat-shock proteins have been found to provide increased protection during ischemia-reperfusion as well as increased postischemic cardiac functional recovery. We sought to determine whether preoperative atrial heat shock levels were correlated with the appearance of postoperative atrial fibrillation.. Preoperative atrial myocardial samples obtained just before cannulation from 101 patients were used to detect immunohistochemically the expression of heat-shock proteins. The derived results were compared statistically with the incidence of postoperative atrial fibrillation, its time of appearance, duration and resistance to administered antiarrhythmics.. The overall incidence of postoperative atrial fibrillation was 22.3%. Of these patients, 58.3% had no detectable heat shock proteins in their cytoplasm, in sharp contrast with 100% of the patients with no atrial fibrillation who were positive for heat shock proteins (p<0.01). Four percent of our patient group had prolonged atrial fibrillation (defined as duration >48 h). These patients had significantly less (p<0.01) nuclear heat shock protein expression compared with the non-atrial fibrillation group. However, the difference of the heat shock protein expression between the prolonged atrial fibrillation and the rest of the atrial fibrillation patients was not significant (p=0.891).. Our results indicate that patients with low preoperative atrial heat shock protein expression have a significantly greater incidence of postoperative atrial fibrillation. Heat shock protein expression did not, however, correlate with the onset of atrial fibrillation and the resistance to administered medications. Heat shock protein preoperative induction as a measure of myocardial preconditioning may potentially decrease the incidence of postoperative atrial fibrillation.

Topics: Atrial Fibrillation; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Cardiovascular Agents; Drug Resistance; Female; Heart Atria; HSP70 Heat-Shock Proteins; Humans; Incidence; Male; Myocardium; Postoperative Complications; Preoperative Care

Medically refractory heart failure may be present in children with cardiomyopathy (CMP) or complex congenital heart disease (CHD). In adults, the surgical management of this condition is either heart transplantation or the Batista operation. From March 1995 to January 2000, a total of 6 children, aged from 1 to 16 years, with medically refractory heart failure associated with CMP or complex CHD underwent cardiac transplantation and one of them also had the Batista operation as a bridge to transplantation. One of the 6 patients died of intractable sepsis 17 days after the operation, but the other 5 were discharged with satisfactory hemodynamics. Immunosuppressive agents, including azathioprine, cyclosporin or FK-506, were given. One patient experienced moderate acute rejection, but it was controlled by FK-506, OKT-3 and solumedrol. However, another suffered from lymphoproliferative disease 8 months after transplant, but it was controlled by intravenous immunoglubulin, alpha-interferon and acyclovir. Cardiac function during serial follow-up (range, 1 month to 5 years) revealed normal systolic and diastolic function and none received any anticongestive medications. Almost all patients received an oversized donor heart. The left ventricle (LV) mass was remodeled, initially as an decrease and later as an increase. The patient who underwent the Batista operation was discharged 1 month after the operation with an increased LV ejection fraction (from 10% to 22%). She was successfully bridged to heart transplantation 7 months after the Batista operation. The results of cardiac transplantation in growing children are satisfactory and remain the mainstay of surgical treatment for medically refractory heart failure in these patients. However, with a shortage of donor hearts, the Batista operation may be adopted as a bridge to heart transplant with a fair response.

Topics: Adolescent; Cardiomyopathy, Dilated; Cardiomyopathy, Restrictive; Cardiovascular Agents; Child; Child, Preschool; Drug Resistance; Female; Follow-Up Studies; Graft Rejection; Heart Defects, Congenital; Heart Failure; Heart Function Tests; Heart Transplantation; Heart Ventricles; Humans; Immunosuppressive Agents; Male; Organ Size; Postoperative Complications; Severity of Illness Index; Survival Rate; Treatment Outcome; Ventricular Remodeling

