Year : 2009 | Volume
: 10 | Issue : 3 | Page : 102--103
|How to cite this article:|
. Cardiovascular News.Heart Views 2009;10:102-103
|How to cite this URL:|
. Cardiovascular News. Heart Views [serial online] 2009 [cited 2021 Oct 24 ];10:102-103
Available from: https://www.heartviews.org/text.asp?2009/10/3/102/63696
Early on-Cardiopulmonary Bypass Hypotension and other Factors Associated with Vasoplegic Syndrome
Vasoplegic syndrome is a form of vasodilatory shock that can occur after cardiopulmonary bypass (CPB). We hypothesized that the severity and duration of the decline in mean arterial pressure immediately after CPB is begun can be used as a predictor of patients will develop vasoplegia in the immediate post-CPB period and of poor clinical outcome. Investigators quantified the decline in mean arterial pressure by calculating an area above the mean arterial blood pressure curve.
2823 adult cardiac surgery cases performed between July 2002 and December 2006 were retrospectively analyzed. Of these 2823, 577 (20.4%) were vasoplegic after separation from CPB. 1645 patients (58.3%) had a clinically significant decline in mean arterial pressure after starting CPB (area above the mean arterial blood pressure curve > 0) and were significantly more likely to become vasoplegic (23.0% versus 16.9%; odds ratio, 1.26; 95% confidence interval, 1.12 to 1.43; P 10 days (odds ratio, 3.30; 95% confidence interval, 1.44 to 7.57; P = 0.005). Additional risk factors for developing vasoplegia that were identified included the additive euroSCORE, procedure type, prebypass mean arterial pressure, length of bypass, administration of pre-CPB vasopressors, core temperature on CPB, pre- and post-CPB hematocrit, the preoperative use of b-blockers or angiotensin-converting enzyme inhibitors, and the intraoperative use of aprotinin.
The results of this investigation suggest that it is possible to predict vasoplegia intraoperatively before separation from CPB and that the presence of a clinically significant area above the mean arterial blood pressure curve serves as a predictor of poor clinical outcome.
Determinants of Surgical Outcome in Patients with Isolated Tricuspid Regurgitation
Researchers sought to identify preoperative predictors of clinical outcomes after surgery in patients with severe tricuspid regurgitation.
Sixty-one consecutive patients (54 women, aged 57 ± 9 years) with isolated severe tricuspid regurgitation undergoing corrective surgery were prospectively enrolled. Twenty-one patients (34%) were in New York Heart Association functional class II, 35 (57%) in class III, and 5 (9%) in class IV. Fifty-seven patients (93%) had previous history of left-sided valve surgery. Preoperative echocardiography revealed pulmonary artery systolic pressure of 41.5 ± 8.7 mm Hg, right ventricular (RV) end-diastolic area of 35.1 ±9 .0cm2, and RV fractional area change of 41.3 ± 8.4%.
The median follow-up duration after surgery was 32 months (range, 12 to 70). Six of the 61 patients died before discharge; thus, operative mortality was 10%. Three of the 55 patients who survived surgery died during follow-up, and 6 patients required readmission because of cardiovascular problems. Thus, 46 patients (75%) remained event free at the end of follow-up. In the 54 patients who underwent 6-month clinical and echocardiographic follow-up, RV end-diastolic area decreased by 29%, with a corresponding 26% reduction in RV fractional area change. Thirty-three patients (61%) showed improved functional capacity after surgery.
On multivariable Cox regression analysis, preoperative hemoglobin level (P 2 predicted event-free survival with a sensitivity of 73% and a specificity of 67%, and a hemoglobin level > 11.3 g/dL predicted event-free survival with a sensitivity of 73% and a specificity of 83%.
Timely correction of severe tricuspid regurgitation carries an acceptable risk and improves functional capacity. Surgery should be considered before the development of advanced RV systolic dysfunction and before the development of anemia.
Atrial Arrhythmias in Adults with Congenital Heart Disease
Atrial arrhythmias increase disease burden in the general adult population. Adults with congenital heart lesions constitute a rapidly growing group of patients with cardiovascular disease. Investigators hypothesized that atrial arrhythmias increase with age and impair health outcomes in this population.
A population-based analysis of prevalence, lifetime risk, mortality, and morbidity associated with atrial arrhythmias in adults with congenital heart disease was conducted from l983 to 2005. In 38 428 adults with congenital heart disease in 2005, 5812 had atrial arrhythmias. Overall, the 20-year risk of developing atrial arrhythmia was 7% in a 20-year-old subject and 38% in a 50-year-old subject. More than 50% of patients with severe congenital heart disease reaching age 18 years developed atrial arrhythmias by age 65 years. In patients with congenital heart disease, the hazard ratio of any adverse event in those with atrial arrhythmias compared with those without was 2.50 (95% confidence interval, 2.38 to 2.62; P Short-Term Hemodynamic Effects of Cardiac Resynchronization Therapy in Patients with Heart Failure, a Narrow QRS Duration, and no Dyssynchrony
Cardiac resynchronization therapy produces both short-term hemodynamic and long-term symptomatic/ mortality benefits in symptomatic heart failure patients with a QRS duration > 120ms. This is conventionally believed to be due principally to relief of dyssynchrony, although we recently showed that relief of external constraint to left ventricular filling may also play a role. Researchers evaluated the short-term hemodynamic effects in symptomatic patients with a QRS duration Bleeding Increases the Risk of Ischemic Events in Patients with Peripheral Arterial Disease
Patients with peripheral arterial disease are at high risk of ischemic events and therefore are treated with antithrombotics. In patients with coronary artery disease or cerebrovascular disease, bleeding is related to the subsequent occurrence of ischemic events. Investigators assessed whether this is also the case in patients with peripheral arterial disease.
All patients from the Dutch Bypass and Oral Anticoagulants or Aspirin (BOA) Study, a multicenter randomized trial comparing oral anticoagulants with aspirin after infrainguinal bypass surgery, were included. The primary outcome event was the composite of nonfatal myocardial infarction, nonfatal ischemic stroke, major amputation, and cardiovascular death. To identify major bleeding as an independent predictor for ischemic events, crude and adjusted hazard ratios with 95% confidence intervals were calculated with multivariable Cox regression models. From 1995 until 1998, 2650 patients were included with 101 nonfatal major bleedings. During a mean follow-up of 14 months, the primary outcome event occurred in 218 patients; 22 events were preceded by a major bleeding. The mean time between major bleeding and the primary outcome event was 4 months. Major bleeding was associated with a 3-fold increased risk of subsequent ischemic events (crude hazard ratio, 3.0; 95% confidence interval, 1.9 to 4.6; adjusted hazard ratio, 3.0; 95% confidence interval, 1.9 to 4.7).
In patients with peripheral arterial disease, as in patients with coronary artery disease or cerebrovascular disease, major bleeding was independently associated with major ischemic complications. Without compromising the benefits of antithrombotics, these findings call for caution relative to the risks of major bleeding.