| 1. |
- Appel, Carl-Fredrik, et al.
(författare)
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Transcatheter versus surgical treatment for aortic stenosis : Patient selection and early outcome
- 2012
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Ingår i: Scandinavian Cardiovascular Journal. - : Informa Healthcare. - 1401-7431 .- 1651-2006. ; 46:5, s. 301-307
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Tidskriftsartikel (refereegranskat)abstract
- Objectives. To describe short-term clinical and echocardiography outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). To explore patient selection criteria for treatment with TAVI. Design. TAVI patients (n = 45) were matched to SAVR patients (n = 45) with respect to age within +/- 10 years, sex and systolic left ventricular function. Results. TAVI patients were older, 82 +/- 8 versus 78 +/- 5 years (p = 0.005) and they had higher logEuroSCORE, 16 +/- 11% versus 8 +/- 4% (p andlt; 0.001). There were no significant differences in 30 days mortality, stroke and myocardial infarction. TAVI patients received less erythrocyte (53% vs. 78%, p = 0.03) and thrombocyte (7% vs. 27%, p = 0.02) transfusions. Postoperative atrial fibrillation was less common (18% vs. 60%, p andlt; 0.001) in the TAVI group. Paravalvular regurgitation was more common in TAVI patients (87% vs. 0%, p andlt; 0.001) and 27% had access site complications. Aortic transvalvular velocity was 2.3 +/- 0.4 m/s versus 2.6 +/- 0.5 m/s (p = 0.002) and mean valve pressure gradient was 12 +/- 4 mmHg versus 15 +/- 5 mmHg (p = 0.01) in the TAVI and SAVR groups, respectively. Twenty-nine (64%) of the TAVI patients had logEuroSCORE andlt; 15%. Conclusions. Both TAVI and SAVR have good short term clinical outcome with excellent hemodynamic result. In clinical practice, factors other than high logEuroSCORE play an important role in patient selection for TAVI.
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| 4. |
- Forsberg, Lena M, et al.
(författare)
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Differences in recovery of left and right ventricular function following aortic valve interventions : a longitudinal echocardiographic study in patients undergoing surgical, transapical or transfemoral aortic valve implantation
- 2013
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Ingår i: Catheterization and cardiovascular interventions. - : Wiley. - 1522-1946 .- 1522-726X. ; 82:6, s. 1004-1014
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Tidskriftsartikel (refereegranskat)abstract
- ObjectivesTo evaluate longitudinal left and right ventricular function (LVF and RVF) after transcatheter aortic valve implantation (TAVI) as compared to surgical aortic valve replacement (SAVR) and LVF and RVF after TAVI by the transfemoral (TF) or transapical (TA) approach.BackgroundKnowledge about differences in recovery of LVF and RVF after TAVI and SAVR is scarce.MethodsSixty patients (age 81 ± 7 years, logistic EuroSCORE 16 ± 10%), undergoing TAVI (TF: n = 35 and TA: n = 25), were examined by echocardiography including atrioventricular plane displacement (AVPD) and peak systolic velocities (PSV) by tissue Doppler at basal RV free wall, LV lateral wall and septum preprocedurally, 7 weeks and 6 months postprocedurally. Twenty-seven SAVR patients were matched to 27 TAVI patients by age, gender and LVF.ResultsEarly postintervention, TAVI patients had improved longitudinal LVF. However, when analyzed separately, only TF, but not TA patients, had improved LV lateral and septal AVPD and PSV (all P ≤ 0.01). All TAVI patients, as well as the TF and TA group had unchanged longitudinal LVF between the early and late follow-ups (all P > 0.05). The SAVR group had higher septal LVF than the matched TAVI group preprocedurally, while postoperatively this difference was diminished. Longitudinal RVF was better in the TF group than in the TA group pre- and postprocedurally. Although the SAVR group had superior longitudinal RVF preoperatively, this was inferior to TAVI postoperatively.Conclusions Postprocedural longitudinal LVF and RVF in patients undergoing TF-TAVI, TA-TAVI, or SAVR differ considerably. Preservation of longitudinal RVF after TAVI might influence the selection of aortic valve intervention in the future.
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| 5. |
- Forsberg, Lena M, et al.
