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PurposeThe frailty concept has become a fundamental part of daily clinical practice. In this study our purpose was to create a risk estimation method with a comprehensive aspect of patients' preoperative frailty.Patients and methodsIn our prospective, observational study, patients were enrolled between September 2014 and August 2017 in the Department of Cardiac Surgery and Department of Vascular Surgery at Semmelweis University, Budapest, Hungary. A comprehensive frailty score was built from four main domains: biological, functional-nutritional, cognitive-psychological and sociological. Each domain contained numerous indicators. In addition, the EUROSCORE for cardiac patients and the Vascular POSSUM for vascular patients were calculated and adjusted for mortality.ResultsData from 228 participants were included for statistical analysis. A total of 161 patients underwent vascular surgery, and 67 underwent cardiac surgery. The preoperatively estimated mortality was not significantly different (median: 2.700, IQR (interquartile range): 2.000–4.900 vs. 3.000, IQR: 1.140–6.000, P = 0.266). The comprehensive frailty index was significantly different (0.400 (0.358–0.467) vs. 0.348 (0.303–0.460), P = 0.001). In deceased patients had elevated comprehensive frailty index (0.371 (0.316–0.445) vs. 0.423 (0.365–0.500), P < 0.001). In the multivariate Cox model an increased risk for mortality in quartiles 2, 3 and 4 compared with quartile 1 as a reference was found (AHR (95% CI): 1.974 (0.982–3.969), 2.306 (1.155–4.603), and 3.058 (1.556–6.010), respectively).ConclusionThe comprehensive frailty index developed in this study could be an important predictor of long-term mortality after vascular or cardiac surgery. Accurate frailty estimation could make the traditional risk scoring systems more accurate and reliable.

Uvod: Postoje ke smrti jsou faktory ovlivňujici vyhořeni a tyto postoje maji různe projevy a kategorie (strach ze smrti, vyhýbani se konfrontace se smrti, neutralni přijeti smrti, přijeti smrti jako zacatku nove kapitoly, přijeti smrti jako uniku). Metody: Studie byla provedena mezi 1. březnem 2018 a 28. unorem 2019 mezi zaměstnanci "Narodni zachranne služby" a cleny organizace "Narodni ambulantni pracovnici Maďarske komory zdravotnických pracovniků". Pro tuto studii jsme použili revidovanou verzi dotazniku Death-Attitude Profile (DAP-R), kterou vytvořili Wong/Reker/Gesser. Maďarska verze dotazniku neexistovala, a proto byl vytvořen jeho překlad. Odpovědi respondentů byly analyzovany pomoci statistickeho programu SPSS 25.0. Výsledky: Překlad dotazniku byl uspěsný. Studie se zucastnilo celkem 669 pracovniků zachranne služby - lekaři zachranne služby, zachranaři, technici v sanitkach, zdravotni sestry pracujici v sanitkach, řidici sanitky (muži - n = 584, 87,3%, ženy - n = 83, 12,4 %; průměrný věk: 42,40 (SD = 10,41, rozsah = 20-64)). Při analýze dat se ukazalo, že kategorie "strach ze smrti" měla nejmensi zastoupeni (M = 2,77, SD = 1,30) a kategorie "neutralni přijeti smrti" (M = 5,86, SD = 1,22) zastoupeni největsi. Zavěr: Překlad dotazniku DAP-R provedeneho v prvni casti nasi studie lze použit jako referencni zaklad pro dalsi studie v Maďarsku. Při srovnani nasich výsledků s jinými studiemi v mezinarodni literatuře je kategorie "strach ze smrti" zastoupena ve větsi miře, než se ocekavalo; nejcastějsim postojem pracovniků zachranne služby ke smrti je "neutralni přijeti smrti".

