Emergencies in Cardiovascular Surgery- A Clinical Judgment and Treatment Strategy
Tanja Anguseva1*,Zan Mitrev2
1Intensive
Care Unit, Special Hospital Zan Mitrev Clinic, Macedonia
2Surgery Department, Special Hospital Zan Mitrev Clinic,Macedonia
*Corresponding author: Tanja Anguseva, Intensive care unit, Special Hospital Zan Mitrev Clinic,Str. Bledski Dogovor #81000 Skopje, Macedonia. Tel: +38923091500, Fax: +38923104947; Email: tanja.anguseva@filipvtori.com
Received Date: 23 June, 2017; Accepted Date: 23 September, 2017; Published Date: 30 September, 2017
Citation: Anguseva T, Mitrev Z (2017) Emergencies in Cardiovascular Surgery- A Clinical Judgment and Treatment Strategy. Cardiolog Res Cardiovasc Med 2: 119.
Urgent surgery is part of a daily practice on
cardiovascular units, and it may be required in patients with conditions such
as acute coronary syndrome, endocarditis and valvular diseases, trauma, acute
aortic dissection as well as Acute Vascular embolization’s and Leriche
Syndrome.
In emergency situation, preoperative patient
work-up for cardio-vascular surgery is quite different from the elective
setting. Since 03/2000 till 01/2012 we have analyzed a consecutive series of 10
023 cases out of which 1823 underwent emergency procedures (18.19%). The most
frequent problems requiring urgent intervention were thoracic aortic aneurysms
(369 cases; 20.24%). Coronary artery disease (829 cases; 45.47%) abdominal
aortic aneurysms (105 cases - 54 with rupture; 2.96%), peripheral vascular (300
cases; 16.46%), and others (271 cases: 14.87%). Urgent thoracic and abdominal
aortic aneurysm repair accounted for 23% respectively and the corresponding
proportion for peripheral vascular surgery is 16%. However, urgent surgery for
acute coronary ischemia, valvular and congenital heart disease accounted for
somewhat less than 60% for each group of these pathologies.
1. Introduction
Urgent surgery follows a path from
resuscitation and stabilization of the patient with a management team, to
preparation of the patient for surgery, and to post-operative and recovery
procedures-all designed to deal quickly with the life-threatening situation.
The first 120 minutes after arriving at an emergency room is a critical window
for the survival from a serious heart disease. There is often little time or no
possibility for extensive diagnosis or gathering patient’s history. Decisions
are made quickly about surgery, often without family members present [1].
Heart attacks are very effectively treated with
urgent surgery depending upon the part of the heart affected, whether there is
arterial blockage and overall health. Arrhythmias can develop, as well as
stroke. The first 48 hours are the most crucial with cardiac events and whether
there is immediate medical and surgical attention. Many cardiac surgeries
result in bypass procedures. A higher
death rate always is associated with bypass surgery done on an emergency basis.
Patients with a positive troponin, always are correlated with a higher
mortality rate after CABG surgery, than those ones with no increased troponin
in blood [2]. The incidence of urgent heart bypass surgery is much higher in
woman than in men, most probably due to lack of earlier cardiac care [3].
Patients with acute coronary syndromes who
require urgent cardiac surgery with a persistent myocardial ischemia represent
complex management challenges. The early administration of antiplatelet and
antithrombotic drugs has improved overall survival for patients with acute
myocardial infarction, but to achieve maximal benefit, these drugs are given
before coronary anatomy is known and before the decision to perform
percutaneous coronary interventions or surgical revascularization has been made
[4]. Even better according to the last 2011 ACCF/AHA guidelines, there is no
necessarily for stopping with aspirin prior to operation. A major bleeding
event secondary to these drugs is associated with a high rate of death in
medically treated patients with acute coronary syndrome. For patients who do
proceed to surgery, strategies to minimize bleeding include stopping of the
anticoagulation therapy and considering platelet and/or coagulation factor transfusion,
standard tranexamic acid and possibly recombinant-activated factor VIIa
administration for refractory bleeding [1].
Mechanical hemodynamic support has emerged as
an important option for patients with acute coronary syndromes in cardiogenic
shock. For these patients, perioperative considerations include maintaining
appropriate anticoagulation, ensuring suitable device flow, and periodically
verifying correct device placement [4].
Urgent CABG for patients with ischemic
mechanical complication (septum rupture, chordal rupture or free wall rupture)
results with higher mortality rate up to 25% [2].
