This systematic review with meta-analysis sought to determine the impact of antioxidants (N-acetylcysteine [NAC], polyunsaturated fatty acids [PUFAs] and vitamins) on incidence of postoperative atrial fibrillation (POAF) and duration of length of hospital stay. Medline, Embase, Elsevier, Sciences online database and Google Scholar literature search was made for studies in randomized controlled trials. The effect sizes measured were odds ratio (OR) for categorical variable and standard mean difference (SMD) with 95% confidence interval (CI) for calculating differences between mean values of duration of hospitalization in intervention and control groups. A value of P < 0.1 for Q-test or I(2) > 50% indicated significant heterogeneity between the studies. Literature search of all major databases retrieved 355 studies. After screening, a total of 23 trials were identified that reported outcomes of 4278 patients undergoing cardiac surgery. Pooled effects estimates on POAF showed a significant reduction after NAC (OR: 0.56, 95% CI: 0.40-0.77, P < 0.001), PUFA (OR: 0.84, 95% CI: 0.71-0.99, P = 0.03) and vitamin C treatment (OR: 0.50, 95% CI: 0.27-0.91, P = 0.02). Hospital length of stay was not reduced after NAC therapy (SMD: 0.082, 95% CI -0.09 to 0.25, P = 0.3), but could be decreased with PUFA (SMD: -0.185, 95% CI: -0.35 to -0.018, P = 0.03) and vitamin C (SMD: -0.325, 95% CI -0.50 to -0.14, P < 0.01). In conclusion, perioperative antioxidant supplementations with NAC, PUFA and vitamin C prevent atrial fibrillation after cardiac surgery. Moreover, PUFA and vitamin C are capable to reduce hospital stay, whereas NAC lacks this capacity.

This systematic review with meta-analysis sought to determine the strength of evidence for the effects of hydration (sodium bicarbonate [SB] and normal saline [NS]), supplementations ( N-acetylcysteine [NAC] and vitamin C), and some common drugs (adenosine antagonists [AAs], statins, loop diuretics, and angiotensin-converting enzyme inhibitors [ACEIs]) on the incidence of contrast-induced nephropathy (CIN) and requirement for hemodialysis after coronary angiography. After screening, a total of 125 trials that reported outcomes were identified. Pooled analysis indicated beneficial effects of SB versus NS (odds ratio [OR] = 0.73; 95% confidence interval [CI]: 0.56-0.94; P = .01), NAC (OR = 0.79; 95% CI: 0.70-0.88; P = .001), vitamin C (OR = 0.64; 95% CI: 0.45-0.89; P = .01), statins (OR = 0.45; 95% CI: 0.35-0.57; P = .001), AA (OR = 0.28; 95% CI: 0.14-0.47; P = .001), loop diuretics (OR = 0.97; 95% CI: 0.33-2.85; P = .9), and ACEI (OR = 1.06; 95% CI: 0.69-1.61; P = .8). Overall, hydration with SB, use of supplements, such as NAC and vitamin C, and administration of statins and AA should always be considered for the prevention of CIN after coronary angiography.

Background:Atrial fibrillation (AF) occurs in 30% patients on the second or third day post operation; therefore, it is the most prevalent and complicated arrhythmia after open heart surgery. White blood cell (WBC) count seems to be most significantly associated with cardiovascular disorders. This study was designed to evaluate the exact relationship between preoperative WBC count and post-Coronary artery bypass graft (CABG) AF in patients with severe left ventricle (LV) dysfunction who underwent elective off-pump coronary artery bypass.Methods:This study was conducted on 104 patients from among 400 patients with severe LV dysfunction undergoing elective off-pump CABG surgery from February 2011 to February 2012, in Afshar Cardiovascular Center, Yazd, Iran. Patients with emergency surgery, unstable angina creatinine higher than 2.0 mg/dL, malignancy, or immunosuppressive disease were excluded. Preoperative serological tests of the participants, such as WBC counts, were saved in their medical dossiers. Of the 400 patients undergoing CABG, AF was found in 54 cases; these 54 male patients formed the experimental group and 60 other patients in the intensive care unit (ICU) and hospital stay without postoperative AF were part of the control group.Results:The average age of the patients was 68.5±12.8 years. WBC counts in patients with and without AF three days before surgery were 12,340±155 and 8,950±170, respectively. On surgical day, WBC counts in the patients with and without AF were 13,188±140 and 9,145±255, respectively (P value three days before surgery: 0.04; P value on surgical day: 0.01). Of the 54 male patients with postoperative AF (POAF), duration of AF was more in cases with elevated WBC count (12,000-14,000) than in those with lower elevated WBC count (10,000-12,000) (]P=0.025), but there was no relationship between frequency of recurrence of AF and grading of elevation of WBC count (]P=0.81).Conclusion:These findings show that three days before surgery and on surgery day, there was a difference in WBC count between both groups. So, preoperative WBC count may predict the incidence and duration of AF; however, it cannot be a predictor of the frequency of recurrence of AF. Finally, WBC count is an independent marker for POAF and duration of AF.

