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Background Elevated, single-measure, postoperative troponin is associated with adverse events after cardiac surgery. We hypothesized that increases in troponin from the first to the second postoperative day are also associated with all-cause, 12-month mortality and major adverse cardiac events (MACE). Methods This observational study included consecutive adults undergoing on-pump cardiac surgery with cardiac arrest. Troponin T was measured on the first and second postoperative day and was classified as “increasing” (>10%), “unchanged” (10% to –10%), or “decreasing” (<–10%). The primary endpoint was all-cause, 12-month mortality. Secondary endpoints were all-cause 12-month mortality or MACE and both outcomes at 30 days. The main analysis was by multivariable Cox regression. Results Of 1,417 included patients, 99 (7.0%) died and 162 (11.4%) died or suffered MACE at 12 months. A significant interaction ( p < 0.001) between first postoperative day troponin and the troponin trend from the first to the second postoperative day on 12-month, all-cause mortality precluded an analysis independent of first postoperative day troponin. Consequently, we stratified patients by their first postoperative day troponin (cutoff, 0.8 μg/L). Increasing troponin was associated with higher mortality in patients with first postoperative day troponin T ≥ 0.8 μg/L (hazard ratio, 1.98; 95% CI, 1.09 to 3.59; p = 0.025). Conclusions Troponin changes from the first to the second postoperative day should not be interpreted without consideration of the first postoperative day troponin concentration. For patients with a first postoperative day troponin ≥ 0.8 μg/L, an increase by more than 10% from the first to the second postoperative day was significantly associated with all-cause, 12-month mortality and other adverse events. [ABSTRACT FROM AUTHOR]

Objectives: Proximal aortic surgery with hypothermic circulatory arrest (HCA) commonly involves perioperative transfusion of allogeneic blood products, including red blood cells, plasma, and platelets. The authors hypothesized that surgery with HCA could be performed without allogeneic blood products and that a thromboelastometry-guided algorithm would reduce the transfusion of allogeneic blood products. Design: A retrospective analysis of prospectively collected data. Patients with and without thromboelastometry guidance were compared by case-control analysis (n = 62 matched patients) and multivariate regression (n = 194 patients). Setting: Single-center university hospital. Participants: This study included 194 patients undergoing elective and emergent procedures with HCA involving the proximal aorta. Interventions: A thromboelastometry-guided treatment algorithm during surgery was used in 153 patients (79%), and conventional coagulation management was used in 41 patients (21%). Measurements and Main Results: During surgery and the following 24hours, allogeneic blood products were transfused in 106 patients (55%). Median (interquartile range) number of allogeneic blood products transfused was 1 unit (0-6 units). Case-control analysis showed lower transfusion rates of red blood cells, plasma, and any allogeneic blood product (all p<0.050) in patients with thromboelastometry guidance. In the multivariate analysis, thromboelastometry guidance was associated with an odds ratio of 0.26 (95% confidence interval, 0.08-0.84; p = 0.025) for the transfusion of any allogeneic blood product. The use of thromboelastometry was not associated with adverse events (odds ratio 0.72; 95% confidence interval, 0.27–1.90; p = 0.507). Conclusions: Allogeneic blood products were avoided in a proportion of patients. The findings further suggest that thromboelastometry-guided coagulation management promoting the use of coagulation factor concentrates decreased the use of allogeneic blood products during complex cardiac surgery. [Copyright &y& Elsevier]

In the recent years, thromboelastography has become a popular monitoring device for hemostasis and transfusion management in major surgery, trauma, and hemophilia. Thromboelastography is performed in whole blood and assesses the viscoelastic property of clot formation under low shear condition. Thromboelastography can be performed with a variety of activator and inhibitors at different concentrations representing the most important factors for different intervals and clot formation variables reported in multiple studies and algorithms. Furthermore, fibrinogen levels and platelet counts have a major influence on thromboelastographic variables. In addition, differences in patient populations, devices, and preanalytical conditions contribute to some conflicting findings in different studies. [Copyright &y& Elsevier]