For patients with chest or back pain symptoms
suggesting dissection of the aorta, as a standard it is provided access to
transesophageal echocardiography, CT scanning using cardio protocol for
visualization not only of the aorta but also of the coronary arteries, as well
as all main branches from the aorta. Cardiologists and cardiovascular surgeons
are available around the clock for management of the full spectrum of cardiac
diseases.
Rupture of abdominal aneurysm results in death
in about 50% of the cases due to kidney failure from shock or disrupted blood
supply, or mesenteries ischemia. An untreated aneurysm is always fatal.
Perioperative management in urgent cardiac
surgery is challenging, because the general condition of the patient is often
poor and only little preoperative information is available. In order to obtain
an optimal surgical outcome, careful assessment of preoperative problems,
prevention and detection of complications must be done without any delay [3].
Preoperative carotid duplex scan should be
performed in every case to assess the steno-occlusive lesion or unstable
plaque, which affects the surgical strategy (e.g. selection of arterial cannulation
site and cerebral protection). Furthermore, this examination is necessary for
final decision of cardiac surgery, whether it will be CABG or combination of
CABG and carotidal vascular surgery (when patient has severe carotid stenosis
and LMN stenosis, with unstable angina) (evidence level base IIB) [2].
Regional cerebral oxygen saturation (rSO2) must
be monitored in all surgeries. If intraoperative drop in rSO2 is detected,
administration of inotropic agents and increase in cardiopulmonary bypass flow
is needed to maintain the mean blood pressure at higher level. Insertion of
Intra-Aortic Balloon Pump (IABP) should be considered when rSO2 cannot be
recovered with those procedures. We have to keep in mind that many of the
patients undergoing urgent surgery are at high risk for coronary artery
disease. If one cannot be weaned from cardiopulmonary bypass, coronary artery
bypass grafting to a major branch may be performed.
Coronary angiography should be performed
immediately when ST-T changes in Electrocardiogram (ECG) or chest symptoms
appear in the postoperative period. Hesitation in making a decision will only
jeopardize the situation.
2. Material
and Methods
2.1.
Clinical setting
The Special Hospital Zan Mitrev Clinic (Old
Name: Surgery FillipII) is a first private hospital for cardiovascular surgery
in Macedonia, with 2 cardiovascular surgeons, 6 cardiologists, 40 ICU and 80
ward beds, equipped with one catheterisation laboratory and 128 slice CT scan
with a 24/7 service level. The cardiology department has four experienced
interventional cardiologists who perform >750 procedures a year, and a
surgery team which performs more than 1500 surgeries per year.
2.2. Patient
From March 2000 to January 2012, we have
analyzed a consecutive series of 10 023 cases out of which 1823 underwent
urgent procedures (18.19%) in our hospital. The major selection criteria were
emergency indications for surgery.
Main strategy of our hospital for accepting
urgent cases is:
• 24
hours Urgent center, with urgent diagnostics (echocardiography, angiography as
well as 128 MSCT scan)
• Well
trained stuff at ICU
• Well
organized transfusion department (30 min for prepared blood up to surgery)
• All
urgent cases had been accepted in the urgent diagnostic center. With the help
of the emergency team every patient had been stabilized and received all necessary
diagnostic procedures.
• For
the patients that need surgery, short time is needed from diagnostics,
preoperative preparation and up to surgery (maximum 30 to 40 min)
• For
the patient who needs stabilization, only 10 min are needed from the entrance
up to ICU acceptance. Patient’s urgency is determined according to the 2011
ACCF/AHA guidelines for aortocoronary bypass surgery, according to which the
following groups of patients require urgent bypass- surgeries.
• Acute
Myocardial Infarction (MI)
• Acute
MI with post infarction mechanical complications (ventricular septal defect,
mitral valve insufficiently with chordal rupture or rupture of the free left
chamber wall
• Cardiogenic
shock
• Life
threatening arrhythmia believed to be ischemic etiology
• Low
cardiac output syndrome ischemic etiology
• Emergency
CABG is recommended after failure of PCI in presence of ongoing ischemia
• Acute
aortic dissection
• Abdominal
aortic rupture
• Other
(severe aortic stenosis, acute mitral insufficiently, acute aortic
insufficiently).
• Acute
peripheral vascular disease including acute stroke.
The preoperative patients' characteristics are
listed in Table 1. The mean age was 69 ± 7 years and 982 patients were male.
