| 1. |
- Barbu, Mikael, et al.
(författare)
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Cardiopulmonary bypass management and acute kidney injury in cardiac surgery patients.
- 2024
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Ingår i: Acta anaesthesiologica Scandinavica. - 1399-6576. ; 68:3, s. 328-336
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Tidskriftsartikel (refereegranskat)abstract
- Cardiopulmonary bypass (CPB) ensures tissue oxygenation during cardiac surgery. New technology allows continuous registration of CPB variables during the operation. The aim of the present investigation was to study the association between CPB management and the risk of postoperative acute kidney injury (AKI).This observational study based on prospectively registered data included 2661 coronary artery bypass grafting and/or valve patients operated during 2016-2020. Individual patient characteristics and postoperative outcomes collected from the SWEDEHEART registry were merged with CPB variables automatically registered every 20s during CPB. Associations between CPB variables and AKI were analyzed with multivariable logistic regression models adjusted for patient characteristics.In total, 387 patients (14.5%) developed postoperative AKI. After adjustments, longer time on CPB and aortic cross-clamp, periods of compromised blood flow during aortic cross-clamp time, and lower nadir hematocrit were associated with the risk of AKI, while mean blood flow, bladder temperature, central venous pressure, and mixed venous oxygen saturation were not. Patient characteristics independently associated with AKI were advanced age, higher body mass index, hypertension, diabetes mellitus, atrial fibrillation, lower left ventricular ejection fraction, estimated glomerular filtration rate<60 or>90mL/min/m2 , and preoperative hemoglobin concentration below or above the normal sex-specific range.To reduce the risk of AKI after cardiac surgery, aortic clamp time and CPB time should be kept short, and low hematocrit and periods of compromised blood flow during aortic cross-clamp time should be avoided if possible.
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| 2. |
- Herrmann, Florian E M, 1990, et al.
(författare)
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Recurrence of Atrial Fibrillation in Patients With New-Onset Postoperative Atrial Fibrillation After Coronary Artery Bypass Grafting.
- 2024
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Ingår i: JAMA network open. - 2574-3805. ; 7:3
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Tidskriftsartikel (refereegranskat)abstract
- New-onset postoperative atrial fibrillation (POAF) occurs in approximately 30% of patients undergoing coronary artery bypass grafting (CABG). It is unknown whether early recurrence is associated with worse outcomes.To test the hypothesis that early AF recurrence in patients with POAF after CABG is associated with worse outcomes.This Swedish nationwide cohort study used prospectively collected data from the SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) registry and 3 other mandatory national registries. The study included patients who underwent isolated first-time CABG between January 1, 2007, and December 31, 2020, and developed POAF. Data analysis was performed between March 6 and September 16, 2023.Early AF recurrence defined as an episode of AF leading to hospital care within 3 months after discharge.The primary outcome was all-cause mortality. Secondary outcomes included ischemic stroke, any thromboembolism, heart failure hospitalization, and major bleeding within 2 years after discharge. The groups were compared with multivariable Cox regression models, with early AF recurrence as a time-dependent covariate. The hypothesis tested was formulated after data collection.Of the 35329 patients identified, 10609 (30.0%) developed POAF after CABG and were included in this study. Their median age was 71 (IQR, 66-76) years. The median follow-up was 7.1 (IQR, 2.9-9.0) years, and most patients (81.6%) were men. Early AF recurrence occurred in 6.7% of patients. Event rates (95% CIs) per 100 patient-years with vs without early AF recurrence were 2.21 (1.49-3.24) vs 2.03 (1.83-2.25) for all-cause mortality, 3.94 (2.92-5.28) vs 2.79 (2.56-3.05) for heart failure hospitalization, and 3.97 (2.95-5.30) vs 2.74 (2.51-2.99) for major bleeding. No association between early AF recurrence and all-cause mortality was observed (adjusted hazard ratio [AHR], 1.17 [95% CI, 0.80-1.74]; P=.41). In exploratory analyses, there was an association with heart failure hospitalization (AHR, 1.80 [95% CI, 1.32-2.45]; P=.001) and major bleeding (AHR, 1.92 [1.42-2.61]; P<.001).In this cohort study of early AF recurrence after POAF in patients who underwent CABG, no association was found between early AF recurrence and all-cause mortality. Exploratory analyses showed associations between AF recurrence and heart failure hospitalization, oral anticoagulation, and major bleeding.