The Oxford Record Linkage Study (ORLS; an epidemiological database) was used to examine relationships between intercurrent cardiovascular drug therapy and cardiac death within 30 days of elective or emergency/urgent surgery under general anaesthesia. Cases identified from the ORLS were paired with matched control patients. Clinical details were obtained from the patients' medical notes. In elective surgical patients, there was no effect of beta-adrenoceptor or calcium entry channel blockade, diuretics or digoxin on cardiac death after adjusting for confounding variables. Use of nitrates was associated with an odds ratio of 4.79 [95% confidence interval (CI) 1.01-22.72] for cardiac death after adjustment for confounding by a history of angina and residual age difference. In emergency/urgent patients, there were significant univariate associations with cardiac death for intercurrent use of angiotensin converting enzyme (ACE) inhibitors (odds ratio 1.18) and diuretics (odds ratio 4.95; 95% CI 1.82-13.46). However, neither maintained significance after adjustment for the confounding effect of cardiac failure. We conclude that, with the possible exception of the use of nitrates in elective surgical patients, chronic intercurrent drug treatment alone does not significantly affect the odds of cardiac death within 30 days of surgery.

Topics: Adrenergic beta-Antagonists; Adult; Aged; Aged, 80 and over; Anesthesia, General; Calcium Channel Blockers; Cardiovascular Agents; Cardiovascular Diseases; Case-Control Studies; Elective Surgical Procedures; Emergencies; England; Female; Humans; Male; Medical Record Linkage; Middle Aged; Nitrates; Odds Ratio; Postoperative Complications

We designed a joint research project to investigate the incidence of ischemic heart diseases in patients undergoing noncardiac surgery and to define the risk of perioperative cardiac complications in these patients. Of the 8358 surgical patients in the 8 departments of anesthesiology between March 1997 and June 1997, 328 (3.9%) had ischemic heart diseases. Among the 328 patients, 54 (16.4%) developed perioperative cardiac events, including myocardial infarction (3 patients) and either lethal or potentially dangerous dysrhythmias (51 patients). Preoperative cardiac assessments were performed while the anesthetic techniques including intensive monitoring and perioperative prophylactic therapy were also employed. Patients with ischemic heart diseases received various types of preoperative evaluation to identify the degree of coronary artery disease and to assess the overall cardiac function. The patients were monitored using a multilead electrocardiogram, an arterial line, a central venous catheter, a pulmonary artery catheter, and by transesophageal echocardiography intraoperatively. Therapeutically, isosorbide, nitroglycerin, beta-blockers, calcium channel blockers, and/or nicorandil were administered to prevent perioperative ischemia. So far, no generally accepted management strategies have been established in patients with cardiovascular disorders based on large-scale outcome trials in Japan. Therefore, nationwide large multicenter trials are awaited with interest in order to establish helpful guidelines to improve the perioperative management and to reduce ischemia in cardiac patients undergoing noncardiac surgery.

Topics: Anesthesia; Cardiovascular Agents; Humans; Incidence; Intraoperative Complications; Monitoring, Intraoperative; Myocardial Infarction; Myocardial Ischemia; Perioperative Care; Postoperative Complications; Practice Guidelines as Topic; Risk

To describe risk factors associated with the development of transplantation coronary artery disease (TCAD).. A retrospective study of the Canadian experience.. Seven hundred and nineteen patients with follow-up of at least 12 months following transplantation and a minimum of one coronary angiogram were analyzed.. Two hundred and fourteen patients (30%) developed angiographic evidence of TCAD during an average follow-up of 50+/-25 months. Actuarial freedom rate from TCAD averaged 60%, and survival averaged 85% five years following transplantation. Abnormal coronary angiograms increased from 11% to 40% between the first and the fifth year following transplantation. The Cox multivariate final model showed that recipients of donor hearts of 50 years and older (RR 4.35, 95% CI 2.32 to 8.15), patients with two or more episodes of acute rejection (RR 1.56, 95% CI 1.11 to 2.21) and patients with a diagnosis of ischemic cardiomyopathy before transplantation (RR 1.38, 95% CI 1.03 to 1.84) were at higher risk of TCAD. The same risk factors also had a significant effect on survival, although patients who were administered a hepatic hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor during follow-up had a higher survival rate (95% versus 85%, P=0.01) five years following heart transplantation.. Recipients of hearts from older donors, patients with an ischemic heart disease before transplantation and those with several episodes of acute rejection are at increased risk for TCAD. Patients who are administered an HMG-CoA reductase inhibitor during follow-up have a higher survival rate five years following transplantation.

