431 LONG-TERM ATRIO-VENTRICULAR BLOCK FOLLOWING VALVE SURGERY: ELECTROCARDIOGRAPHIC AND SURGICAL PREDICTORS
Jacopo FarinaMauro BiffiCarlo SaviniSofía Sol MartínLuca Di MarcoGianluca FolesaniMatteo ZiacchiIgor DiembergerCristian MartignaniDavide Pacini
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Abstract Background Bradyarrhythmias requiring pacemaker implantation (PM) in patients undergoing valve surgery may occur even after several years. The incidence of PM implantation after valve surgery and its predictors are unclear. Methods A retrospective, monocentric, cohort study was conducted. Consecutive patients undergoing valve surgery at the Division of Cardiac Surgery at the Bologna University Hospital from 2005 to 2010 were enrolled. The primary endpoint of the study was to evaluate the incidence of PM implantation in patients undergoing valve surgery, at different follow-up times, and to evaluate the predictors of PM implantation. Results We included 1046 patients (61.8% male, median age 63 years). Of these 735 (70%) reached a 10 year of follow-up and 11.4% required PM implantation. In single valve surgery, mitral interventions had a higher incidence of PM implantation compared to aortic ones, albeit not significantly different (11% vs 8.1%, HR 1.2, IC 95% 0.6-2.1, p=0.590). Among combined surgery, interventions on both atrioventricular valves doubled the risk compared to those performed on aortic and mitral valves (23.1% vs 12%). Moreover, interventions involving both atrioventricular valves independently predicted PM implantation in the long term (HR 2.0, IC 95% 1.1-3.7, p=0.022). Preoperative atrioventricular conduction disease strongly predicted long-term atrio-ventricular block: right bundle branch block with or without left anterior fascicular block (LAFB) was the major predictor (HR 7.2, IC 95% 2.8-19, p<0.001, HR 6.8, IC 95% 3.9-11.7, p<0.001 respectively), followed by left bundle branch block (HR 5.1, IC 95% 2.6-10.3, p<0.001), LAFB (HR 4.2, IC 95% 1.9-8.9, p<0.001) and a non-specific ventricular conduction delay (HR=3.3, IC 95% 1.3-8.4, p=0.012). Age was also predictive, PM implantation probability increasing at each year-age increase (HR 1.02, IC 95% 1.01-1.04, p=0.022) Conclusions Patients undergoing valvular surgery have a continuing risk of atrioventricular block requiring PM therapy late after surgery; combined surgery on atrio-ventricular valves carries the highest risk, while preoperative atrioventricular conduction disease have different risks of AVB at long-term.Keywords:
Atrioventricular block
Cardiothoracic surgery
Vascular surgery
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Background: Cardiac conduction disease is often progressive and requires pacemaker implantation at advanced stages. However, the predictive ability of electrocardiographic abnormalities for pacemaker is not well investigated. Methods and Results: This prospective, community-based, observational cohort study was based on annual health examinations. We studied the association of electrocardiographic abnormalities with the risk of development of complete atrioventricular block. Participants with complete atrioventricular block at baseline were excluded. A total of 180,152 participants (age, 59 ± years; 122,457 women) were included in this study. During a follow-up of 8.8 ± 4.4 years, 127 participants (0.07%) developed complete atrioventricular block. In multivariate models, male gender, age, first-degree atrioventricular block, second-degree atrioventricular block, left bundle branch block, electrocardiographic left ventricular hypertrophy, and atrial fibrillation, but not right bundle branch block, were ass...
Atrioventricular block
Bundle branch block
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We investigated if elevated cardiac troponin I (cTnI) serum levels before non-cardiac surgery were predictors of postoperative cardiac events in patients with end stage renal disease (ESRD) undergoing dialysis. In total, 703 consecutive patients with ESRD undergoing dialysis who underwent non-cardiac surgery were enrolled. Preoperative cTnI serum levels were measured at least once in all patients. The primary endpoint was defined as a composite of cardiac death, myocardial infarction (MI), and pulmonary edema during hospitalization or within 30 days after surgery in patients with a hospitalization longer than 30 days after surgery. Postoperative cardiac events occurred in 48 (6.8%) out of 703 patients (cardiac death 1, MI 18, and pulmonary edema 33). Diabetes mellitus (DM), previous ischemic heart disease, and congestive heart failure were more common in patients with postoperative cardiac events. Peak cTnI serum levels were higher in patients with postoperative cardiac event (180 ± 420 ng/L vs. 80 ± 190 ng/L, p = 0.008), and also elevated peak cTnI levels > 45 ng/L were more common in patients with postoperative cardiac events (66.8% vs. 30.5%, p < 0.001). Multivariate logistic regression analysis showed that DM (odds ratio [OR] 2.509, 95% confidence interval [CI] 1.178-5.345, p = 0.017) and serum peak cTnI levels ≥ 45 ng/L (OR 3.167, 95% CI 1.557-6.444, p = 0.001) were independent predictors for the primary outcome of cardiac death/MI/pulmonary edema. Moreover, cTnI levels ≥ 45 ng/L had an incremental prognostic value to the revised cardiac risk index (RCRI) (Chi-square = 23, p < 0.001), and to the combined RCRI and left ventricular ejection fraction (Chi-square = 12, p = 0.001). Elevated preoperative cTnI levels are predictors of postoperative cardiac events including cardiac death, MI, and pulmonary edema in patients with ESRD undergoing non-cardiac surgery.