(författare)
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Left and right ventricular function in aortic stenosis patients 8 weeks post-transcatheter aortic valve implantation or surgical aortic valve replacement
- 2011
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Ingår i: European Journal of Echocardiography. - : Oxford University Press (OUP). - 1525-2167 .- 1532-2114. ; 12:8, s. 603-611
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Tidskriftsartikel (refereegranskat)abstract
- Aims Knowledge of longitudinal left and right ventricular (LV and RV) function after transcatheter aortic valve implantation (TAVI) is scarce. We hypothesized that the longitudinal systolic biventricular function in aortic stenosis (AS) patients is affected differently by TAVI and surgical aortic valve replacement (SAVR). less thanbrgreater than less thanbrgreater thanMethods and results Thirty-three AS patients (all-TAVI group, age 81 +/- 9 years, 18 female), with EuroSCORE 18 +/- 9%, were accepted for TAVI. Seventeen of these patients were matched (by gender, age, and LV function) to 17 patients undergoing SAVR. Conventional echocardiographic parameters, systolic atrioventricular plane displacement (AVPD) at standard sites and peak systolic velocity (PSV) by pulsed tissue Doppler at basal RV free wall, LV lateral wall, and septum were studied before and 8 weeks after the procedure. Procedural success was 100%, and 30-day mortality 9%. In all TAVI patients, AVPD(lateral), PSV(lateral), AVPD(septal), and PSV(septal) increased (P andlt; 0.001, 0.003, 0.006 and 0.002). When studying the matched patients postoperatively, both the SAVR and TAVI patients had increased PSV(lateral) and AVPD(lateral) (SAVR: P = 0.03 and P = 0.04, TAVI: P = 0.04 and P = 0.01). The PSV(RV) increased in the all-TAVI group (P = 0.007), while the AVPD(RV) was unchanged. SAVR patients had decreased AVPD(RV) (P = 0.001) and PSV(RV) (P = 0.004), while the matched TAVI patients had unchanged RV function parameters. less thanbrgreater than less thanbrgreater thanConclusion An improvement in regional longitudinal LV function in the septal and lateral wall could be seen after TAVI. Among the matched patients, both the TAVI and SAVR patients seemed to improve LV function in the lateral wall. RV systolic function increased in TAVI patients, but was impaired in the matched SAVR group at the 8-week follow-up.
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| 6. |
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| 7. |
- Holm, Jonas, et al.
(författare)
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EuroSCORE II and N-terminal pro-B-type natriuretic peptide for risk evaluation : an observational longitudinal study in patients undergoing coronary artery bypass graft surgery
- 2014
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Ingår i: British Journal of Anaesthesia. - : Oxford University Press. - 0007-0912 .- 1471-6771. ; 113:1, s. 75-82
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Tidskriftsartikel (refereegranskat)abstract
- Background: Postoperative heart failure remains the major cause of death after cardiac surgery. As N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a predictor for postoperative heart failure, the aim was to evaluate if preoperative NT-proBNP could provide additional prognostic information to the recently launched EuroSCORE II.Methods: A total of 365 patients with acute coronary syndrome (ACS) undergoing isolated coronary artery bypass graft (CABG) surgery were studied prospectively. Preoperative NT-proBNP and EuroSCORE II were evaluated with regard to severe circulatory failure after operation according to prespecified criteria. To assess what clinical outcomes are indicated by NT-proBNP levels in different risk categories, the patients were stratified according to EuroSCORE II. Based on receiver operating characteristics analysis, these cohorts were assessed with regard to preoperative NT-proBNP below or above 1028 ng litre(-1). The follow-up time averaged 4.4 (0.7) yr.Results: Preoperative NT-proBNP >= 1028 ng litre(-1) [odds ratio (OR) 9.9,95% confidence interval (CI) 1.01-98.9; P=0.049] and EuroSCORE II (OR 1.24, 95% CI 1.06-1.46; P=0.008) independently predicted severe circulatory failure after operation. In intermediate-risk patients (EuroSCORE II 2.0-10.0), NT-proBNP >= 1028 ng litre(-1) was associated with a higher incidence of severe circulatory failure (6.6% vs 0%; P=0.007), renal failure (14.8% vs 5.4%; P=0.03), stroke (6.6% vs 0.7%; P=0.03), longer intensive care unit stay [37 (35) vs 27 (38) h; P=0.002], and worse long-term survival.Conclusions: Combining EuroSCORE II and preoperative NT-proBNP appears to improve risk prediction with regard to severe circulatory failure after isolated CABG for ACS. NT-proBNP may be particularly useful in patients at intermediate risk according to EuroSCORE II.