The atherosclerosis risk factors distribution was as follows: 65% active
smokers, 56% suffering from systemic hypertension and 70% under treatment for
hypercholesterolemia. A positive anamnesis of previous acute myocardial
infarction was given in 966 cases (53%) and 638 patients (35%) had previous
hospitalization during the week before surgery. Among them, 638 patients (35%)
developed signs of severe low cardiac output, 543 patients required a
pre-operative Intra-Aortic Balloon Pump (IABP), and an urgent intubation with
mechanical ventilation was necessary 234 times.
All patients underwent a preoperative cardiac
assessment with a chest X-ray, an ECG, a standard coronary angiogram and a
trans-thoracic echocardiogram as well as Doppler ultrasound of the carotidal
arteries.
Patients with transthoracic ultrasound signs
for acute dissection received immediately MSCT scan using a cardio protocol for
estimation of the coronary arteries as well as other main branches of the aorta
(truncus, carotidal, mesenteries, renal artery). By ultrasound echo evaluation
the mean Left Ventricle Ejection Fraction (LVEF) rate was 27 ± 8%. Onsets of
mitral valve dysfunction or regurgitation with left ventricular dilatation
and/or focal dysfunction were important criteria for urgent coronary
revascularization and pre-operative intra-aortic balloon pump insertion, if
other therapies were contraindicated (i.e. thrombolysis and primary
angioplasty).
MSCT scan was performed on all patients with
aortic disease with tendency to precise the type of dissection, or aneurysm and
to classify whether the patient is operable or not.
2.3. Surgical
Technique - Specificity
Patients were prepared for surgery following
the conventional guidelines and transoesophageal echocardiography was routinely
performed intraoperatively. Through a median sternotomy, all patients were
cannulated in the standard way except for patients who were necessary to be put
on heart lung machine under reanimation. For these patients, we used femoral
cannulation and right atrium for heart-lung circulation. Myocardium was preserved with continues warm
cardioplegy, performed in ante grade and retrograde fashion.
In patients with acute dissection after
cannulation of the right subclavian artery, and a temporary hitching of the
brachiocephalic trunk, brain perfusion with 2-2.5l of blood, and 40mmHg
pressure, on 28-30°C cooling is enabled. On such a way patient has sufficient
brain perfusion while distal arch anastomosis is created.
For patients with ruptured abdominal aneurysm
the crucial point was proximal clamping of the aorta. Following the incision of
the aneurysm an occlusion is performed by placing two fingers on the proximal
site of the normal aortic lumen. Afterwards, a proximal clamp is safely placed
in order to ensure a bloodless surgery field. In all urgent surgeries, we
employ cell-server, for re-using patient’s own blood.
3. Results
Most frequent problems requiring urgent
intervention were thoracic aortic aneurysms (369 cases; 20.24%); coronary
artery disease (829 cases;45.47%) abdominal aortic aneurysms (105 cases - 54
with rupture; 2.96%), peripheral vascular diseases (300 cases; 16.46%), and
others (271 cases: 14.87%). Urgent thoracic and abdominal aortic aneurysm
repair accounted for 23% respectively and the corresponding proportion for
peripheral vascular surgery is 16%.
However, urgent surgery for acute coronary
ischemia, valvular and congenital heart disease accounted for somewhat less
than 60% for each group of these pathologies.
3.1. Coronary
artery disease 829 cases; 45.47% of the urgent procedures
Treatment strategy:
v Invasive
monitoring, IABP or catecholamines if necessary.
v Urgent
CABG for unstablepatient’s troponin negative.
v Acute
myocardial infarction with complications (VSD, chordal rupture) -ICU
stabilisation -invasive lines,IABP, catecholamines -after that surgery.
v Patients
in cardiogenic shock- urgent CABG after stabilisation.
v Unstable
patients with troponin I positive test- ICU stabilisation until biomarkers
become negative, then surgery.
v Patients
with ischemic dilative cardiomyopathy- preoperative ICU stabilisation and
surgical intervention.
v All
829 high-risk patients were operated for urgent multiple myocardial
revascularization.
v 722
(87%) of them had been with ischemic left ventricle aneurysm.
v With
urgent reanimation, under CPR, surgery was performed on 10 patients.
v With
acute mitral regurgitation, due to acute mitral valve regurgitation (ischemic
chordal rupture) 56 patients were operated. With ischemic VSD were operated 6 patients,
one of them died.
v 4
patients entered urgently in the operating theatre due to ischemic rupture of
the left chamber, 2 had been a first operation and 2 had been after surgery,
due to reperfusion rupture of the antero-apical part of the left chamber.
v All 4
patients entered in the operating theatre under manual massage, with an urgent
preparation of the operating table for less than 10 minutes. 2 survived, 2
died. (Survival rate 50%).
