The ideal cardioplegic strategy in thoracic aorta operations requiring long cardiopulmonary bypass and cross-clamp time has not been established. Suboptimal myocardial protection may lead to myocardial damage and possible post-operative complications. We evaluate post-operative cardiac Troponin I (cTnI) release, low cardiac output syndrome (LCOS) and mortality, using a cold crystalloid single-dose intracellular or cold blood multidose cardioplegia in 112 elective or emergent thoracic aorta operation patients. Fifty-four patients (HTK group) received Custodiol® cardioplegic solution and 58 received cold blood cardioplegia (CB group). Cross-clamp time, cardiopulmonary bypass (CPB) time and cTnI peak release were similar in both groups. No differences were found for atrial and ventricular arrhythmias, inotropic support, LCOS and in-hospital mortality. Two-way ANOVA analysis revealed an interactive effect on cTnI peak (p=0.012) of cardioplegic solution type across the cross-clamp time quintile. In the fifth quintile, cross-clamp time patient (>160 min) cTnI peak value was higher in CB patients (p=0.044). HTK and CB cardioplegic solutions assure similar myocardial protection in patients undergoing thoracic aorta operations. In long cross-clamp times, the lower post-operative cTnI release detected using HTK may be indicative of a better myocardial protection in these extreme conditions.
Acute adrenal ischemia represents a rare cause of adrenal insufficiency which should be promptly diagnosed in order to preserve adrenal vitality and function. Our study aims to retrospectively evaluate the diagnostic accuracy of the CT capsular sign as an indicator of adrenal ischemia and its association with vascular involvement. Between January 2013 and January 2014, 69 consecutive patients (47 men, 22 women; mean age 46; range 22-67) with suspected adrenal insufficiency based on clinical and biochemical data underwent 320-row CT examination in our Emergency Department. Written informed consent was obtained for the CT examinations, and the institutional review board approval was obtained for our retrospective study. CT multi-planar images were retrospectively and independently analyzed by two radiologists searching for the patency of adrenal vessels, enlarged adrenals, the presence of the "capsular sign" represented by a peripheral subtle hyperdense line around a hypodense enlarged adrenal, and the presence of any periadrenal inflammatory changes. All CT findings were then compared with the surgical findings (n = 5), follow-up examinations (n = 20), or autopsy (n = 4). Sensitivity, specificity, diagnostic accuracy (DA), positive predictive value (PPV), and negative predictive value (NPV) were calculated for the "capsular sign" and were further evaluated by ROC analysis. Acute adrenal ischemia occurred in 29/69 patients (42 %), unilateral in 20, and bilateral in 9. Forty of sixty-nine patients (58 %) had no evidence of adrenal disease on CT. Thrombosis of the main adrenal vein was found in 20/29 (69 %) and non-venous ischemia in 9/29 (31 %). The capsular sign was found in 24/29 patients (83 %). Sensitivity, specificity, DA, PPV, and NPV values of 83, 100, 93, 100, and 89 %, respectively, were obtained. The capsular sign represents a CT indicator of acute adrenal ischemia, with a specificity of 100 % and leading to a prompt diagnosis in the early phase of the disease.
The impact of coronary artery disease (CAD) on all–cause mortality and overall disabilities is well–established. Percutaneous and/or surgical coronary revascularization procedures dramatically reduced the occurrence of adverse cardiovascular events in patients suffering with atherosclerosis. Specifically, guidelines from the European Society of Cardiology on the management of myocardial revascularization promoted coronary artery by–pass graft (CABG) intervention in patients with specific alterations in coronary tree due to higher beneficial effects of this procedure as compared to percutaneous one. Left internal mammary artery (LIMA) is one of the best–performing vessels in CABG procedures due to its location and its own structural characteristics. Nevertheless, non–invasive assessment of its patency is challenging. Doppler Ultrasonography (DU) might perform as a reliable technique for non–invasive evaluation of the patency of LIMA. Data from literature revealed that DU may detect severe (>70%) stenosis of the LIMA graft. In this case, pulsed–wave Doppler might show peak diastolic velocity/peak systolic velocity < 0.5 and diastolic fraction < 50%). Stress test might also be adopted for the evaluation of patency of LIMA through DU. The aim of this narrative review is to evaluate the impact of DU on the evaluation of the patency of LIMA graft in patients who undergo follow–up after CABG intervention. The aim of this narrative review is to evaluate the impact of DU on the evaluation of the patency of LIMA graft in patients who undergo follow–up after CABG intervention.
Aims We have recently proposed a new prediction model for risk mortality based on four parameters of congestion to predict mortality in patients with acute or chronic heart failure. This risk model (HYDRA Score, HS) is based on the number of parameters of congestion above significant cut–offs (range 0–4): BNP >441 pg/mL, estimated plasma volume status (ePVS) >5.3 dL/gr, bioimpedance vector analysis (BIVA) >73.8%, and BUN/creatinine ratio (BUN/Cr) >25. As bioimpedance vector analysis is a measure of peripheral congestion but it is not frequently used in clinical practice, we evaluated the performance of the risk model by including the presence of peripheral edema in place of BIVA (HYDRA Semplified Score, HSS). Methods and results We analysed data from 436 HF patients. During a one–year follow–up 81 patients died (18.6%). Discrimination for all–cause mortality was compared by Harrell‘s C–statistic. Calibration was assessed by Hosmer–Lemeshow test and global performance by Nagelkerke‘s R2. Correlation between scores was assessed by Spearman rank test. Correlation between the scores was good (rho = 0.91, p<0.001). The two risk models showed similar results in terms of discrimination analyses (HS 0.786 vs HSS 0.760; p=0.09) and global performance (R2 = 0.26 and R2 =0.21). The Hosmer–Lemeshow goodness–of–fit test demonstrated the best calibration of HS risk model (χ2 6.5, P=0.60 for HS model and χ2 7.7, P=0.45 for HSS model). Conclusions Simplified HYDRA score seems a good and friendly model risk to predict one–year mortality in patients with heart failure and could be used as alternative to HYDRA score.
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