Vascular surgery
Cardiothoracic surgery
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Summary: Atrioventricular block (A-V block) was documented in 150 (13.8%) of 1083 patients with acute myocardial infarction. Those with A-V block differed significantly from the remainder, being older, having higher peak levels of serum lactic dehydrogenase and a greater incidence of left ventricular failure and of death in hospital. These differences were due mainly to the inclusion of 90 patients with complete heart block (CHB). Among those patients whose CHB complicated anterior infarction there was a significantly greater incidence of previous infarction. Lesser grades of A-V block and right bundle branch block (RBBB) commonly heralded the onset of CHB, which occurred more frequently in those with inferior infarction. Markers of death in those with CHB were anterior infarction, RBBB, and a slow subsidiary pacemaker with a wide ventricular complex. Pacing is recommended for all patients with CHB and for those with RBBB; the reasons for this are presented in detail.
Atrioventricular block
Bundle branch block
Lactic dehydrogenase
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A review of extracorporeal membrane oxygenation in child after cardiac surgery: analyses of outcomes
Results Age and weight were 12 ± 17months and 6.4 ± 3.3kg, respectively. Twenty patients had single ventricle and 38 had biventricular physiology. The duration of ECMO was 8.4 ± 4.4 days. Fifty-two (84%) were successfully weaned off ECMO and 34 (55%) survived to hospital discharge. The weaning from ECMO was affected by peak serum lactate during ECMO (risk ratio = 1.02, 95% CI: 1.003-1.036, p = 0.0181) and the diagnosis of isomerism (46, 0.0004-0.41, 0.0085) by multivariate analysis. Indication for ECMO and surgical procedures were not significant predictors. Factors associate with failure of hospital discharge despite successful decannulation were as follows: weight (0.32, 0.14-0.62, 0.0001), ECMO duration (1.3, 1.02-1.72, 0.0352), the duration of the day between decannulation and the first day of negative water balance after ECMO (1.3, 1.13-1.54, 0.0001), the use of nitric oxide gas after ECMO (8.4, 1.81-46.66, 0.0068). Survivor vs. non-survivor to the hospital discharge was 7.1 ± 4.1 vs. 10.0 ± 4.2 (days) in ECMO duration (p = 0.0073) and 2.1 ± 1.5 vs. 8.3 ± 10.2 (days) in the negative water balance (p = 0.0004).
Cardiothoracic surgery
Extracorporeal circulation
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Uncontrolled diabetes mellitus increases morbidity and mortality after cardiac surgery. Haemoglobin A1c (Hb A1c) is used to measure long-term glucose control. There have been reports of a higher incidence of wound infections with uncontrolled Hb A1c levels in patients undergoing cardiac surgery.
Cardiothoracic surgery
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Cardiothoracic surgery
Vascular surgery
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Background/IntroductionCardiac surgery service is dependent on the availability of cardiac intensive care facility.some patients are eligible for fast-track protocol.We investigate the factors determining prolonged intensive care stay following cardiac surgery, with the view to developing a model that predicts prolonged stay. Aims/ObjectivesDevelop a scoring model that predicts prolonged intensive care stay following cardiac surgery
Cardiothoracic surgery
Fast track
Vascular surgery
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Logistic EuroSCORE overestimates the risk profile of octogenarians undergoing aortic valve replacement by traditional surgery. EuroSCORE II, that was created in an attempt to improve this previous version, has been evaluated in the general population. However, to our knowledge, there are no studies evaluating the predictive performance of EuroSCORE II in the elderly population undergoing surgery for aortic valve replacement despite the fact that the majority of patients receiving transcatheter techniques are octogenarians and this new version is being used for the selection of high-risk surgical patients.
EuroSCORE
Cardiothoracic surgery
Valve replacement
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Objective:To disuss the diagnosis and treatment of severe atrioventricular block resulted from myocarditis in pediatrics. Methods: 2 pediatric patients with serious atrioventricular block resulted from myocarditis were treated with 1-3 months follow-up. Results: One case was cured and the other showed improvement. Conclusion: Once a patient was confirmed by electrocardiogram (ECG) as severe atrioventricular block, medication should be applied in time and if necessary, temporary pacemaker installment as well.
Atrioventricular block
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