Topics: Adult; Antihypertensive Agents; Arteriosclerosis; Aspirin; Cardiovascular Agents; Cyclosporine; Cytomegalovirus Infections; Diltiazem; Female; Follow-Up Studies; Heart Transplantation; Humans; Male; Middle Aged; Myocardial Ischemia; Postoperative Care; Postoperative Complications

Pharmacologic stress testing with adenosine in heart transplant recipients implies a high risk of atrioventricular block. Dipyridamole is preferable as a coronary vasodilator.

Topics: Adenosine; Adolescent; Adult; Cardiovascular Agents; Dipyridamole; Dose-Response Relationship, Drug; Exercise Test; Female; Heart Block; Heart Transplantation; Humans; Infusions, Intravenous; Male; Middle Aged; Postoperative Complications; Risk Factors

The estimation of an individual patient's "resistance" to major surgery has become an complex matter. Clinical parameters allow risk stratification in a large number of patients who are about to undergo noncardiac surgery. Low risk patients can be "cleared" for surgery. Moderate risk patients should undergo further testing. Exercise testing and pharmacological stress testing with myocardial perfusion imaging can refine risk estimation in these patients. This risk stratification is well backed by scientific data, although most of it is derived from studies in the same very high risk population, i.e. patients scheduled for vascular surgery. Less hard evidence exists when it comes to the management of the high-risk patient. Coronary bypass surgery should probably be reserved for those in whom additional indications for this procedure exist. The perioperative use of beta-blockers can possibly reduce operative risk. Data on perioperative monitoring and anesthetic technique are not yet convincing. The relative merits of various perioperative management strategies will remain uncertain until randomised trials are performed to evaluate the alternatives systematically.

Topics: Age Factors; Anesthesia; Cardiovascular Agents; Coronary Angiography; Female; Heart Diseases; Heart Function Tests; Humans; Male; Myocardial Revascularization; Postoperative Complications; Preoperative Care; Risk Factors; Surgical Procedures, Operative

It has been well documented that the use of the internal thoracic artery yields better long-term patency rates than saphenous vein grafts for coronary artery bypass grafting. This knowledge has prompted surgeons to use other arterial conduits such as the radial artery.. Between April 1994 and January 1996, radial artery grafts were used in 83 patients (mean age, 54.6 years) undergoing myocardial revascularization. All patients received diltiazem, 80 mg orally three times daily. Angiographic studies were performed in the early post-operative period in 61 patients, and 6 to 19 months later in 12 patients.. There were four hospital deaths (4.8%), none of them due to cardiac causes. Perioperative myocardial infarction was observed in 3 patients, 1 related to a radial artery graft occlusion. Of 61 grafts studied early, 59 were patent (96.7%), but two grafts showed diffuse spasm. Twelve patients had a second angiogram after a mean interval of 8.7 months, and all grafts were patent. One patient who had a diffuse spasm at the early study had recurrent symptoms, and repeat angiogram showed further narrowing of the graft (string sign).. Our results suggest that with proper care, the radial artery may be used for coronary artery bypass grafting with good early results. Long-term follow-up and angiography studies will be needed to establish the merit of the radial artery as a graft for coronary artery operations.

