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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., (Copyright 2010 Elsevier Inc. All rights reserved.)

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]

This study tested the hypothesis that the preload-adjusted maximal power index (PA-PWRmax) is a load-independent index of human myocardial contractility. Based on the ventricular pressure-volume relationship and derived from stroke work, the index is the product of instantaneous ventricular pressure and volume changes, divided by a correction term of end-diastolic volume (EDV2) or end-diastolic area (EDA3/2) to adjust for preload effects. Echocardiographic measures of instantaneous ventricular area change may be used to obtain PA-PWRmax noninvasively. We prospectively evaluated 28 human subjects undergoing cardiac evacuation before cardiopulmonary bypass procedures. Continuous peripheral arterial pressure, pulmonary arterial pressure, and echocardiographic views of the left ventricle in the transgastric short-axis view were recorded. Simultaneously gated instantaneous fractional shortening (FS) and PA-PWRmax indices were calculated, with FS = (EDA – ESA)/EDA and PA-PWRmax = [MAP (EDA – ESA)]/ EDA3/2, where ESA = end-systolic area and MAP = instantaneous mean arterial pressure. FS decreased uniformly with cardiac evacuation and decreasing pulmonary artery diastolic pressure (t = –5.4; 95% confidence interval, –10 to –0.046; p < 0.001), as did PA-PWRmax (t = –5.8; 95% confidence interval, –2.25 to –1.08; p < 0.001). FS and PA-PWRmax showed a strong downward correlation (r = 0.81). Unlike previous studies of autonomically denervated animals, our study did not find PA-PWRmax to be preload independent, perhaps because of the instantaneous homeostatic mechanisms of the human autonomic nervous system linking contractility to loading conditions. Copyright © 2004 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

A 49-year-old male patient presented with a paravalvular leakage 18 years after aortic valve replacement. The patient received a mechanical valve and was weaned uneventfully from cardiopulmonary bypass. After a drop in the pressure curve of the left radial artery an additional line was placed in the proximal ascending aorta showing normal systemic pressure. Transesophageal echocardiography showed a massive circular thrombosis of the distal aortic arch. The patient received a covered stent to expand the residual aortic lumen and left the hospital in good health. [ABSTRACT FROM AUTHOR]

Background--The independent predictive value of troponin T (TNT) after on-pump cardiac surgery was established in several studies. However, adjustment was limited to preoperative risk factors without considering perioperative complications. Data on the prognostic value of postoperative B-type natriuretic peptide (BNP) are scarce. Our aim was to assess the independent value o f TNT and BNP to predict 12-month outcome after cardiac surgery with adjustment for preoperative risk estimates and postoperative complications and to report risk stratification gains when considering the European System for Cardiac Operative Risk Evaluation (EuroSCORE) combined with postoperative biomarkers. Methods and Results--This prospective cohort study included consecutive patients undergoing on-pump cardiac surgery between 2007 and 2010. We evaluated postoperative TNT and BNP, the EuroSCORE, and postoperative complications as predictors of adverse events using Cox regression. The primary end point was death or major adverse cardiac events within 1 year after surgery. We calculated the net reclassification index of TNT and BNP in addition to the EuroSCORE. We enrolled 1559 patients, of whom 176 (11.3%) experienced an event. The adjusted hazard ratio of TNT >0.8 µg/L was 2.13 (95% confidence interval, 1.47-3.15) and of BNP >790 ng/L was 2.44 (95% confidence interval, 1.65-3.62). The net reclassification index of the addition of TNT and BNP to the EuroSCORE was 0.276 (95% confidence interval, 0.195-0.348). Conclusions--Postoperative TNT and BNP are strong predictors of 1-year events after on-pump cardiac surgery independent of preoperative risk factors and postoperative complications. Updating the preoperative EuroSCORE risk with postoperative TNT and BNP after surgery allows for improved prediction of 1-year death or major adverse cardiac events. (Circulation. 2014;130:948-957.) [ABSTRACT FROM AUTHOR]

The article presents a study which evaluates the important role played by impaired cholinergic transmission on the development of delirium. Results show that there was no treatment effect of Mini-Mental State Examinations as well as clock drawing tests nor was the difference in the number of patients receiving haloperidol in the placebo groups. It is concluded that due to methodological issues, failed trial does not support the occurrence of oral rivastigmine's prophylactic administration.