Publications by authors named "Ziae Totonchi"

26 Publications

  • Page 1 of 1

Remote ischemic preconditioning effects on inflammatory markers and myocardial protection in coronary artery bypass graft surgery.

Perfusion 2020 Dec 7:267659120979293. Epub 2020 Dec 7.

Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.

Background: Induction of short episodes of ischemia to remote organs, namely upper or lower limbs, literally known as remote ischemic preconditioning (RIPC) has been suggested as a preconditioning approach to ameliorate ischemia/reperfusion injury (IRI). RIPC has been demonstrated to effectively protect various vital organs, including heart, against the next ischemic events in preclinical studies. However, human studies are required to approve its clinical applicability. Present study was performed to evaluate the effect of RIPC on the myocardial protection and inflammatory response markers in patients undergoing coronary artery bypass graft surgery.

Methods: In this randomized clinical trial, 43 coronary artery bypass graft (CABG) patients from Imam Hossein educational hospital were allocated in two groups, RIPC (21 patients) and control (22 patients). Serum level of interleukin (IL)-4, IL-8, and IL-10, interferon (IFN)-γ and Cardiac Troponin-I (cTnI) were measured in (1) after induction of anesthesia (before incision of skin), (2) after separation from CPB and (3) 24 hours after ICU arrival.Results:increase pack cell transfusions were observed in control group in ICU. Serum level of IL-10 at 24 hours after ICU admission was significantly higher in the RIPC group. Significantly lower amounts of IL-8 at post-CPB time were observed in the RIPC group in comparison with control.Conclusion:RIPC regulates the circulatory inflammatory cytokines, IL-8 decrement and IL-10 elevation, which could be translated into protection against IRI. However, further studies with larger sample sizes with careful consideration of parameters such as use of propofol as an anesthetic in the patients should be conducted to consolidate the findings from the current study.
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http://dx.doi.org/10.1177/0267659120979293DOI Listing
December 2020

Comparison of sedation between dexmedetomidine and propofol during transesophageal echocardiography: A randomized controlled trial.

Ann Card Anaesth 2019 Jul-Sep;22(3):285-290

Department of Anesthesia, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran.

Background: This study aimed to compare sedation characteristics of dexmedetomidine (Dex) and propofol during transesophageal echocardiography (TEE) in cardiac patients.

Methods: This clinical trial was conducted on 65 cardiac patients, who underwent TEE in a referral heart hospital. The patients were randomly divided into two groups: Dex (n = 34) and propofol (n = 31). The depth of sedation in the patients was assessed at 5-min intervals until the end of the TEE examination. The patient, physicians' satisfaction was recorded. Furthermore, blood pressure, heart and respiratory rates, peripheral oxygen saturation, and the bispectral index (BIS) of the patients were measured. The occurrence of apnea, hypotension or bradycardia was documented.

Results: Demographic variables were similar in both groups. Time from the beginning of sedation to the start of TEE was significantly longer in the Dex group (P = 0.01). Duration of the TEE examination was not different between the two groups. Interestingly, the recovery time was shorter in the Dex group than in the propofol group. There were no significant differences regarding patient and physician satisfaction with sedation quality. Hemodynamic profile was mainly similar in both groups. There was a significantly lower BIS level in the Dex group. There was no significant difference in the incidence of apnea or hypotension between the groups.

Conclusions: Time from the beginning of sedation with Dex was longer than that with propofol. However, Dex was able to provide satisfactory sedation levels, hemodynamic stability, short recovery time, and acceptable patient and practitioner satisfaction during TEE in our cardiac patients.
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http://dx.doi.org/10.4103/aca.ACA_42_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6639890PMC
August 2020

Feasibility of On-table Extubation After Cardiac Surgery with Cardiopulmonary Bypass: A Randomized Clinical Trial.

Anesth Pain Med 2018 Oct 24;8(5):e80158. Epub 2018 Sep 24.

Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.

Background: The use of short-acting anesthetics, muscle relaxation, and anesthesia depth monitoring allows maintaining sufficient anesthesia depth, fast recovery, and extubation of the patients in the operating room (OR). We evaluated the feasibility of extubation in the OR in cardiac surgery.

Methods: This clinical trial was performed on 100 adult patients who underwent elective noncomplex cardiac surgery using cardiopulmonary bypass. Additional to the routine monitoring, the patients' depth of anesthesia and neuromuscular blocked were assessed by bispectral index and nerve stimulator, respectively. In the on-table extubation (OTE) group (n = 50), a limited dose of sufentanil (0.15 µg/kg/h) and inhalational anesthetics were used for early waking. In the control group (n = 50), the same anesthesia-inducing drugs were used but the dose of sufentanil during the operation was 0.7 - 0.8 µg/kg/h. After the operation, cardiorespiratory parameters and ICU stay were documented.

Results: Demographic and clinical variables were comparable in both study groups. In the OTE group, we failed to extubate two patients in the OR (success rate of 96%). There were no significant differences between the two groups in terms of systolic and diastolic blood pressure at the time of entering the ICU (P > 0.05). Heart rate was lower in the OTE than in the control group at ICU admission (89.4 ± 13.1 vs. 97.6 ± 12.0 bpm; P = 0.008). The ICU stay time was lower in the OTE group (34 (21.5 - 44) vs. 48 (44 - 60) h; P = 0.001).

Conclusions: Combined inhalational-intravenous anesthesia along with using multiple anesthesia monitoring systems allows reducing the dose of total anesthetics and maintaining adequate anesthesia depth during noncomplex cardiac surgery with cardiopulmonary bypass. Thus, extubation of the trachea in the OR is feasible in these patients.
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http://dx.doi.org/10.5812/aapm.80158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6240920PMC
October 2018

Relationship between maximum clot firmness in ROTEM and postoperative bleeding after coronary artery bypass graft surgery in patients using clopidogrel.

Ann Card Anaesth 2018 Apr-Jun;21(2):175-180

Faculty of Medicine, University of Medical Sciences, Tehran, Iran.

Background: The aim of the present study was to investigate the relationship between maximum clot firmness (MCF) in rotational thromboelastometry (ROTEM) and postoperative bleeding in patients on clopidogrel after emergency coronary artery bypass graft surgery (CABG).

Methods: This observational study recruited 60 patients posted for emergency CABG following unsuccessful primary percutaneous coronary intervention (PCI) while on 600 mg of clopidogrel. The study population was divided into 2 groups on the basis of their MCF in the extrinsically activated thromboelastometric (EXTEM) component of the (preoperative) ROTEM test: patients with MCF <50 mm (n = 16) and those with MCF ≥50 mm (n = 44). Postoperative chest tube drainage amount, need for blood product transfusion, postoperative complications, and duration of mechanical ventilation after CABG were recorded. Results: No significant differences were observed between the two groups regarding duration of surgery, cardiopulmonary bypass, and aortic cross-clamp time. Chest tube drainage at 6, 12, and 24 h after Intensive Care Unit admission were significantly higher in the patients with MCF below 50 mm. The need for blood product transfusion was higher in the group with MCF <50 mm. In patients who experienced postoperative bleeding of 1000 mL or more, the ROTEM parameters of INTEM (Intrinsically activated thromboelastomery) α and MCF, EXTEM α and MCF, and HEPTEM (INTEM assay performed in the presence of heparinase) MCF (but not FIBTEM (Thromboelastometric assay for the fibrin part of the clot) values) were significantly lower than those with postoperative bleeding <1000 mL (P ≤ 0.05).