Objectives: Right ventricular dysfunction occurs very soon after conventional coronary bypass surgery with cardiopulmonary bypass and might not recover within 1 year after the operation. It has been postulated that performing coronary surgery without cardiopulmonary bypass might preserve right ventricular function. We hypothesized that right ventricular global and overall systolic functions are better preserved 3 months after off-pump surgery than after conventional coronary bypass surgery. Methods: Fifty patients scheduled for elective coronary bypass surgery were randomly assigned to conventional or off-pump surgery. Right ventricular function was assessed by means of transthoracic echocardiographic analysis the day before the operation and 3 months later. Right ventricular myocardial performance index was used as a marker of global right ventricular function, and right ventricular fractional area change was used as a marker of overall right ventricular systolic function. Peak systolic velocities of the lateral tricuspid annulus were studied to assess regional systolic function of the right ventricular free wall. Results: Surgical intervention was completed according to randomization in 48 of 50 patients. Demographic and perioperative characteristics were similar in the 2 groups. Over the study period, right ventricular myocardial performance index and right ventricular fractional area change did not change in comparison with the baseline values in both groups. Peak systolic velocity of the lateral tricuspid annulus was decreased significantly in both groups 3 months after the operation. There were no significant intergroup differences in any echocardiographic marker of right ventricular function. Conclusions: Global right ventricular function was not better preserved 3 months after off-pump surgery than after conventional coronary bypass surgery. [ABSTRACT FROM AUTHOR]

Objectives: Postoperative delirium after cardiac surgery is associated with increased morbidity and mortality as well as prolonged stay in both the intensive care unit and the hospital. The authors sought to identify modifiable risk factors associated with the development of postoperative delirium in elderly patients after elective cardiac surgery in order to be able to design follow-up studies aimed at the prevention of delirium by optimizing perioperative management. Design: A post hoc analysis of data from patients enrolled in a randomized controlled trial was performed. Setting: A single university hospital. Participants: One hundred thirteen patients aged 65 or older undergoing elective cardiac surgery with cardiopulmonary bypass. Interventions: None. Measurements and Mains Results: Screening for delirium was performed using the Confusion Assessment Method (CAM) on the first 6 postoperative days. A multivariable logistic regression model was developed to identify significant risk factors and to control for confounders. Delirium developed in 35 of 113 patients (30%). The multivariable model showed the maximum value of C-reactive protein measured postoperatively, the dose of fentanyl per kilogram of body weight administered intraoperatively, and the duration of mechanical ventilation to be independently associated with delirium. Conclusions: In this post hoc analysis, larger doses of fentanyl administered intraoperatively and longer duration of mechanical ventilation were associated with postoperative delirium in the elderly after cardiac surgery. Prospective randomized trials should be performed to test the hypotheses that a reduced dose of fentanyl administered intraoperatively, the use of a different opioid, or weaning protocols aimed at early extubation prevent delirium in these patients. [ABSTRACT FROM AUTHOR]

Background: The prognostic value of troponin T for midterm outcome in cardiac surgery is insufficiently known. We aimed to assess the value of troponin T to predict 12-month outcome after cardiac surgery, as a single predictor and in combination with the European system for cardiac operative risk evaluation (EuroSCORE). Methods: This cohort study included consecutive patients undergoing on-pump cardiac surgery between January 2005 and December 2006. We evaluated postoperative troponin T (TNT) on days 1 and 2 and the EuroSCORE as predictor variables. The primary composite endpoint was all-cause mortality or any major adverse cardiac event (MACE) at 12 months. Logistic regression was used to study the prognostic effect of TNT in a univariate analysis and after adjustment for EuroSCORE. The area under the receiver-operator curve (AUC) was calculated to report the discriminatory performance of the models. Results: Seven hundred forty-one patients were available for analysis. Within 12 months after surgery, 92 (12.4%) patients had a MACE, 48 (6.5%) of whom died. A multivariate model of continuous TNT and the continuous logistic EuroSCORE showed a significant independent association between TNT and the composite endpoint (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.02 to 1.04 per 0.1 μg/L increase in TNT). The AUC for the prediction of the composite endpoint of the model combining TNT and the EuroSCORE was 0.72; when based on EuroSCORE alone it was 0.64 (p < 0.0001). Conclusions: Postoperative TNT increase (per 0.1 μg/L) is a strong independent predictor of 12-month outcome after on-pump cardiac surgery. Updating the preoperative EuroSCORE risk with postoperative TNT allows for better prediction of 12-month MACE and all-cause mortality. [Copyright &y& Elsevier]