The mean number of graft/patient was 2.9 ± 0.6
and the Left Internal Mammary Artery (LIMA) was used in 827. In two cases, the
mammary artery was not used because the time spent to harvest the mammary
artery would have endangered the patient's hemodynamic stability. The mean CPB
time was 84 ± 19 minutes and the mean total operative time was 188 ± 36
minutes. 722 (87%) of CABG patients received a left ventricle reconstructive
surgery.
Survival rate was 93.5 with 54 dead patients
(main reason for deathwas low cardiac output). CVVHDF was performed in 10
patients. Pre-operative IABP was implanted in 543 (65.5%) patients.
Percutaneous tracheostomy in 15 patients and percutaneous gastrostomy in 25
patients, 13(1.57%) patients developed sepsis. Mesenteric ischemia with
abdominal surgery was performed in 25(3.02%) patients. Average in hospital stay
was 38.5± 9.8 days.
3.2. Thoracic
aortic aneurysm 369 cases, 20.24% of the urgent procedures
Treatment
strategy:
• invasive
monitoring, biochemistry
• for
patient without any cons cess, or with extremely high negative basic excess,
with signs for mesentherial ischemia and bowel suffering, operation is not
recommended, because of the terminal stadium of the disease
• all
other cases urgent surgery
From the 369 (20.24%) patients with thoracic
aortic aneurysm, 95 had been patients with chronic aortic aneurysm and 274 with
acute dissection.
Survival rate was 94.9% with 19 dead patients.
3 patients had been treated with continuous
reno-renal replacement therapy (CVVHDF) due to acute renal insufficiency, 6 received
percutaneous tracheotomy (long time ventilation 24 ±4-5 days). Percutaneous
gastrostomy for feeding was performed in 5 patients. Average in hospital stay
was 38 ± 8-9 days.
5 patients who had extremely deep and
refractory negative BE>-10 without any conscious, and mesenterial ischemia
with a bowel suffering died after surgery because of terminal metabolic
changes.
3.3. Abdominal
aortic aneurysms (105 cases-54 with rupture; 2.96%)
Treatment
strategy:
- Invasive lines
- Volume supplying
- Urgent surgery
54 (2.96%) patients with rupture of the
abdominal aorta had been urgently entered in the operating theatre. Time from
entrance to operation was less than 30minutes.
35 patients got infrarenal aortic replacement
with anAlbograftinterponat, 10were with aorto-biiliacal, and 5 with
aorto-iliacal replacement.
In the postoperative period only one patient
died due to multi-organ failure. 2 patients were placed on continuous
reno-renal replacement therapy due to acute renal failure. One patient had
combined surgery, distal aorta replacement and collonostoma due to mesenteric
gangrene (a.mesenterica inferior occlusion).
3 patients got abdominal surgery due to
mesenteric ischemia (a.mesenterica inferior). Media inhospital stay was 22± 12
days.
5 patients got percutaneous tracheotomy due to
long time ventilation (20± 3-5days)
3.4. Peripheral
vascular (300cases; 16.46% of the urgent procedures)
Treatment
strategy:
- invasive
lines
- volume
supplying
- anticoagulant
therapy
- urgent
surgery
All patients had been immediately diagnosed by
64 MSCT scan, urgent surgery was performed in the next 1 hour after acceptance
in our unit. 3 patients needed urgent re-operations (in the next 2 days) due to
graft occlusion. The in-hospital stay was 5-6 ± 1-2 days.
Ten patients from the vascular group had been
operated in 24 to max 72 hours after getting stroke, one of them was in
coma.Two patients died, 8 had been completely recovered and turned back in a
normal life, including the patient who was in coma, but he had slight left
sided hemiparesis with psychological instability. Survival rate 99.33 %
3.5. Others
(271 cases: 14.87%)
Treatment
strategy:
- invasive lines,
catecholamines, ICI stabilization
- appropriate
operation
Urgent aortic valve surgery -54 patient’sdue to
severe aortic stenosis (terminal valvular disease) (3 patients died
pre-operatively, 2 died postoperatively)
Urgent aortic valve surgery due to aortic
insufficiency gr IV -65 patients (1 patient died postoperatively).
Extirpation of myxoma -116 cases (survival rate
100%).
35 patients with acute rupture of the chorda of
the mitral valve
1 patient with tumor in the right atrium.