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| 3. |
- Martinsson, Andreas, et al.
(författare)
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Renin-angiotensin system inhibition after surgical aortic valve replacement for aortic stenosis.
- 2024
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Ingår i: Heart (British Cardiac Society). - 1468-201X. ; 110:3, s. 202-208
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Tidskriftsartikel (refereegranskat)abstract
- The optimal medical therapy after surgical aortic valve replacement (SAVR) for aortic stenosis remains unknown. Renin-angiotensin system (RAS) inhibitors could potentially improve cardiac remodelling and clinical outcomes after SAVR.All patients undergoing SAVR due to aortic stenosis in Sweden 2006-2020 and surviving 6 months after surgery were included. The primary outcome was major adverse cardiovascular events (MACEs; all-cause mortality, stroke or myocardial infarction). Secondary endpoints included the individual components of MACE and cardiovascular mortality. Time-updated adjusted Cox regression models were used to compare patients with and without RAS inhibitors. Subgroup analyses were performed, as well as a comparison between angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs).A total of 11894 patients (mean age, 69.5 years, 40.4%women) were included. Median follow-up time was 5.4 (2.7-8.5) years. At baseline, 53.6% of patients were dispensed RAS inhibitors, this proportion remained stable during follow-up. RAS inhibition was associated with a lower risk of MACE (adjusted hazard ratio (aHR) 0.87 (95% CI 0.81 to 0.93), p<0.001), mainly driven by a lower risk of all-cause death (aHR 0.79 (0.73 to 0.86), p<0.001). The lower MACE risk was consistent in all subgroups except for those with mechanical prostheses (aHR 1.07 (0.84 to 1.37), p for interaction=0.040). Both treatment with ACE inhibitors (aHR 0.89 (95% CI 0.82 to 0.97)) and ARBs (0.87 (0.81 to 0.93)) were associated with lower risk of MACE.The results of this study suggest that medical therapy with an RAS inhibitor after SAVR is associated with a 13% lower risk of MACE and a 21% lower risk of all-cause death.
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| 4. |
- Sultanian, Pedram, et al.
(författare)
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Early ICD implantation following out-of-hospital cardiac arrest: a retrospective cohort study from the Swedish Registry for Cardiopulmonary Resuscitation.
- 2024
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Ingår i: BMJ open. - 2044-6055. ; 14:2
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Tidskriftsartikel (refereegranskat)abstract
- It is unclear whether an implantable cardioverter-defibrillator (ICD) is generally beneficial in survivors of out-of-hospital cardiac arrest (OHCA).We studied the association between ICD implantation prior to discharge and survival in patients with cardiac aetiology or initial shockable rhythm in OHCA.We conducted a retrospective cohort study in the Swedish Registry for Cardiopulmonary Resuscitation. Treatment associations were estimated using propensity scores. We used gradient boosting, Bayesian additive regression trees, neural networks, extreme gradient boosting and logistic regression to generate multiple propensity scores. We selected the model yielding maximum covariate balance to obtain weights, which were used in a Cox regression to calculate HRs for death or recurrent cardiac arrest.All cases discharged alive during 2010 to 2020 with a cardiac aetiology or initial shockable rhythm were included. A total of 959 individuals were discharged with an ICD, and 2046 were discharged without one.Among those experiencing events, 25% did so within 90 days in the ICD group, compared with 52% in the other group. All HRs favoured ICD implantation. The overall HR (95%CI) for ICD versus no ICD was 0.38 (0.26 to 0.56). The HR was 0.42 (0.28 to 0.63) in cases with initial shockable rhythm; 0.18 (0.06 to 0.58) in non-shockable rhythm; 0.32 (0.20 to 0.53) in cases with a history of coronary artery disease; 0.36 (0.22 to 0.61) in heart failure and 0.30 (0.13 to 0.69) in those with diabetes. Similar associations were noted in all subgroups.Among survivors of OHCA, those discharged with an ICD had approximately 60% lower risk of death or recurrent cardiac arrest. A randomised trial is warranted to study this further.