SummaryThis systematic review with meta-analysis sought to determine the strength of evidence in terms of the impact of common antioxidant supplementations, such as N-acetylcysteine (NAC), vitamin C, and polyunsaturated fatty acids (PUFA) on perioperative outcomes after cardiac surgery with particular focus on the incidence of atrial fibrillation (AF) and acute kidney injury (AKI) with associated mortality. A total of 29 trials were identified that reported incidence of AF and 17 trials that reported incidence of AKI. Pooled analysis reported that NAC (OR=0.5; P=.001), vitamin C (OR=0.4; P=.001), and PUFA (OR=0.8; P=.01) administration were associated with significantly reduced incidence of AF. In terms of postoperative AKI, only NAC was shown to be a beneficial supplement that was able to significantly reduce the incidence of AKI (OR=0.7; P=.01), and NAC could also significantly decrease overall mortality (OR=0.3; P=.03) following cardiac surgery. The use of NAC in patients undergoing cardiac surgery should be strongly recommended due to its combined cardio-renal protective effects and reduced mortality. Also, PUFA and vitamin C might be able to significantly decrease the incidence of arrhythmia; however, reno-protective effects and impact on overall mortality of these supplements seem to be less impressive. K E Y W O R D SAcute renal injury, Atrial fibrillation, Cardiac surgery, N-acetylcysteine, Polyunsaturated fatty acids, Vitamin C

This systematic review with meta-analysis sought to determine the protective effects of corticosteroids on clinical outcomes following coronary artery bypass grafting (CABG). Medline, Embase, Elsevier and Sciences online database as well as Google scholar literature were used for selecting appropriate studies with randomized controlled design. The effect sizes measured were odds ratio (OR) for categorical variables and weighted mean difference with 95% confidence interval (CI) for calculating differences between mean values of duration of hospitalization in intervention and control groups. Values of P < 0.1 for Q-test or I(2) > 50% indicated significant heterogeneity between the studies. The literature search of all major databases retrieved 3735 studies. After screening, a total of 45 trials were identified that reported outcomes. Pooled analysis was performed on incidence of atrial fibrillation (OR of 0.71; 95% CI: 0.59-0.86; P = 0.000), stroke (OR of 1.61; 95% CI: 0.63-4.1; P = 0.3), infection (OR of 1.03; 95% CI: 0.68-1.5; P = 0.8), re-infarction (OR of 0.88; 95% CI: 0.47-1.63; P = 0.6), length of ventilation time [weighted mean difference (WMD) of 0.257; 95% CI: 0.10-0.41; P = 0.00], length of hospital stay (WMD of -0.48; 95% CI: -0.66 to -0.3; P = 0.000), amount of blood loss (WMD of -124.05; 95% CI: -147.72 to -100.38; P = 0.00), re-exploration (OR of 1.25; 95% CI: 0.66-2.35; P = 0.4) and mortality (OR of 0.87; 95% CI: 0.46-1.64; P = 0.6). Overall, steroid prophylaxis in patients undergoing CABG could significantly reduce complications such as atrial fibrillation and length of hospital stay, but slightly increased the length of ventilation time. On the other hand, no significant impact on the incidence of infection was observed compared with the placebo.

This systematic review with meta-analysis sought to determine the impact of posterior pericardiotomy on incidences of atrial fibrillation and supraventricular arrhythmias, pericardial effusion, pleural effusion, tamponade, and the length of hospital stay after cardiac surgery. We searched for randomized controlled trials, using Medline, Embase, Elsevier and Sciences online databases as well as Google Scholar literature. The effect sizes measured were odds ratio for categorical variables and standard mean difference with 95% confidence interval for calculating differences between mean values of hospital stay in intervention and control groups. A value of p < 0.1 for Q test or I(2 )> 50% indicated significant heterogeneity between the studies. The literature search of all major databases retrieved 20 studies. After screening, 12 suitable trials were identified, which reported outcomes of 2052 patients undergoing cardiac surgery. Posterior pericardiotomy had an odds ratio of 0.33 [95% confidence interval: 0.18-0.61] p < 0.001 for atrial fibrillation; odds ratio 0.32 [0.15-0.67] p = 0.003 for supraventricular arrhythmias; odds ratio 0.09 [0.04-0.19] p = 0.000 for early pericardial effusion and odds ratio 0.04 [0.02-0.08] p < 0.001 for late pericardial effusion; odds ratio 1.64 [1.23-2.20] p = 0.001 for pleural effusion, odds ratio 0.07 [0.02-0.27] p < 0.001 for tamponade, and standard mean difference = 0.01 [-0.12 to 0.14] p = 0.8 for hospital stay. Posterior pericardiotomy is a simple intraoperative technique that can improve postoperative clinical outcomes. However, the incidence of pleural effusion associated with posterior pericardiotomy might be higher.