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| 8. |
- Holm, Jonas, 1971-
(författare)
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Markers of hemodynamic state and heart failure as predictors for outcome in cardiac surgery : with special reference to mixed venous oxygen saturation and natriuretic peptides
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Postoperative heart failure or low cardiac output syndrome is the major cause for morbidity and mortality in cardiac surgery. Unfortunately commonly used methods to assess hemodynamic state and heart failure are not well documented with regard to outcome. The aim for this dissertation was to study the predictive values of postoperative Mixed Venous Oxygen saturation (SvO2) and preoperative NT-proBNP for outcomes related to postoperative heart failure.SvO2 was studied retrospectively in two cohorts of patients, one cohort operated with isolated Aortic Valve Replacement (AVR) for aortic stenosis, (n=396) and one operated with isolated Coronary Artery Bypass Grafting (CABG), (n=2755). SvO2 measured early after surgery, on admission to the intensive care unit (ICU), predicted postoperative morbidity and mortality. Our results suggest that, on admission to ICU SvO2 < 55 - 60% after AVR and SvO2 < 60% after CABG merits increased attention.Preoperative NT-proBNP was studied in a cohort of patients with acute coronary syndrome (ACS) undergoing CABG with or without concomitant procedure. These patients (n=383) were included prospectively and evaluated with regard to mortality and severe circulatory failure postoperatively by an end-points committee blinded to NT-proBNP results. Preoperative NT-proBNP ≥ 1028 ng/L independently predicted increased risk for severe circulatory failure postoperatively in patients with ACS undergoing isolated CABG. Preoperative NT-proBNP provided additional prognostic information to EuroSCORE II in this cohort, particularly in patients at intermediate risk. Preoperative NT-proBNP appears to be markedly higher in patients having CABG with concomitant procedures than in patients undergoing isolated CABG. Further studies are warranted to identify preoperative NTproBNP risk thresholds for different heart conditions and surgery-specific cohorts.In conclusion this dissertation shows that:Postoperative SvO2 on admission to ICU is a prognostic marker for morbidity and mortality after AVR and CABG.Preoperative NT-proBNP ≥ 1028 ng/L independently predicts severe circulatory failure postoperatively in patients undergoing isolated CABG and provides additional prognostic information to EuroSCORE II.The high negative predictive value of the identified cutoff levels for preoperative NTproBNP and postoperative SvO2 could be useful for pre and postoperative decisionmaking.
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| 9. |
- Holm, Jonas, et al.
(författare)
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Mixed venous oxygen saturation is a prognostic marker after surgery for aortic stenosis
- 2010
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Ingår i: ACTA ANAESTHESIOLOGICA SCANDINAVICA. - : Blackwell Publishing Ltd. - 0001-5172 .- 1399-6576. ; 54:5, s. 589-595
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Tidskriftsartikel (refereegranskat)abstract
- Background Adequate monitoring of the hemodynamic state is essential after cardiac surgery and is vital for medical decision making, particularly concerning hemodynamic management. Unfortunately, commonly used methods to assess the hemodynamic state are not well documented with regard to outcome. Mixed venous oxygen saturation (SvO(2)) was therefore investigated after cardiac surgery. Methods Detailed data regarding mortality were available on all patients undergoing aortic valve replacement for isolated aortic stenosis during a 5-year period in the southeast region of Sweden (n=396). SvO(2) was routinely measured on admission to the intensive care unit (ICU) and registered in a database. A receiver operating characteristics (ROC) analysis of SvO(2) in relation to post-operative mortality related to cardiac failure and all-cause mortality within 30 days was performed. Results The area under the curve (AUC) was 0.97 (95% CI 0.96-1.00) for mortality related to cardiac failure (P=0.001) and 0.76 (95% CI 0.53-0.99) for all-cause mortality (P=0.011). The best cutoff for mortality related to cardiac failure was SvO(2) 53.7%, with a sensitivity of 1.00 and a specificity of 0.94. The negative predictive value was 100%. The best cutoff for all-cause mortality was SvO(2) 58.1%, with a sensitivity of 0.75 and a specificity of 0.84. The negative predictive value was 99.4%. Post-operative morbidity was also markedly increased in patients with a low SvO(2). Conclusion SvO(2), on admission to the ICU after surgery for aortic stenosis, demonstrated excellent sensitivity and specificity for post-operative mortality related to cardiac failure and a fairly good AUC for all-cause mortality, with an excellent negative predictive value.