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| 5. |
- Sultanian, Pedram, et al.
(författare)
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Prediction of survival in out-of-hospital cardiac arrest: the updated Swedish cardiac arrest risk score (SCARS) model
- 2024
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Ingår i: EUROPEAN HEART JOURNAL - DIGITAL HEALTH. - 2634-3916.
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Tidskriftsartikel (refereegranskat)abstract
- Aims Out-of-hospital cardiac arrest (OHCA) is a major health concern worldwide. Although one-third of all patients achieve a return of spontaneous circulation and may undergo a difficult period in the intensive care unit, only 1 in 10 survive. This study aims to improve our previously developed machine learning model for early prognostication of survival in OHCA.Methods and results We studied all cases registered in the Swedish Cardiopulmonary Resuscitation Registry during 2010 and 2020 (n = 55 615). We compared the predictive performance of extreme gradient boosting (XGB), light gradient boosting machine (LightGBM), logistic regression, CatBoost, random forest, and TabNet. For each framework, we developed models that optimized (i) a weighted F1 score to penalize models that yielded more false negatives and (ii) a precision-recall area under the curve (PR AUC). LightGBM assigned higher importance values to a larger set of variables, while XGB made predictions using fewer predictors. The area under the curve receiver operating characteristic (AUC ROC) scores for LightGBM were 0.958 (optimized for weighted F1) and 0.961 (optimized for a PR AUC), while for XGB, the scores were 0.958 and 0.960, respectively. The calibration plots showed a subtle underestimation of survival for LightGBM, contrasting with a mild overestimation for XGB models. In the crucial range of 0-10% likelihood of survival, the XGB model, optimized with the PR AUC, emerged as a clinically safe model.Conclusion We improved our previous prediction model by creating a parsimonious model with an AUC ROC at 0.96, with excellent calibration and no apparent risk of underestimating survival in the critical probability range (0-10%). The model is available at www.gocares.se.
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| 6. |
- Thorsteinsson, Egill Gauti, et al.
(författare)
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[New-onset postoperative atrial fibrillation following coronary artery bypass grafting: Incidence, clinical course and short-term outcomes].
- 2024
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Ingår i: Laeknabladid. - 1670-4959. ; 110:1, s. 11-19
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Tidskriftsartikel (refereegranskat)abstract
- The aims of this retrospective study were to investigate the incidence, clinical course and short term outcomes of new-onset postoperative atrial fibrillation (POAF) following coronary artery bypass surgery (CABG).A nation-wide study on 1622 patients who underwent CABG from 2006-2020 at Landspitali University Hospital. Clinical data were extracted from registries and 121 patients with pre-existing AF excluded, leaving 1501 patients for further analysis. Patient charts and postoperative ECGs were manually reviewed for determining details of POAF, which was defined as a postoperative episode of AF before discharge lasting at least 5 minutes. Patients with POAF (n=483) were compared to non-POAF patients (n=1018).Altogether 483 (32.2%) patients developed POAF; the annual incidence decreasing over time (tau= -0,45, p=0.023). Most patients were diagnosed on the second day postoperatively (43.5%) and over 90% were diagnosed within 4 days. The median number of POAF episodes was 3 (IQR: 1-5), the first episode lasting 1-6 hours in half of the cases and the total POAF-duration being 12 hours median (IQR: 5-30). Over 94% of cases converted to sinus rythm before discharge, with 25 (5.3%) patients being discharged in AF. Most patients were treated with beta-blockers (98.8%), amiodarone (95%) and 14.9% with electric cardioversion. POAF-patients were older, had higher EuroSCORE II and a longer hospital stay, however, they had similar rates of early postoperative stroke and 30 day mortality.The incidence of POAF remains high and was associated with prolonged hospital stay, but not significantly higher 30 day mortality or early postoperative stroke compared to patients in sinus rhythm. POAF-episodes were predominantly transient and almost 95% of patients were discharged in sinus rythm.
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