Topics: Administration, Oral; Adult; Aged; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Vasospasm; Diltiazem; Female; Follow-Up Studies; Graft Occlusion, Vascular; Humans; Male; Middle Aged; Myocardial Infarction; Postoperative Complications; Radial Artery; Recurrence; Survival Rate; Vascular Patency; Vasoconstriction; Vasodilator Agents

Topics: Adrenergic beta-Antagonists; Calcium Channel Blockers; Cardiovascular Agents; Coronary Disease; Humans; Intraoperative Complications; Myocardial Ischemia; Postoperative Complications

The cases of 85 patients with spinal deformation (m:22, f:63; age: 21.6 +/- 12.9 y.) who underwent the spondylodesis according to Harrington were analysed retrospectively to evaluate the need of pharmacological treatment in the perioperative phase. Central analgetics such as pethidine, piritramide and pentacocine were prescribed most frequently. Propyphenazone containing formulations were the preferred peripheral analgetics. Sedation with benzodiazepines and neuroleptic was used regularly. Flucloxacillin and gentamicin were the flavoured antibiotics for perioperative prophylaxis. Impaired motility of the GIT-tract was treated with drugs such as carbachol or dexpanthenol.

Topics: Adult; Analgesics; Anti-Bacterial Agents; Cardiovascular Agents; Child; Female; Gastrointestinal Agents; Humans; Hypnotics and Sedatives; Internal Fixators; Male; Middle Aged; Pain, Postoperative; Postoperative Complications; Retrospective Studies; Scoliosis

Topics: Adult; Anesthesia; Cardiovascular Agents; Heart Transplantation; Heart, Artificial; Humans; Male; Postoperative Complications; Time Factors

Topics: Age Factors; Aged; Anesthesia; Cardiovascular Agents; Coronary Disease; Heart Diseases; Hemodynamics; Humans; Middle Aged; Postoperative Complications; Preoperative Care; Risk; Surgical Procedures, Operative

Topics: Adrenergic beta-Antagonists; Aged; Antidotes; Calcium Channel Blockers; Cardiovascular Agents; Cathartics; Dialysis; Digitalis; Diuretics; Emetics; Fluid Therapy; Gastric Lavage; Humans; Lidocaine; Plants, Medicinal; Plants, Toxic; Postoperative Complications; Quinidine

From 1972 to 1980, 23 patients (Group A) with native valve infective endocarditis underwent surgical intervention, often for multiple indications, during the active stage of the infective process because of progressive class III and IV (New York Heart Association) heart failure (12 patients), persistent severe hypotension (3 patients), uncontrolled infection for over 21 days (11 patients), aortic root abscess (2 patients), and pericarditis (1 patient). Eighty-five patients (Group B) with active native valve endocarditis, matched for severity of illness, were treated medically. Two patients (9%) in Group A and 43 patients (51%) in Group B died during the hospital admission (p less than 0.001). Any difference in long-term cumulative survival rate between the 2 groups was largely due to the beneficial impact of surgical management on the hospital mortality. Of 23 patients in Group A, 11 (48%) had an entirely uncomplicated postoperative course. Long-term mortality rates in those with aortic valve endocarditis treated medically (79%) were significantly higher than in those with mitral valve involvement (47%) (p less than 0.05). Patients with aortic valve involvement treated surgically had a better hospital (p less than 0.005) and long-term (p less than 0.0005) survival rate than those treated medically. Two groups at risk for postoperative complications were identified; 3 of 11 patients (27%) with uncontrolled infection had an early postoperative recurrence, and 4 of 7 patients (57%) with an aortic root abscess had postoperative prosthetic paravalvular regurgitation. Surgery therefore effects a substantial reduction in hospital mortality in patients with complicated active infective endocarditis (9% versus 51%), but patients with preoperative prolonged periods of uncontrolled infection or with aortic root abscess are liable to postoperative complications.

Topics: Adolescent; Adult; Aged; Anti-Bacterial Agents; Cardiovascular Agents; Child; Endocarditis, Bacterial; Female; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Postoperative Complications; Prognosis

Topics: Anesthetics, Local; Cardiovascular Agents; Drug Hypersensitivity; Lidocaine; Postoperative Complications; Toxicology