The cumulative results are presented in the
next Table 3.
Patients were followed up for one to 12 years
after surgery: they all had a standard trans-thoracic echocardiogram and a
clinical examination. Excluding the 35 patients who died following cardiac
arrest, all 1706 survivors have an acceptable quality of life with a mean LVEF
of 36 ± 11.8%. There were 25 cardiac re-operations (in the group with CABG
surgery), major neurological events or acute myocardial infarctions, although
one patient required an Implantable Cardiac Defibrillator (ICD) to prevent
severe electrical dysfunctions originating from their ischemic cardiomyopathy.
Follow-up details are listed in Table 4.
4. Discussion
Urgent cases in cardiovascular surgery ask for
well-trained team including experienced cardiovascular surgeon. Urgent diagnostics
is very important for life-saving treatment. Well organized urgent center gives
a chance to emergency patients to be accepted, stabilized, receive the right
diagnosis, and on time surgery, with a low mortality rate. In addition,
improvements in surgical technique and postoperative care mean that cardiac
arrest in the surgical intensive care is much less common. As a result, the
staff is less familiar with emergency chest reoperation when such an arrest
occurs [5,6].
The optimal treatment for patients presenting
with unstable angina, acute coronary syndrome, onset of myocardial infarction
or severe left ventricular dysfunction and carrying a diffuse multi-vessel
coronary artery disease is still controversial. In particular, patients with
severe multi-vessel coronary artery disease or main stump disease, presenting
comorbidities that contraindicate the thrombolysis, or showing signs of acute
and severe left ventricular dysfunction with low cardiac output requiring
urgent mechanical circulatory support, can derive big benefits from emergency
on-pump multiple myocardial revascularization. Nevertheless, the standard
surgical technique, with cardioplegic arrest and cardiopulmonary bypass, may
not be the ideal solution in this cohort of very high-risk and unstable
patients: in particular, cardioplegic arrest and aortic cross clamping have
been isolated as independent surgical risk factors for high-risk patients
suffering from acute coronary syndrome and severe cardiac dysfunction, while
the avoidance of cardiopulmonary bypass does not confer significant clinical
advantages, as suggested by recent reports [7-11]. In particular, our patients
were not suitable for alternative non-surgical treatments, they were operated
in the shortest delay, and they were preoperatively treated with IABP and/or
low doses of inotropic drugs in order to achieve a certain degree of
hemodynamic stability, when needed. The biggest benefits deriving from the
on-pump beating heart technique were the reduction of the hemodynamic instability
caused by surgical manipulations, the absence of global myocardial ischemia
during aortic cross-clamping time and the absence of reperfusion after
cardioplegic arrest. It is important decision when to perform CABG surgery in
patient with subacute myocardial revascularization. It is well known that
reperfusion effects of the left chamber myocardium can result with a myocardial
rupture and need for urgent re-sternotomy and re-operation with a left chamber
ventriculoplasty as it was shown in our two cases. In conclusion, one of the
main problems in patients undergoing emergency CABG remains the myocardial
protection and the side effects coming from the transitory myocardial ischemia
during arrested heart surgery (possibly due to myocardial edema) [1,12]. Pre-operative
ICU stabilization even in the urgent cases showed that the results from
performed surgery are close to those one like in an elective case.
The in-hospital mortality rate for patients
diagnosed with thoracic aortic dissection is 26 % [1]. Our low rate of
mortality rate was result from on time diagnostic, and surgical technique,
thanks to which patients had less postoperative complications (no severe
hypothermia coagulopathy resulting).
Currently, there are no national
guideline-recommended diagnosis-to-treatment times for aortic dissection-as in
the less than 90 minutes for door-to-balloon times for acute MI. However, if
the diagnosis is specifically made prior to arrival, the average goal is
approximately 90 minutes from time of presentation according to Clarian
(Indiana University Health organization, specialized in urgent surgery).
Approximately two out of three patients with a
ruptured AAA die before they even reach a hospital. For those patients who
actually make it to the hospital and undergo surgery, there is a 50 to 70
percent mortality rate associated with a ruptured AAA. Despite the need for
urgent treatment, there is no standardized, guideline-recommended timeline from
ruptured AAA diagnosis to treatment.
“The only reason these patients don’t die
immediately is because the retroperitoneum, which separates the major blood
vessels from the bowels, is thick and tough enough to hold a small leak in
place for a while. However, if the patient’s blood pressure rises and causes
rupture or pumping of blood into the free abdominal cavity, the patient will
likely bleed to death before we can rush the patient to surgery [13].”