Conclusions: When platelet aggregometry is not available, the ROTEM test could be useful for the prediction of increased risk bleeding after emergency CABG in patients who have received a loading dose of clopidogrel.
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http://dx.doi.org/10.4103/aca.ACA_139_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914219PMC
November 2018

Inflammatory cytokine response and cardiac troponin I changes in cardiopulmonary bypass using two cardioplegia solutions; del Nido and modified St. Thomas': a randomized controlled trial.

Perfusion 2017 Jul 3;32(5):394-402. Epub 2017 Feb 3.

4 Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran.

Background: Long intervals of del Nido (DN) solution administration, 90 minutes, may result in rewarming of the myocardial tissue and elevate metabolic demand and hypoxia. This will potentially increase inflammatory response due to ischemia-reperfusion injury. We conducted this study to compare the inflammatory response between patients receiving DN and multi-dose St Thomas' cardioplegia solution (MST) in cardiopulmonary bypass (CPB) surgery for the correction of tetralogy of Fallot (TF).

Methods: Fifty-nine pediatric patients undergoing TF total correction surgery were randomly assigned into two groups: DN and MST. The patients' demographic data, blood chemistry parameters, hemodynamics and other clinical variables were recorded. TNF-a, IL-6, IL-8, IL-10 and cTnI were measured after anesthesia induction (before skin incision), immediately after cross-clamp removal and 24 hours after admission to the intensive care unit (ICU).

Results: Thirty-two patients of a mean age of 28.0±16.4 months received DN and 27 patients of a mean age of 24.2±15.9 months received MST. Perioperative clinical parameters were not significantly different between the two groups. Cytokine levels for all patients were significantly increased after surgery. Inter-group comparisons of cytokine levels demonstrated no significant differences in TNF-α, IL-6 and IL-8 cytokines levels. IL-10 level showed a moderately significant increase in the MST group compared to the DN group after surgery (2.94±0.9 vs. 2.46±0.61 log10 pg/mL, respectively; p=0.039). Postoperative lactate level was significantly different between two groups (2.475±1.29 vs 1.63±0.82 mg/dL in DN and MST groups, respectively; p=0.007). CTnI levels increased after surgery and remained constant until 24 hours after surgery. Significant differences between the MST and DN groups, at all times, were not detected.

Conclusions: The anti-inflammatory cytokine response in the MST group is significantly better than in the DN group. This may be due to shorter intervals of the MST cardioplegia solution administration, which prevents rewarming of the myocardium, increased metabolic demand and hypoxia. Decreasing the intervals of DN administration may improve its cardioprotective properties.
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http://dx.doi.org/10.1177/0267659117691119DOI Listing
July 2017

Predictors of Prolonged Mechanical Ventilation in Pediatric Patients After Cardiac Surgery for Congenital Heart Disease.

Res Cardiovasc Med 2016 Aug 20;5(3):e30391. Epub 2016 Jul 20.

Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran.

Background: The duration of mechanical ventilation (MV) is one of the most important clinical factors which predict outcomes in pediatric cardiac surgery. The prolonged mechanical ventilation (PMV) following cardiac surgery is a multifactorial phenomenon and there are conflicts regarding its predictors in pediatric population between different centers.

Objectives: The current study aimed to describe PMV predictors in patients undergoing cardiac surgery for congenital heart disease in a tertiary center for pediatric cardiovascular diseases in Iran.

Patients And Methods: From May to December 2014, all pediatric patients (less than a month - 15 years old) admitted to pediatric Intensive Care Unit (PICU) after congenital heart surgeries were consecutively included. The PMV was defined as mechanical ventilation duration more than 72 hours as medium PMV and more than seven days as extended PMV. The demographic data and variables probably related to PMV were recorded during the PICU stay.

Results: A total of 300 patients, 56.7% male, were enrolled in this study. Their mean age was 32 ± 40 months .The median duration (IQR) of MV was 18 hours (8.6 - 48 hours). The incidence of PMV more than 72 hours and seven days was 20% and 10.7%, respectively. Younger age, lower weight, heart failure, higher doses of inotropes, pulmonary hypertension, respiratory infections and delayed sternal closure were independent predictors of PMV in multivariate analyses.

