1,721,016 research outputs found
Acute respiratory distress syndrome after cardiac surgery
No full textAcute respiratory distress syndrome (ARDS) is a leading cause of postoperative respiratory failure, with a mortality rate approaching 40% in the general population and 80% in the subset of patients undergoing cardiac surgery. The increased risk of ARDS in these patients has traditionally been associated with the use of cardiopulmonary bypass (CPB), the need for blood product transfusions, large volume shifts, mechanical ventilation and direct surgical insult. Indeed, the impact of ARDS in the cardiac population is substantial, affecting not only survival but also in-hospital length of stay and long-term physical and psychological morbidity. No patient undergoing cardiac surgery can be considered ARDS risk-free. Early identification of those at higher risk is crucial to warrant the adoption of both surgical and non-surgical specific preventative strategies. The present review focuses on epidemiology, risk assessment, pathophysiology, prevention and management of ARDS in the specific setting of patients undergoing cardiac surgery
Considerations about the Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) trial
No full textN/
Open repair of descending and thoracoabdominal aortic aneurysms in octogenarians
No full textObjective: Despite improved outcomes for open repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA), these operations remain challenging in octogenarians. Patients unsuitable for thoracic endovascular aortic repair require open surgery to avoid catastrophic rupture. We analyzed our results for DTA/TAAA repair in these elderly patients. Methods: Our institutional aortic database was queried to identify those ≥80 years old and those <80 years old undergoing open DTA/TAAA repair. Logistic and Cox regression analyses were used to account for confounders and to identify predictors of perioperative and long-term outcomes. Results: From 1997 to 2017, there were 783 patients who underwent open repair of DTA or TAAA; 96 (12.3%) were ≥80 years old. Octogenarians were more likely to be female (P =.018), with chronic pulmonary disease (P =.012), severe peripheral vascular disease (P <.001), and hypertension (P =.025). Degenerative aneurysms were more common among octogenarians (P <.001), whereas chronic and acute dissections were more common among those younger than 80 years (P <.001 for both). Operative mortality was 5.6% and was not negatively affected by advanced age (<80 years, 5.7%; ≥80 years, 5.6%; P =.852). Other than an increased incidence of left recurrent nerve palsy in the younger cohort (<80 years, 6.7%; ≥ 80 years, 1.0%; P =.029), there were no significant differences in the incidence of major postoperative complications. Logistic regression modeling showed that age ≥80 years was not predictive of operative mortality or postoperative complications. A greater percentage of octogenarians had aortic reconstruction with a clamp and sew strategy (85.4% vs 61.6%; P <.001), which led to significantly shorter cross-clamp times in this cohort (26.6 minutes vs 30.7 minutes; P <.004). In octogenarians, the incidence of major postoperative adverse events was associated with extent II aneurysms (odds ratio, 2.6; P <.025). Short- and long-term survival was significantly reduced in octogenarians. Conclusions: In select octogenarians, open repair of DTA/TAAA can be performed with acceptable risk. A simplified surgical approach may provide the best opportunity for a successful outcome
Secondary prevention for CABG patients: take two arterial grafts at the time of your coronary operation
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Comparison of SYNTAX score strata effects of percutaneous and surgical revascularization trials. A meta-analysis
No full textObjectives: The evidence supporting the use of the Synergy Between Percuta-neous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) score for risk stratification is controversial. We performed a systematic review and meta-analysis of all the randomized controlled trials comparing percutaneous cor-onary intervention versus coronary artery bypass grafting that reported their out-comes stratified by SYNTAX score, focusing on between-strata comparisons.Methods: A systematic review of MEDLINE, EMBASE, Cochrane Library databases was performed. Incidence rate ratios were pooled with a random effect model. Between-group statistical heterogeneity according to accepted SYNTAX score tertiles was computed in the main analysis. Ratios of incidence rate ratios were computed to appraise between-strata effect, as sensitivity analysis. Primary and secondary out-comes were major adverse cardiac and cerebrovascular events and all-cause mortality, respectively. Separate sub-analyses were performed for left main and multivessel disease.Results: From 425 citations, 6 trials were eventually included (8269 patients [4134 percu-taneous coronary interventions, 4135 coronary artery bypass graftings]; mean follow-up: 6.2 years [range: 3.8-10]). Overall, percutaneous coronary intervention was associated with a significant increase in major adverse cardiac and cerebrovascular events (inci-dence rate ratio, 1.39, 95% confidence interval, 1.27-1.51) and nonsignificant increase in all-cause mortality (incidence rate ratio, 1.17, 95% confidence interval, 0.98-1.40). There was no significant statistical heterogeneity of treatment effect by SYNTAX score for ma-jor adverse cardiac and cerebrovascular events or mortality (P = .40 and P = .34, respec-tively). Results were consistent also for patients with left main and multivessel disease (major adverse cardiac and cerebrovascular events: P = .85 in left main, P = .78 in multi-vessel disease 0.78; mortality: P = .12 in left main; P = .34 in multivessel disease). Results of analysis based on ratios of incidence rate ratios were consistent with the main analysis.Conclusions: No significant association was found between SYNTAX score and the comparative effectiveness of percutaneous coronary intervention and coronary artery bypass grafting. These findings have implications for clinical practice, future guidelines, and the design of percutaneous coronary intervention versus coronary artery bypass grafting trials. (J Thorac Cardiovasc Surg 2023;165:1405-13
Poor tolerance and limited effects of isosorbide-5-mononitrate in microvascular angina
No full textOBJECTIVES:
To assess the effects of isosorbide-5-mononitrate (ISMN) in patients with microvascular angina (MVA).
