27 research outputs found
Activation of the coagulation system in coronary artery bypass grafting operation: comparison between on-pump and off-pump techniques
No full textObjective: Comparing peri-operative activation of the coagulation and fibrinolytic systems and platelet function in patients receiving CABG operation by means of on pump or off pump techniques. Methods: 32 consecutive patients requiring elective CABG were enrolled in the study and assigned in a randomized fashion to: on pump group or off pump group. Heparin was given at the same dose (300 U/kg) and antifibrinolytic drugs were not administered. Activation of the coagulation system was evaluated by means of Prothrombin Fragment 1.2 (PF-1.2) and Tissue Factor (TF) measurements; fibrinolysis was evaluated measuring Tissutal Plasminogen Activator (TPA), Plasminogen Activator Inhibitor-1 (PAI-1) and D-Dimer (D-D) formation. Platelets function was evaluated by means of the Platelet Function Analyzer (PFA-100®). Blood samples were collected at T0 (during induction of anesthesia), T1 (45 min after heparin administration), T2 (15 min after protamine administration), T3 (3 h after the end of the operation), T4 (postoperative day (POD) 1), T5 (POD4), and T6 (POD6). Results were corrected for haemodilution. Results: No statically significative differences were found in pre, peri and post-operative clinical characteristics between the two groups, except for heparinization time (on pump group 159.6±40.4 min; off pump group 121.6±35.7; P<0.05) and hemoglobin value at POD6 (on pump group 9.3±2.34 g/dl; off pump group 10.9±1.35 g/dl; P<0.05). The coagulation system was activated during cardiopulmonary bypass (CPB) and highest levels of PF-1.2 were measured at T1, T2 and T3 (P<0.05 compared with off pump group); a trend towards increased levels of PF-1.2 was observed in both groups at T4,T5 and T6. TF production was similar in the two groups and no statistically significative differences were found at any sample time. The fibrinolytic system was more activated in the on pump group as demonstrated by TPA levels at T1 (P<0.05), PAI-1 levels at T2 (P<0.05) and D-D levels at T2 and T3 (P<0.05). Not surprisingly, CPB induces platelet dysfunction; PFA-100 bleeding times were significantly elevated in on pump group at T1, T2 and T3 (P<0.05). PFA-100 bleeding postoperative times were not prolonged in both groups despite aspirin administration. Conclusions: Off-pump patients produce less activation of the coagulation system and do not activate fibrinolysis during the operation; their platelet function is preserved during and after the operation. This may explain the reported reduced rate of postoperative bleeding associated with this technique. The absence of fibrinolysis together with functioning platelets and increased thrombin formation postoperatively suggest that off pump patients may experience a pro-thrombotic state
Cardiac Troponin I release following coronary artery bypass surgery. Effects on operative and mid-term survival
No full textObjective: Myocardial infarction (MI) associated with coronary artery bypass grafting (CABG) operations represents a serious and relatively frequent peri-operative complication. Markers of myocardial necrosis are usually found elevated in patients undergoing coronary bypass operation with cardiac arrest. Cardiac troponin I (cTnI) is the preferred marker to detect acute myocardial ischemia. Its ability to predict short and, particularly, midterm outcome following coronary bypass operations is uncertain. The aim of the presented study is to assess the role of postoperative cTnI in predicting in-hospital and mid-term outcome in non-selected patients undergoing CABG and to suggest a critical use of cTnI to improve post-operative care of patients with elevated troponin release. Methods: Between May 2000 and February 2003, 230 unselected patients undergoing surgical revascularization had cTnI measured preoperatively and 11 times postoperatively. Patients with unstable angina and recent MI (<7 days) were included in the study. Patients undergoing aortic dissection surgery and those undergoing heart valve procedures with associated CABG as well as patients transferred on emergency in the operative room following complicated percutaneous coronary intervention were excluded. A receiver operating characteristics (ROC) curve was constructed using cTnI postoperative peak values to assess prognostic specificity and sensitivity of the test. 13 ng/ml is the cut-off value used to assess the prognostic significance of peak cTnI postoperative release for short and mid-term outcome for mortality and hospitalization for cardiac causes. Mean and maximal follow-up were 22.6±10.7 and 48.3 months, completeness 90%. Results: 146 patients (63.5%) had postoperative cTnI peak values <13 ng/ml (mean peak value 6.6±3.1 ng/ml), 84 patients (36.5%) had postoperative cTnI peak values >13 ng/ml (mean peak value 45.5±59.9 ng/ml). Patients with peak cTnI >13 ng/ml were older, had lower body mass index and had higher preoperative cTnI values. They required longer cross-clamp time and CPB time. Post-operative results are shown. Hospital death was significantly higher in cTnI >13 ng/ml group (9.5% vs. 0.7%, P = 0.0009). = 0.0009). Multivariate analysis showed that cTnI >13 ng/ml was the only independent predictor of hospital death (OR 10.33, P = 0.04) and hospital death for = 0.04) and hospital death for cardiac causes. Two years follow-up demonstrate that cTnI postoperative release had no influence on mid-term mortality and hospitalization for cardiac causes.Conclusions: The presented is the largest study reporting mid-term survival for CABG patients based on postoperative cTnI release. CTnI is a valuable marker for immediate myocardial damage following coronary bypass operations. CTnI postoperative release does not predict mid-term outcome