Objectives: Right ventricular dysfunction is a possible cause of cardiac failure after coronary surgery. The use of cardiopulmonary bypass is regarded as a major cause for its occurrence, and it has been postulated that performing coronary surgery without cardiopulmonary bypass might reduce ventricular dysfunction. Therefore, this prospective, randomized, controlled study tested the hypothesis that off-pump coronary surgery would better preserve right ventricular systolic and diastolic function than conventional bypass surgery. Methods: Fifty patients scheduled for elective coronary artery bypass surgery were randomly assigned to conventional or off-pump surgery. Right ventricular function was assessed by intraoperative transesophageal echocardiography immediately before and after coronary surgery. Right ventricular ejection fraction was used as a marker of global systolic function and tricuspid early/late (atrial) ratio as a marker of the global diastolic function. Peak systolic and early diastolic velocities of the lateral tricuspid annulus were studied to assess systolic and diastolic function in the area of the right ventricular free wall. Results: Surgery was completed according to randomization in 48 of 50 patients. Preoperative characteristics were similar in both groups. Intraoperative differences between the two groups included a higher volume of allogeneic blood transfusion in the conventional surgery group. At the end of surgery, global systolic right ventricular function was similarly maintained and diastolic function similarly impaired in both groups. There were no significant intergroup differences in any of the echocardiographic markers of right ventricular function. Conclusions: Off-pump surgery did not better preserve right ventricular systolic and diastolic function than did conventional coronary surgery. [Copyright &y& Elsevier]

Background: Knowledge of the prognostic information of preoperative 12-lead electrocardiogram (ECG) recordings in patients with coronary artery disease (CAD) undergoing noncardiac surgery is limited. Methods: The prognostic information derived from the preoperative ECGs of 172 CAD patients undergoing major noncardiac surgery was analyzed to determine its predictive value for long-term outcome. Primary end point was all-cause mortality; secondary end point was major adverse cardiac events (MACE) at 2 years. Results: Prevalence of ECG abnormalities was 53% for T-wave alterations; 46% for Q waves; 38% for ST deviations; and, depending on the criterion used, 2% to 19% for left ventricular hypertrophy. During follow-up, 40 (23%) patients died and 31 (18%) had MACE. After adjustment for clinical baseline findings, including current medication with β-blockers, ST depressions (odds ratio [OR] 4.5, 95% confidence interval [CI] 1.9-10.5) and faster heart rate (HR) (OR 1.6, 95% CI 1.1-2.4, per 10 beats per minute [bpm] increase) were independent predictors of all-cause mortality. Faster HR (OR 1.7, 95% CI 1.1-2.6, per 10-bpm increase) was also an independent predictor of MACE. The predictive value of ECG variables did not change after adjustment for occurence of perioperative ischemia. Conclusion: In CAD patients, the preoperative ECG contains important prognostic information and is predictive of long-term outcome independent of clinical findings and perioperative ischemia. [Copyright &y& Elsevier]

Abstract: Introduction: Preexisting electrocardiographic abnormalities may limit accuracy of continuous electrocardiography (cECG) for ischemia determination. The American College of Cardiology/American Heart Association published criteria for the exclusion of unsuitable cECG curves from ST-segment interpretation. These criteria consider medication and 12-lead ECG findings (medication- and 12-lead ECG-based criteria) and cECG lead characteristics (cECG-based criteria). Methods: We recorded cECG in 300 patients undergoing major noncardiac surgery. We determined postoperative troponin and 12-month outcome. We compared the associations of cECG-detected ischemia with troponin and 12-month outcome with and without adherence to the criteria. Results: Adherence to the medication- and 12-lead ECG-based criteria enhanced the association between troponin and perioperative ischemia in CM5 (odds ratio, 3.74; 95% confidence interval, 1.88-7.44) and 7.03 (2.67-18.49), respectively; P = .049). Similarly, the association between ischemia in CM5 and 12-month outcome tended to increase (P = .081). Conclusions: Applying the guideline criteria for the interpretation of cECG enhanced cECG diagnostic value in surgical patients. [Copyright &y& Elsevier]