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| 10. |
- Holm, Jonas, et al.
(författare)
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Mixed venous oxygen saturation predicts short- and long-term outcome after coronary artery bypass grafting surgery: a retrospective cohort analysis
- 2011
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Ingår i: British Journal of Anaesthesia. - : Oxford University Press (OUP). - 0007-0912 .- 1471-6771. ; 107:3, s. 344-350
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Tidskriftsartikel (refereegranskat)abstract
- Background. Complications of an inadequate haemodynamic state are a leading cause of morbidity and mortality after cardiac surgery. Unfortunately, commonly used methods to assess haemodynamic status are not well documented with respect to outcome. The aim of this study was to investigate SV(O2) as a prognostic marker for short-and long-term outcome in a large unselected coronary artery bypass grafting (CABG) cohort and in subgroups with or without treatment for intraoperative heart failure. less thanbrgreater than less thanbrgreater thanMethods. Two thousand seven hundred and fifty-five consecutive CABG patients and subgroups comprising 344 patients with and 2411 patients without intraoperative heart failure, respectively, were investigated. SV(O2) was routinely measured on admission to the intensive care unit (ICU). The mean (SD) follow-up was 10.2 (1.5) yr. less thanbrgreater than less thanbrgreater thanResults. The best cut-off for 30 day mortality related to heart failure based on receiver-operating characteristic analysis was SV(O2) 60.1%. Patients with SV(O2) andlt;60% had higher 30 day mortality (5.4% vs 1.0%; P andlt; 0.0001) and lower 5 yr survival (81.4% vs 90.5%; P andlt; 0.0001). The incidences of perioperative myocardial infarction, renal failure, and stroke were also significantly higher, leading to a longer ICU stay. Similar prognostic information was obtained in the subgroups that were admitted to ICU with or without treatment for intraoperative heart failure. In patients admitted to ICU without treatment for intraoperative heart failure and SV(O2) andgt;= 60%, 30 day mortality was 0.5% and 5 yr survival 92.1%. less thanbrgreater than less thanbrgreater thanConclusions. SV(O2) andlt;60% on admission to ICU was related to worse short- and long-term outcome after CABG, regardless of whether the patients were admitted to ICU with or without treatment for intraoperative heart failure.
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| 11. |
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| 12. |
- Holm, Jonas, et al.
(författare)
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Preoperative NT-proBNP independently predicts outcome in patients with acute coronary syndrome undergoing CABG
- 2013
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Ingår i: Scandinavian Cardiovascular Journal. - : Informa Healthcare. - 1401-7431 .- 1651-2006. ; 47:1, s. 28-35
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Tidskriftsartikel (refereegranskat)abstract
- Objectives. The predictive value of preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) was evaluated in patients with acute coronary syndrome undergoing coronary artery bypass grafting (CABG). Design. As a substudy to a clinical trial 383 patients with acute coronary syndrome undergoing CABG were studied. 17 patients had a concomitant procedure. NT-proBNP was measured immediately preoperatively and evaluated with regard to in-hospital mortality, and severe circulatory failure postoperatively according to prespecified criteria. Follow-up was 3.2 +/- 0.9 years. Results. In patients with isolated CABG, receiver operating characteristics (ROC) analysis showed an area under the curve (AUC) of 0.82 for in-hospital mortality and 0.87 for severe circulatory failure respectively with a best cut-off for preoperative NT-proBNP of 1028 ng/L. This cut-off level independently predicted severe circulatory failure. Patients with NT-proBNP andlt; 1028 ng/L had significantly better long-term survival (p = 0.004). Preoperative NT-proBNP was higher in patients with concomitant procedure than isolated CABG (2146 +/- 1858 v 887 +/- 1635 ng/L; p = 0.0005). In patients with concomitant procedure ROC analysis showed an AUC of 0.93 for severe circulatory failure with a best cut-off for preoperative NT-proBNP of 3145 ng/L. Conclusions. Preoperative NT-proBNP predicted in-hospital mortality, severe circulatory failure postoperatively and long-term survival in patients undergoing surgery for acute coronary syndrome but a higher threshold was found in patients having concomitant procedures.