METHODS:
We randomized 20 MVA patients, treated with a β-blocker or a calcium antagonist, to 60 mg slow-release ISMN (halved to 30 mg if not tolerated) or placebo once a day for 4 weeks; the patients were then switched to the other treatment for another 4 weeks. Their clinical status was assessed with the Seattle Angina Questionnaire (SAQ) and the EuroQoL score for quality of life. The exercise stress test (EST), coronary blood flow (CBF) response to nitrate and the cold pressor test (CPT), brachial artery flow-mediated dilation (FMD) and nitrate-mediated dilation (NMD) were also assessed.
RESULTS:
Nine patients (45%) did not complete the ISMN phase due to side effects; 2 patients refused a follow-up. Nine patients completed the study. The SAQ and EuroQoL scores were significantly better with ISMN than with placebo, although the differences were small. No differences were found between the treatments in the EST results, CBF response to nitroglycerin (p = 0.55) and the CPT (p = 0.54), FMD (p = 0.26) and NMD (p = 0.35).
CONCLUSIONS:
In this study, a high proportion of MVA patients showed an intolerance to ISMN; in those tolerating the drug, significant effects on their angina status were observed, but the benefit appeared to be modest and independent of effects on coronary microvascular function
Statistical primer. Individual patient data meta-analysis and meta-analytic approaches in case of non-proportional hazards
No full textIndividual patient data (IPD) meta-analyses build upon traditional (aggregate data) meta-analyses by collecting IPD from the individual studies rather than using aggregated summary data. Although both traditional and IPD meta-analyses produce a summary effect estimate, IPD meta-analyses allow for the analysis of data to be performed as a single dataset. This allows for standardization of exposure, outcomes, and analytic methods across individual studies. IPD meta-analyses also allow the utilization of statistical methods typically used in cohort studies, such as multivariable regression, survival analysis, propensity score matching, uniform subgroup and sensitivity analyses, better management of missing data, and incorporation of unpublished data. However, they are more time-intensive, costly, and subject to participation bias. A separate issue relates to the meta-analytic challenges when the proportional hazards assumption is violated. In these instances, alternative methods of reporting time-to-event estimates, such as restricted mean survival time should be used. This statistical primer summarizes key concepts in both scenarios and provides pertinent examples
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Systematic reviews and meta-analyses in cardiac surgery: rules of the road - 2
No full textIn the era of evidence-based medicine, systematic reviews and meta-analyses are considered at the top of evidence hierarchy. Despite the almost exponential increase in the number of published meta-analyses over the course of the last decades, only a small minority of them is of high quality, with major flaws involving every aspect of the meta-analytic process. The strength of a meta-analysis is closely linked to the quality of the included studies. Once preliminary phases are completed, it is vital that selected papers undergo a thorough quality assessment, using the most appropriate tools among those available. Analytical approaches must be tailored to the nature of the extracted data and the specific purpose of the meta-analysis. Appraisal of heterogeneity is a key step to inform subgroup or meta-regression analyses. The solidity of the results of the main analysis (especially in meta-analyses of observational studies or studies with high heterogeneity) should be tested by means of pertinent sensitivity analyses. Finally, the investigators should be aware of the possibility of publication bias and make efforts to assess it using qualitative and quantitative methods. The aim of the second part of this expert review is to provide guidance on how to appropriately perform trial level meta-analyses, with particular focus on the quality assessment of the included studies, the choice of the appropriate statistical approach, the methods to deal with heterogeneity (including subgroup, meta-regression and sensitivity analyses), and the appraisal of publication bias
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