Background In recent decades, previous studies have noted the importance of frailty, which is a frequently used term in perioperative risk evaluations. Psychological and socioeconomical domains were investigated as part of frailty syndrome. The aim of this study was to assess the importance of these factors in mortality after vascular surgery. Methods In our prospective, observational study (ClinicalTrials.gov Identifier: NCT02224222), we examined 164 patients who underwent elective vascular surgery between 2014 and 2017. At the outpatient anaesthesiology clinic, patients completed a questionnaire about cognitive functions, depression and anxiety, social support and self-reported quality of life were assessed using a comprehensive frailty index, in addition to medical variables. Propensity score matching was performed to analyse the difference between patients and controls in a nationwide population cohort. The primary outcome was 4 year mortality. The Kaplan-Meier method and Cox regression analysis were used for statistical analyses. Results The patients’ mean age was 67.05 years (SD: 9.49 years). Mini-Mental State Examination scores of less than 27 points were recorded for 41 patients. Overall mortality rates were 22.4 and 47.6% in the control and cognitive impairment groups, respectively (p = 0.013). In the univariate Cox regression analysis, cognitive impairment measured using age- and education-adjusted MMSE scores increased the risk of mortality (AHR: 2.842, 95% CI: 1.389-5.815, p = 0.004). Conclusion Even mild cognitive dysfunction measured preoperatively using the MMSE represents a potentially important risk factor for mortality after vascular surgery.

Objectives Thyroid dysfunction has been shown to be associated with increased all-cause mortality and severity of chronic heart failure in critical illness and severe cardiac diseases. The present study was conducted to ascertain the relationship between perioperative free triiodothyronine and free tetraiodothyronine (fT4) levels and postoperative adverse outcomes after heart transplantation (HTX). Design Retrospective, observational study. Setting Single-center study in a quaternary care university clinical center. Participants The study comprised adult patients who underwent HTX between 2015 and 2019 and had at least 1 perioperative thyroid hormone laboratory test on the day of surgery or in the 24 hours before/after the procedure (free triiodothyronine, fT4, and thyroid-stimulating hormone). Interventions No interventions were applied. Measurements and Main Results The primary outcome was primary graft dysfunction (PGD), defined by the consensus conference of the International Society for Heart and Lung Transplantation. A total of 151 patients were included in the final analyses. Twenty-nine (19.2%) patients had PGD. Fourteen (9.3%) patients had low fT4 levels. An independent association was found between fT4 and PGD (odds ratio 6.49; 95% confidence interval 2.26-18.61; p = 0.001), with adjusted multivariate Cox regression models. Conclusion The perioperative fT4 level could be a prognostic marker of adverse outcomes in HTX. The authors suggest appropriate perioperative monitoring of fT4 levels. Additional research is warranted to examine the optimal timing, dosage, and method of replacement.

Introduction: Veno-arterial extracorporeal membrane oxygenation is a valuable therapeutic approach in patients with severe heart failure due to different etiologies. Current prognosis with veno-arterial extracorporeal membrane oxygenation is unsatisfactory, and the risk stratification is still challenging. Therefore, we aimed to evaluate the predictive value of different baseline model for end-stage liver disease scores for survival in patients with veno-arterial extracorporeal membrane oxygenation. Methods: We conducted an observational, retrospective study of consecutive veno-arterial extracorporeal membrane oxygenation-treated patients between January 2012 and August 2018. The four types of model for end-stage liver disease scores—model for end-stage liver disease, international normalized ratio-excluded model for end-stage liver disease, modified model for end-stage liver disease, and model for end-stage liver disease with sodium—were calculated preoperatively. Veno-arterial extracorporeal membrane oxygenation was used based on the four clinical indications: primer graft failure after heart transplantation, weaning failure from cardiopulmonary bypass, acute myocardial infarction with refractory cardiogenic shock, and bridge to transplantation or bridge to candidacy. The primary endpoint of the study was overall mortality. The secondary endpoint was in-hospital mortality. We performed univariable and multivariable Cox regression analyses. Results: Data from 135 patients were analyzed. The median follow-up was 952 days (interquartile range = 417–1555 days). In-hospital mortality was 62.2%, and overall mortality was 71.1%. The multivariable Cox regression analysis is adjusted for indication, and the survival after veno-arterial extracorporeal membrane oxygenation score showed that the following scores were associated with overall mortality: model for end-stage liver disease (hazard ratio = 1.04; 95% confidence interval = 1.01–1.07; p = 0.016), modified model for end-stage liver disease (hazard ratio = 1.04; 95% confidence interval = 1.01–1.06; p = 0.006), and model for end-stage liver disease with sodium (hazard ratio = 1.05; 95% confidence interval = 1.02–1.08; p = 0.001). Conclusion: Model for end-stage liver disease, modified model for end-stage liver disease, and model for end-stage liver disease with sodium scores could be useful in the risk stratification of veno-arterial extracorporeal membrane oxygenation treatment in varying clinical indications.