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| 13. |
- Hultkvist, Henrik, et al.
(författare)
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The combined impact of postoperative heart failure and euroScore on long-term outcome after surgery for aortic stenosis
- 2011
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Ingår i: Journal of Heart Valve Disease. - 0966-8519 .- 2053-2644. ; 20:6, s. 633-638
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND AND AIM OF THE STUDY:Although the EuroSCORE was developed for predicting operative mortality after cardiac surgery, it has also been shown to predict long-term mortality. It has been reported that postoperative heart failure (PHF) in association with surgery, albeit comparatively benign in the short term, has a profound impact on five-year survival after surgery for aortic stenosis (AS). The study aim was to determine the combined impact of EuroSCORE and PHF on long-term survival after isolated aortic valve replacement (AVR) for AS.METHODS:A total of 397 patients (48% females; average age 70 +/- 10 years) who underwent AVR for AS at the authors' institution between 1995 and 2000 was studied. The cohort was subdivided according to the additive EuroSCORE into a high-risk group (EuroSCORE >7) and a low-risk group (EuroSCORE < or = 7), and further analyzed in relation to PHF.RESULTS:The average follow up was 8.1 years (range: 5.2-11.2 years). Forty-five patients (11%) were treated for procedure-associated PHF. Patients with or without PHF and a high-risk EuroSCORE had crude five-year survivals of 57% and 64%, respectively (p = 0.6), whereas those with or without PHF but with a low-risk EuroSCORE had crude five-year survivals of 58% and 89%, respectively (p = 0.0003).CONCLUSION:Both PHF and a high EuroSCORE were associated with poor long-term survival. The role of PHF per se for the long-term prognosis was illustrated by the fact that the negative impact on long-term survival was almost as profound in patients of the low-risk group as of the high-risk group.
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| 18. |
- Vidlund, Mårten, et al.
(författare)
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GLUTAMICS : a randomized clinical trial on glutamate infusion in patients operated for acute coronary syndrome
- 2011
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Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- Background: Glutamate has been claimed to protect the heart from ischemia and to facilitate metabolic and hemodynamic recovery after ischemia. The GLUTAMICS-trial investigated if intravenous glutamate infusion given in association with surgery for acute coronary syndrome can reduce mortality and prevent or mitigate myocardial injury and postoperative heart failure. Methods: In this investigator-initiated prospective, double-blind study 861 patients undergoing surgery for acute coronary syndrome in three Swedish Hospitals were randomly assigned to intravenous infusion of glutamate (n=428) or saline (n=433) perioperatively. The primary endpoint was a composite of postoperative mortality (30 days), perioperative myocardial infarction and left ventricular heart failure on weaning from cardiopulmonary bypass. Results: Thirty-day mortality was 0.9 % in the glutamate group and 1.2% in the control group. Cardiac mortality was 0.2% in the glutamate group and 0.9% the control group. The incidence of the composite primary end point was 7.2% in the glutamate group and 5.8% in the control group. None of these differences were statistically significant. Regarding secondary end points significantly fewer patients in the glutamate group were hemodynamically unstable at completion of surgery (0.3% v 1.8%; p=0.035) or in need of intra-aortic balloon pump on arrival to the intensive care unit (0.0% v 1.2%; p=0.026). In patients with severe unstable angina (CCS class IV; n=475) the incidence of severe circulatory failure according to prespecified criteria was significantly lower in the glutamate group (2.6% v 6.6%; p=0.036). Conclusions: The primary endpoint did not differ significantly between the groups. Regarding secondary end points there were significant differences compatible with a beneficial effect of glutamate on myocardial recovery. (ClinicalTrials.gov Identifier: NCT00489827)
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| 19. |
- Vidlund, Mårten, 1968-, et al.