Antithrombin after cardiac surgery: Implications on short and mid-term outcome
No full textBackgrounds: Antithrombin (AT) drop during cardiac surgery has been described. The causes and the effects of this phenomenon are not clear. The objective of the study is to evaluate the relationship of AT postoperative values on short and mid-term outcome after cardiac surgery. Methods: Between January and June 2005, 405 patients, who underwent cardiac operations at our Institution had AT values available preoperatively and postoperatively. Using Receiver Operating Characteristic curves, a cut-off equal to 63.7% for ICU-arrival AT was chosen in order to divide the entire population in two groups (117 patients with ICU-arrival AT < 63.7%, Low AT group, and 288 patients with ICU-arrival AT > 63.7%, High AT group). Objective of the study was to evaluate the predictive role of ICU-arrival AT < 63.7% on in-hospital mortality and morbidity and on 18 months follow-up after cardiac surgery. Results: ICU-arrival AT was significantly lower than preoperative AT (90.7 ± 16.3% vs. 71.2 ± 15.1%, P < 0.0001). Patients in the Low AT group were older, more often female, had a worse Euroscore and required longer CPB duration and cross clamp time. They had significantly higher preoperative and postoperative d-dimer levels. ICU arrival AT < 63.7% was not associated with increased in-hospital mortality but it was an independent risk factor for longer mechanical ventilation, need of inotropic support, excessive bleeding and blood products transfusion. ICU arrival-AT < 63.7% was associated with worse survival during 18 months follow up (92.3% vs. 85.4% in the High AT and Low AT group, respectively, P = 0.05). Conclusions: Low AT after cardiac surgery is associated with higher incidences of peri-operative complications and worse survival in the mid-term. Future studies should clarify the pathophysiologic mechanism of this findings and possible therapeutic directions. © Springer Science+Business Media, LLC 2008
Perioperative inflammatory, coagulative and fibrinolytic state in patients having an operation for acute Type A aortic dissection
No full textMyocardial injury after off-pump coronary artery bypass grafting operation
No full textObjective: Perioperative myocardial ischemia is less pronounced in off-pump coronary artery bypass (OPCAB) compared to on-pump coronary artery bypass; however, the threshold over which the postoperative release of cardiac troponin I (cTnI) release and creatine kinase-MB (CK-MB) after OPCAB should be considered clinically relevant is unknown. The study was designated to evaluate if perioperative myocardial damage, measured by means of postoperative release of cTnI and CK-MB, has an influence on short- and mid-term outcome after OPCAB operations. Methods: Two hundred and sixty-one unselected patients undergoing OPCAB had cTnI and CK-MB measured preoperatively and nine times postoperatively. Postoperative peak values were evaluated and the 80th percentiles were used to segregate the population into two groups for each marker. The following cut-offs were used: 7.1 ng/dl for cTnI peak and 36.3 ng/dl for CK-MB peak. Results: Patients with cTnI>7.1 ng/ml (n=51) and CK-MB>36.3 ng/ml (n=48) had a longer mechanical ventilation and ICU length of stay. Nevertheless, hospital mortality did not differ between groups. Survival after 3 years was 92.8+/-2.3% and 81.8+/-6.2 for patients with postoperative cTnI peak7.1 ng/ml, respectively (p=0.003). It was 93+/-2.2% and 80+/-6.8% for patients with CK-MB36.3 ng/ml, respectively (p=0.005). Adjusted hazard ratios for mid-term mortality were HR 2.7 (CI 1-7.6), p=0.05 for cTnI>7.1 ng/dl and HR 3.1 (CI 1-9.1), p=0.04 for CK-MB>36.3 ng/ml. Conclusion: Perioperative myocardial damage should not be considered an innocuous event following OPCAB operations since the survival rate over 3 years is significantly worse in patients with the highest postoperative peak release of cTnI and CK-MB
Preoperative Cardiac Troponin I to Assess Midterm Risks of Coronary Bypass Grafting Operations in Patients With Recent Myocardial Infarction
No full textBackground: The optimal timing for coronary artery bypass grafting (CABG) in patients with recent acute myocardial infarction (AMI) is unclear. Cardiac troponin I (cTnI) is a widely accepted biomarker of myocardial damage. The objective of this study was to determine whether preoperative cTnI values could be used to determine risk stratification for CABG operations in patients with recent AMI. Methods: Evaluated were 184 patients who sustained an AMI within 21 days of undergoing nonurgent CABG operations. They were divided into two groups according to their preoperative cTnI values: 117 patients with cTnI of 0.15 ng/mL or less and 67 with cTnI exceeding 0.15 ng/mL. Associations between study variables and events were assessed with logistic regression modelling. Time from AMI to operation was evaluated to define preoperative cTnI variation. Results: Values of cTnI tended to decrease when the interval between AMI and the operation increased. Preoperative cTnI values were significantly associated with a higher incidence of major postoperative complications (low cardiac output syndrome, intraaortic balloon pump necessity, mechanical ventilation >72 hours, acute renal failure, in-hospital mortality). Perioperative myocardial damage was more pronounced in patients with cTnI exceeding 0.15 ng/mL. Multivariate analyses revealed cTnI exceeding 0.15 ng/mL was an independent predictor for 6-month mortality (odds ratio, 3.7; p = 0.043). Conclusions: Preoperative cTnI exceeding 0.15 ng/mL in patients with recent AMI undergoing CABG is associated with higher postoperative myocardial damage and is a strong determinant of postoperative morbidity and mortality within the 6-month period