BACKGROUND The frailty score has been developed to determine physiological functioning capacity. The aim of our research was to explore the relationship between frailty factors and mortality in cardiac surgery patients. METHODS Our research is an observational, single-center, prospective cohort study (registered on ClinicalTrials.gov: NCT02224222), and we studied 69 patients who underwent elective cardiac surgery between 2014 and 2017. Thirty days before the surgery, they completed a questionnaire that contained questions related to social support, self-reported life quality-happiness, cognitive functions, anxiety and depression. Demographic, anthropometric and medical data were widely collected. The Geriatric Nutritional Risk Index (GNRI) and the Comprehensive Geriatric Assessment (CGA)-based frailty index were calculated as a sum and the domains, respectively. Cox regression and the Kaplan-Meier tests were applied to analyze survival and relative risk. The primary outcome was mid-term mortality. RESULTS The patients' mean age was 65.43 years [standard deviation (SD): 9.81 years]. The median followup was 1,656 days of survival [interquartile range (IQR), 1,336-2,081 years], during this period 14 patients died. The median of EuroSCORE II was 1.56 (1.00-2.58) points. The median preoperative albumin level was 32.80 g/L (IQR, 29.9-35.8 g/L). Major adverse cardiovascular and cerebral events (MACCEs) occurred 7 times during follow-up. The nutrition score of the CGA was significantly associated with worse long-term survival [score; hazard ratio (HR): 5.35; 95% CI: 1.10-25.91, P=0.037]. After adjustment for EuroSCORE II and postoperative complications the noncardiovascular CGA score was associated with overall mortality [adjusted hazard ratio (AHR): 1.44, 95% CI: 1.02-2.04, P=0.036]. In the multivariable Cox regression, GNRI

Introduction The hepatic venous flow reflects the pressure changes of the right ventricle. (1) Therefore, it starts to appear as a part of the echocardiographic examinations. Moreover, the back-and-forth link between the cardiovascular state and the liver is well-known for several years. (2,3) Our objective was to evaluate the association between preoperative and postoperative hepatic venous flow and the outcome of patients who underwent cardiac surgery. Methods Our prospective, observational study included 30 patients who underwent cardiac surgery between 2021 January and June at our Heart and Vascular Centre. Beside the routine echocardiographic examination, we also measured the venous blood flow in the common hepatic vein before the influx into the Inferior Vena Cava with Doppler ultrasound before and after the surgical procedure. We recorded the standard four waves’ (V, D, S, A) maximal speed and velocity time integral (VTI). In our database we recorded the patients’ demographic data, preoperative and postoperative hemodynamic and hepatobiliar markers and the EuroSCORE. We collected the length of stay (LOS), the intensive care unit stay, the vasopressor and inotrope need, and the occurrence of acute kidney injury (AKI). Our primary outcome was AKI, it was defined by the Kidney Disease Improving Global Outcomes (KDIGO) guidelines, which is one of the first signs of circulation problems. We used the SPSS 22 program to analyse our data, with descriptive parameters and Cox-regression analyses. Results Median age was 67.9 (IQR 25-75: 60.6-73.6), none of them had any liver or renal disease in their medical history. Most common surgical procedure was AVR (atrial valve repair) (40%). During the first postoperative week 6 patients developed AKI. Between the AKI and non-AKI subgroups with Inverse Probability Weighting we found a significant difference at the postoperative A and D waves’ VTI, (p=0,031 and 0,022) and the preoperative retrograde/anterograde waves’ VTI ratio after adjustment for age, Euroscore, diabetes and GFR. (p=0,001). With paired-samples T test the V waves’ VTI's difference was significant between the preoperative and postoperative measurement. Discussion The increment in the hepatic venous retrograde waves, which are related to hepatic stasis, can predict worse outcomes among cardiac patients. Therefore, we might include this potentially useful tool in routine echocardiographic examinations and monitoring through the whole hospital stay.