Once patients are diagnosed in the hospital
setting, the goal is to keep a patient’s blood pressure low to avoid a free
rupture, and transport them quickly to the operating room, still there are a
lot of controversies for the patients with acute episode of stroke. Our
experiences showed that surgical revascularizationsreturn bigger part of
cerebral function and decrease the degree of invalidity in the patient.
5. Conclusion
In conclusion, although further reports and
randomized clinical trials are necessary to compare results coming from
different surgical strategies undertaken to treat such a subgroup of high-risk
patients, we strongly believe that, following reported data and looking closely
to our surgical activity in this field, that on time diagnosis, emergency prep
of the patients allows to choose right surgical strategy for the patient and to
perform the strategy on time to get a better clinical results with a better
survival rate.
The decision-making process was an “Intensive,
large-scope exercise” due to multidisciplinary team required to treat these
patients.
Figure 1:
Acute Aortic Dissection of The Ascending Aorta.
Figure 2: Acute Rupture
of the Abdominal Aorta. Figure 3:
Control CT Scan after Surgery.
Figure 4: Leriche Syndrome. Figure 5: Control CT Scan after Surgery.
Figure 6: Acute Occlusion
of Right ACI. Figure 7: Control CT Scan after Surgery.
Graph 1:
Mortality Rates in the Different Groups.
Baseline patient profile*
|
No. of Patients |
Total No of patients |
1823 |
Age (years) |
69 ± 7 (range 57-79) |
Gender (M/F) |
982/841 |
CCS angina class |
|
III |
966 (53%) |
IV |
565 (31%) |
LVEF (%) |
27 ± 8 |
Hypertension |
1020 (56%) |
Smoke |
1184 (65%) |
Hypercholesterolemia |
1276 (70%) |
Diabetes mellitus (I&II) |
291 (16%) |
Peripheral vascular disease |
638 (35%) |
Prior myocardial infarction |
966 (53%) |
Myocardial infarction < 7 days |
638 (35%) |
Preoperative IABP |
543 (29%) |
Preoperative mechanical ventilation |
234 (13%) |
Severe low cardiac output |
638 (35%) |
Left main stump disease |
437 (24%) |
Acute aortic dissection |
274 (15%) |
Abdominal aortic rupture |
54 (2.96%) |
Other (Acute Valvular Disease) |
271 (14.78%) |
Peripheral vascular disease |
300 (14.46%) |
*Stroke |
10 (0.5%) |
* Data are presented as mean ± SD or N (%) CCS: Canadian Cardiovascular Society Angina Class; New York Heart Association; LVEF: Left Ventricular Ejection Fraction; MI: Myocardial Infarction; IABP: Intra-Aortic Balloon Pump. |
Table 1: Baseline patients profile.
Type of Surgery
|
Aortic Dissection |
Aortic Aneurysm |
Tyrone David |
38 |
34 |
Suspension of the aortic annulus |
64 |
27 |
Reinforcement of the free margine of the semilunar leaflet |
15 |
10 |
Replacement of the aortic valve |
34 |
17 |
Graft Interponat |
56 |
|
Reimplantation of the main vessels of the head |
67 |
7 |
Table 2
Postoperative results*
|
|
No. of patients
|
1823 |
Hospital mortality |
82 (4.50%) |
Ventilation time (hours) |
26 ± 37 (range 7-168) |
Pre-operative IABP |
543 (29.69%) |
Total bleeding (mL) |
1340 ± 903 |
Re-exploration for bleeding |
7 |
Myocardial infarction |
1 |
Postoperative LVEF (%) |
34.4 ± 8.5 |
Low cardiac output |
50 (2.7%) |
Transitory acute renal failure |
15 (0.82%) |
Sternal infection |
9 (0.5%) |
Intensive care unit stay (days) |
24.4 ± 6.4 (range 3-45) |
Hospital stay (days) |
28 ± 6.7 (range 8-34) |
* Data are presented as mean ± SD or N (%):IABP: Intra-Aortic Balloon Pump; CK-MB: LVEF: Left Ventricular Ejection Fraction. |
Table 3
Follow-up results*
|
|
Mean follow-up time (months) |
2 ± 144 |
No. of patients |
1744 |
Internal cardiac defibrillator |
1 |
Cardiac death |
35 (1.91%) |
LVEF (%) |
36 ± 11.8 |
* Data are presented as mean ± SD or N (%) LVEF: Left Ventricular Ejection Fraction. |
Table 4
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