(författare)
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GLUTAMICS-a randomized clinical trial on glutamate infusion in 861 patients undergoing surgery for acute coronary syndrome
- 2012
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Ingår i: Journal of Thoracic and Cardiovascular Surgery. - New York, USA : Elsevier. - 0022-5223 .- 1097-685X .- 1524-0274. ; 144:4, s. 922-
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Tidskriftsartikel (refereegranskat)abstract
- Objective: Glutamate has been claimed to protect the heart from ischemia and to facilitate metabolic and hemodynamic recovery after ischemia. The GLUTAmate for Metabolic Intervention in Coronary Surgery trial investigated whether an intravenous glutamate infusion given in association with surgery for acute coronary syndrome could reduce mortality and prevent or mitigate myocardial injury and postoperative heart failure. less thanbrgreater than less thanbrgreater thanMethods: In the present prospective, triple-center, double-blind study, 861 patients undergoing surgery for acute coronary syndrome were randomly assigned to an intravenous infusion of glutamate (n=428) or saline (n=433) perioperatively. less thanbrgreater than less thanbrgreater thanResults: The incidence of the primary endpoint-a composite of 30-day mortality, perioperative myocardial infarction, and left ventricular heart failure at weaning from cardiopulmonary bypass-was 7.3% versus 5.8% (P=.41) in the glutamate and control groups, respectively. Patients with left ventricular failure at weaning from cardiopulmonary bypass had a shorter median intensive care unit stay (25 vs 92 hours; P=.02) if they were treated with glutamate. In patients with unstable angina (Canadian Cardiovascular Society class IV) undergoing isolated coronary artery bypass grafting (n=458), the incidence of severe circulatory failure according to the prespecified criteria was significantly lower in the glutamate group (1.3% vs 6.9%; P=.004). On multivariate analysis, glutamate infusion was associated with a reduced risk of developing severe circulatory failure (odds ratio, 0.17; 95% confidence interval, 0.04-0.72; P=.02). A relative risk reduction exceeding 50% for developing severe circulatory failure was seen in most risk groups undergoing isolated coronary artery bypass grafting, with those with diabetes a notable exception. less thanbrgreater than less thanbrgreater thanConclusions: The primary endpoint did not differ significantly between the groups. The secondary outcomes and post hoc analyses warrant additional studies with regard to the potential beneficial effect of glutamate on postischemic myocardial recovery.
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| 21. |
- Vidlund, Mårten, et al.
(författare)
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The S-100B substudy of the GLUTAMICS-trial : glutamate infusion not associated with sustained elevation of plasma S-100B after coronary surgery
- 2010
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Ingår i: Clinical Nutrition. - : Elsevier BV. - 0261-5614 .- 1532-1983. ; 29:3, s. 358-364
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Tidskriftsartikel (refereegranskat)abstract
- Background & aimsConcerns have been raised about potential neurological injury related to exogenous glutamate. In cardiac surgery glutamate has been administered as a putative cardioprotective agent by cardioplegia or intravenous infusion. In the GLUTAMICS trial, in addition to surveillance of clinical neurological injuries, a prespecified subgroup was analyzed with regard to postoperative S-100B levels to detect potential subclinical neurological injury related to glutamate infusion.MethodsSixty-nine patients operated on for unstable coronary syndrome were randomized to intravenous infusion of glutamate (n=35) or saline (n=34) perioperatively. Plasma levels of S-100B were obtained on the third postoperative day.ResultsS-100B in the glutamate group and the control group were 0.079±0.034μg/L and 0.090±0.042μg/L respectively (p=0.245). There were no patients with stroke or mortality. Three patients in the control group and two in the glutamate group had postoperative confusion. These patients had significantly elevated S-100B compared with those without confusion (0.132±0.047vs 0.081±0.036μg/L; p=0.003). Overall, 21 patients had S-100B above reference level (≥0.10μg/L) and these patients had significantly more calcifications in the ascending aorta on epiaortic scanning.ConclusionsIntravenous glutamate infusion during surgery for unstable coronary artery disease did not initiate a sustained elevation of plasma S-100B. Thus, no evidence for subclinical neurological injury related to glutamate infusion was found. In contrast, postoperative elevation of plasma S-100B was linked to calcification of the ascending aorta and postoperative confusion.
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