Background: In the last decades prior studies noted the importance of frailty which is a frequently used term in perioperative risk evaluation. We investigated frailty syndrome as the psychological and socioeconomic elements of the human being. The aim of this study was assessing the importance of these factors for mortality after vascular surgery.Methods: In our prospective, observational study (ClinicalTrials.gov Identifier: NCT02224222) we examined 164 patients who underwent an elective vascular surgery between 2014 and 2017. At the point of admission they filled out a questionnaire, in this way the patients’ cognitive functions, depression and anxiety, social support and self-reported life quality were mapped. We used Cox regression and Kaplan-Meier method for relative risk calculation and survival analyses. Propensity score matching was performed to analyze the difference between patient and control, nation-wide population cohort. Effects of psychosocial factors on long term mortality were defined as primary outcome. Results: The patients mean age were 67.05 years (SD: 9.49 years). One out of four patients had some kind of cognitive impairment measured by Mini Mental State Examination with modified, more sensitive cut-off values. In univariate Cox regression higher MMSE score was associated decreased risk for all-cause mortality (OR: 0.883, 95% CI: 0.802-0.973, p=0.012). After clusters were created according to MMSE score relative risks were calculated. Even mild cognitive dysfunction could increase risk for long term mortality (AHR: 1.634, 95% CI: 1.118-2.368, p=0.009).Conclusion: Even mild cognitive dysfunction measured by the MMSE preoperatively could be an important risk factor for mortality after vascular surgery.

Background Pituitary dysfunction after brainstem death can cause various hormone deficiencies in potential heart donors. The aim of this study was to evaluate the relationship between hormone replacement therapy (HRT; including antidiuretic hormone analog, thyroid hormone, and methylprednisolone) in heart donors and the recipients’ outcomes after heart transplantation (HTx). Methods We retrospectively analyzed HTxs performed between January 2012 and October 2018. Donor and recipient characteristics were retrieved with a focus on endocrine parameters and HRT. The primary outcome was primary graft dysfunction (PGD). Secondary outcomes were the 30-day and 2-year mortality of the recipients. Univariate and multivariate Cox regression analyses were applied. Results The study included 297 HTxs. PGD occurred in 56 recipients (18.9%). In the multivariable Cox analysis, methylprednisolone and thyroxine treatment in donors were associated with a lower odds for PGD (odds ratio [OR], 0.43; 95% CI, 0.19-1.01; P = .052; and OR,: 0.34; 95% CI, 0.15-0.76; P = .009, respectively). In multivariate analysis, thyroxine treatment in donors was associated with a lower odds of PGD (OR, 0.38; 95% CI, 0.17-0.86; P = .020). Donor thyroxine supplementation also had a beneficial effect on recipients’ 2-year survival (OR, 0.53; 95% CI, 0.29-0.96; P = .036). Conclusions Combined thyroxine and methylprednisolone treatment could be a protective factor against PGD. Thyroxine administration was associated with better 2-year survival in recipients.

Introduction Perioperative risk estimation score systems used in cardiac surgical daily practice contains variables about preoperative laboratory parameters. C reactive protein was studied as a potential risk factor in cardiovascular/coronary artery diseases (CAD). We aimed to identify the relationship between the preoperative C reactive protein level and surgical patients postoperative mortality. Methods Current study was performed in a cardiac surgery center at Semmelweis University, Budapest, Hungary. During a retrospective analysis patients who underwent coronary artery bypass graft surgery were examined between 2009 and 2019. Routine preoperative patient and laboratory parameters, basic surgical variables were collected. The effect of preoperative C reactive protein and overall mortality was observed as primary outcome. After descriptive statistics clustering was performed. Low CRP level was coded below 1,99, normal between 2 and 4,99, elevated between 5 and 9,99 and high above 10mg/L. Survival analysis (Kaplan-Meier method) and Cox-regression were performed using clusters. Results Totally 1010 patients were enrolled, 75.2% were male. Median age was 66 years (IQR: 61-72ys), the median follow-up time was 899 days (IQR: 482-1473 days). During follow-up 144 patients (14.26%) has died. Elective surgery was 26.34%, urgent 57.03% and acute/rescue 16.63% of the cases. According to CRP level: 43.66% was low, 29.90% normal, 13.37% elevated and 13.03% high. In the aspect of survival there was a significant difference between normal and elevated (p=0.002) and normal and high (p Discussion Even the mildly elevated preoperative C reactive protein level could be an independent risk factor in patients undergoing coronary artery bypass grafting. Consideration of the preoperative CRP level could be a useful supplement to general risk estimation score systems.