Updated Perspectives on the Diagnosis and Management of Familial Adenomatous Polyposis
No full textFilippos Kyriakidis,1,* Dionysios Kogias,2,* Theodora Maria Venou,1,* Eleni Karlafti,3,4 Daniel Paramythiotis5 1Second Chemotherapy Department, Theagenio Cancer Hospital of Thessaloniki, Thessaloniki, Greece; 2First Department of Internal Medicine, University General Hospital of Alexandroupolis, Alexandroupolis, Greece; 3Emergency Department, AHEPA General University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; 4First Propaedeutic Department of Internal Medicine, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, Thessaloniki, Greece; 5First Propaedeutic Surgery Department, AHEPA University General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece*These authors contributed equally to this workCorrespondence: Filippos Kyriakidis, Tel +30 6984996573, Email [email protected]: Familial adenomatous polyposis (FAP) is an autosomal dominant cancer predisposition syndrome marked by extensive colorectal polyposis and a high risk of colorectal cancer (CRC). Having access to screening and enrollment programs can improve survival for patients with FAP by enabling them to undergo surgery before the development of colorectal cancer. Provided that there are a variety of surgical options available to treat colorectal polyps in patients with adenomatous polyposis, the appropriate surgical option for each patient should be considered. The gold-standard treatment to reduce this risk is prophylactic colectomy, typically by the age of 40. However, colectomy is linked to morbidity and constitutes an ineffective way at preventing extra-colonic disease manifestations, such as desmoid disease, thyroid malignancy, duodenal polyposis, and cancer. Moreover, extensive studies have been conducted into the use of chemopreventive agents to prevent disease progression and delay the necessity for a colectomy as well as the onset of extracolonic disease. The ideal chemoprevention agent should demonstrate a biologically plausible mechanism of action and provide safety, easy tolerance over an extended period of time and a lasting and clinically meaningful effect. Although many pharmaceutical and non-pharmaceutical products have been tested through the years, there has not yet been a chemoprevention agent that meets these criteria. Thus, it is necessary to develop new FAP agents that target novel pathways, such as the mTOR pathway. The aim of this article is to review the prior literature on FAP in order to concentrate the current and future perspectives of diagnosis and treatment. In conclusion, we will provide an update on the diagnostic and therapeutic options, surgical or pharmaceutical, while focusing on the potential treatment strategies that could further reduce the risk of CRC.Keywords: FAP, colorectal cancer, surveillance, genetic testing, surgery, chemopreventio
Detection of oncogenes in chronic pancreatitis
No full textBackgroundThe pathogenesis of chronic pancreatitis (CP) remains poorly understood. Recently, molecular biology has identified the genetic background for many patients with hereditary CP. In addition, a number of studies have focused on the detection of proto‐oncogenes and tumour suppressor gene mutations in the pathogenesis of CP. So far, the use of these mutations (with the exception of mutations causing hereditary CP), as diagnostic and prognostic markers is still controversial.DiscussionIt is well known that the risk of pancreatic cancer in patients with CP, especially the hereditary form, is high. At present, there is insufficient evidence to show a clear relationship between the development of pancreatic cancer and certain mutations. New biotechnological methods, such as DNA array expression analysis, expand our knowledge of the molecular pathogenesis of this disease and may help to develop specific diagnostic, prognostic and therapeutic tools. However, until long‐term studies examine the safety and efficacy of certain genetic markers, long‐term follow‐up of patients with CP who harbour mutations is needed
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Pheochromocytoma crisis presenting with cardiogenic shock
No full textPheochromocytoma is a catecholamine-secreting tumor of the adrenal glands whose typical presentation includes the triad of headache, palpitations, and diaphoresis. Pheochromocytoma crisis is an urgent medical condition whose diagnosis and management constitute a challenge for physicians. We present the case of a 55-year-old man who developed cardiogenic shock in the setting of a pheochromocytoma crisis. After stabilizing blood pressure with combined administration of α- and β-blockers, the tumor was surgically removed. Our diagnostic and therapeutic challenges are discussed