Purpose:Atrial fibrillation (AF) is the most common type of arrhythmia following elective off-pump coronary bypass graft (CABG) surgery, occurring on the 2nd or 3rd postoperative day. Postoperative atrial fibrillation and early complications may be the cause of long term morbidity and mortality after hospital discharge. High sensitive C-reactive protein (hsCRP) seems to be most significantly associated with cardiovascular disorders. This study was designed to evaluate whether preoperative hsCRP (≥3 mg/dl) can predict post-elective off-pump CABG, AF, and early complications in patients with severe left ventricle dysfunction (Ejection Fraction (EF)<30%).Methods:This study was conducted on 104 patients with severe left ventriclar dysfunction (EF < 30%), undergoing elective off-pump CABG surgery during April to September 2011 at the Afshar Cardiovascular Center in Yazd, Iran. Patients undergoing emergency surgery and those with unstable angina, creatinine higher than 2.0 mg/dl, malignancy, or immunosuppressive disease were excluded from the study. The subjects were divided into two groups: Group I with preoperative increased hsCRP (>3 mg/dl) (n=51) and group N with preoperative normal hsCRP (<3 mg/dl) (n=53). We evaluated post-CABG variables including incidence, duration, and frequency of AF, early morbidity (bleeding, infection, vomiting, renal and respiratory dysfunctions), ICU or hospital stay and early mortality. Data were then analyzed by Analysis of Variance (ANOVA), Chi-square and Fisher exact test for quantitative and qualitative variables.Results:The average age of the patients was 62.5 years, 75 cases (72.1%) were male, and 39 (37.5%) were female. Postoperative AF occurred in 19 cases (18.2%); 17 cases (33.3%) had hsCRP≥3 mg/dl and 2 cases (3.8%) had hsCRP≤3 mg/dl (P=0.03). Postoperative midsternotomy infection, respiratory dysfunction, and hospital stay were significantly higher in group I compared with group N (P<0.05). No statistical significant differences were identified between the two groups concerning other postoperative complications (bleeding, vomiting, renal dysfunction and ICU stay) (P>0.05).Conclusion:Preoperative hsCRP ≥3 mg/dl can predict incidence of postoperative atrial fibrillation and early complications such as midsternotomy infection, respiratory dysfunction, and hospital stay following elective off-pump CABG.

Background:Atrial fibrillation (AF) is the most common arrhythmia after open heart surgery that can lead to early morbidity and mortality following operation. Mitral stenosis (MS) is a structural abnormality of the mitral valve apparatus that can be resulted from previous rheumatic fever or non-rheumatic fever such as congenital mitral stenosis, malignant carcinoid disease etc. This study was designed to test the hypothesis that type of mitral stenosis can affect the incidence, duration and frequency of AF post mitral valve replacement.Materials and Methods:We selected fifty patients with rheumatic mitral stenosis and 50 patients with non-rheumatic mitral stenosis who were candidates for mitral valve replacement (MVR) surgery. Pre-operative tests such as CRP, ESR, CBC, UA, ANA, APL (IgM, IgG), ANCA, RF were performed on participants’ samples and the type of mitral stenosis, rheumatic or non-rheumatic, was determined clinically. Early post-operative complications such as infection, bleeding, vomiting, renal and respiratory dysfunction etc., were recorded. All patients underwent holter monitoring after being out of ICU to the time of discharge.Results:The mean age of patients was 48.56 ± 17.64 years. 57 cases (57%) were male, and 43 cases (43%) were female. Post-operative AF occurred in 14 cases (14%); 3 cases (6%) in non-rheumatic mitral stenosis group, and 11 cases (22%) in the rheumatic mitral stenosis group. There was a significant relationship between the incidence of AF and type of mitral stenosis (P = 0.02). Renal dysfunction after MVR was higher in rheumatic MS group than in non-rheumatic MS group (P = 0.026). There was no relationship between the type of mitral stenosis (rheumatic or non-rheumatic) and early mortality after mitral valve replacement (P = 0.8).Conclusion:We concluded that the type of mitral stenosis affect post-operative outcomes, especially the incidence of atrial fibrillation and some complications after mitral valve replacement.