Introduction The correct cost-benefit estimation and the more accurately perioperative risk evaluation is one of the more difficult task in the perioperative medicine. We wanted to study more than the obvious parameters, so we looked for less studied predictors, such as different peripherial hormone levels. Every hormone molecule acts a complex pathway, so we truely believe that the insufficient function or decreased serum level of these mediators could be heavy influence for the perioperative adverse events. Methods Our single center prospective, observational study approved by the IRB and registered at clinicaltrials.gov (NCT03736499). We enrolled 89 patients between 25.01.2019 and 30.04.2019 who underwent elective cardiac surgical procedure. In the preoperative period we measured different hormone levels in serum (TSH, free T3 and T4, prolactine and testosterone) and collected the demographic parameters. We corrigated the normal hormone levels for age and gender. We recorded the length of postoperative intensive care unit stay, length of mechanical ventilation, dose of different vasopressor and inotropic agents, fluid balance, blood transfusion and bleeding. The adverse outcomes were also collected. The primary outcome was the all-cause mortality. Secondary outcome were the length of ICU stay, length of mechanical ventilation and the frequency of different adverse events. We performed descriptive statistics, chi square test and Mann-Whitney U test using the IBM-SPSS 22.0 statistic software. Results Median age was 66.0 years (IQR: 59.0-73.0), 64.04% of the patients were male, median of BMI was 28.22 (IQR: 25.44-31.44). The median of EuroSCOREII was 1.94 (IQR: 1.17-3.05). The mean follow up time was 52.8±20.68 days. 8 patients (8.98%) died during the follow up time, the median length of ICU stay was 45 hours (IQR: 22.0-92.0), the median length of mechanical ventilation was 9 hours (IQR: 5.0-19.0). In univariable Cox regression serum free T3 was correlated with all cause mortality (OR: 0.266, CI 95%: 0.096-0.735, p = 0.011) and the abnormal level of free T3 was associated with higher infection rate (OR: 6.052, CI 95%: 1.271-28.832, p = 0.024). Using nonparametric tests we found association between abnormal serum prolactine level and postoperative arrhythmias (p = 0.017) and between abnormal serum testosterone level and prolonged length of ICU stay (p = 0.002). Discussion The evaluation of serum hormone levels could help to make more precise estimation of perioperative risk in adult patients waiting heart surgery. Further examination should be performed, to establish stronger correlation between fine hormonal dysregulation and postoperation complications.

Introduction Thyroid dysfunction after serious systematic stress is a widely known phenomenon., called non-thyroidal illness syndrome or euthyroid sick syndrome. Triiodothyronine (T3) and tetra iodothyronine (T4) decrease without previous thyroid disorders could be an early sign. Current phenomenon in our special, critically ill patient population is not well-studied yet. Methods Our single centre retrospective study was approved by the IRB (65/2017). The data of patients undergoing orthotopic heart transplantation between January 2015 and January 2019 were analysed. Data on survival was refreshed on the 2nd of May 2019. Demographic variables, thyroid diseases and hormone replacement therapy in medical history, the United Network for Organ Sharing (UNOS) score, baseline T3 and T4 levels (pmol/L) and postoperative complications were collected into our dataset. Our primary outcome was 30-day mortality, secondary outcomes were overall and in-hospital mortality. For further analysis, multivariable Cox regression were applied. Results Final analysis included 75 patients, 26.7% (n = 20) were female. Median time of follow-up was 592 day (IQR25-75: 395-839). Thirty-day, overall and in-hospital mortality were 6.7% (n = 5), 12% (n = 9) and 9.3%(n = 7), respectively. Median T3 level was 2.94 pmol/L (IQR25-75: 2.40-3.85) and T4 level was 14.34 pmol/L (IQR25-75: 11.87-16.36). Twelve (16%) patients had hypothyroidism in their medical history and 8 (10.7%) patients had hyperthyroidism, 9 (12%) patient were on thyroid hormone replacement therapy before the procedure. Median age was 52 year (IQR25-75: 45-58), median UNOS score was 3 (IQR25-75: 2-5). After adjustment of the UNOS score, T4 level were independently associated with 30-day (OR: 1.10; 95% CI: 1.01-1.21; p = 0.038) and in-hospital mortality (OR: 1.10; 95% CI: 1.01-1.20; p = 0.031). Nevertheless, T3 level showed no associations with our outcomes. Discussion Thyroid function should be monitored in the perioperative period of heart transplantation, dynamics of T4 may represent a clinically important marker. Thyroid hormone replacement in the early phase might need further investigations.