Conclusions: The results of this study indicated that PMV predictors could be specific for each center and a good administration program is needed for each pediatric cardiac surgery center for the preoperative management of patients undergoing congenital heart surgeries.
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http://dx.doi.org/10.5812/cardiovascmed.30391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5219893PMC
August 2016

Comparison of Two Pain Assessment Tools, "Facial Expression" and "Critical Care Pain Observation Tool" in Intubated Patients After Cardiac Surgery.

Anesth Pain Med 2016 Feb 18;6(1):e33434. Epub 2016 Jan 18.

Cardiology Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.

Background: Critical-care patients are at higher risk of untreated pain, because they are often unable to communicate owing to altered mental status, tracheal intubation and sedation.

Objectives: This study compared two pain assessment tools on tracheal intubated critically ill patients in a cardiac post-anesthesia care unit, who were unable to communicate verbally. The studied tools were "critical-care pain observation tool (CPOT)" and "facial expression (FE)".

Patients And Methods: This was a prospective study based on diagnostic test evaluation. A sample of 91 intubated patients was selected from cardiac post-anesthesia care unit. Collected data were demographic characteristics, vital signs, FE and CPOT tools' scale. Pain was assessed with CPOT and FE scores five times. The first assessment was performed in at least 3 hours after admission of patients to ICU. Then, the pain intensity was reassessed every 30 minutes. In addition, blood pressure, heart rate, respiratory rate and oxygen saturation were measured simultaneously.

Results: At the first period, the frequency of "severe" pain intensity using the CPOT was 58.2% and with the FE tool was 67% (P = 0.001). Both tools demonstrated reduction in severity of pain on second and third assessment times. Significantly increasing level of pain and blood pressure due to nursing painful procedures (endo-tracheal suctioning, changing patient's position, etc.), were obtained by CPOT in fourth assessment. FE was not able to detect such important findings (κ = 0.249). In the fifth step, pain intensity was reduced. The most agreement between the two tools was observed when the reported pain was "severe" (κ = 0.787, P < 0.001) and "mild" (κ = 0.851, P < 0.001).

Conclusions: The sensitivity of CPOT was higher for detection and evaluation of pain in intubated postoperative patients compared with "Facial Expression". Best agreement between these tools was observed in two extremes of pain intensity.
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http://dx.doi.org/10.5812/aapm.33434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4834529PMC
February 2016

Moderate Patient-Prosthesis Mismatch Has No Negative Effect on Patients' Functional Status After Aortic Valve Replacement With CarboMedics Prosthesis.

Res Cardiovasc Med 2016 May 5;5(2):e29038. Epub 2016 Mar 5.

Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran.

Background: Patient-prosthesis mismatch (PPM) after aortic valve replacement (AVR) is the subject of continuing debate in the cardiac surgery field.

Objectives: The aim of this study was to evaluate the frequency and severity of patient-prosthesis mismatch (PPM) and the functional status of patients undergoing aortic valve replacement (AVR) using a CarboMedics prosthesis in the mid-term follow up.

Patients And Methods: We retrospectively studied 66 consecutive patients who were referred to AVR with a CarboMedics prosthesis at the Rajaie cardiovascular medical and research center, a university referral hospital in Tehran, Iran. The severity of PPM as well as clinical and echocardiographic parameters and the patients' New York heat association (NYHA) functional classification status, operative data and postoperative complications, and mortality in a mid-term (4 - 5 months) follow up period was assessed. Severe PPM was defined as the effective orifice area (EOA) indexed to the patient's body surface area (BSA) < 0.65 cm(2)/m(2) and moderate PPM was defined as the indexed effective orifice area (IEOA) between 0.65 and 0.85 cm(2)/m(2).

Results: Of the 66 studied patients, 39 were male and 27 were female. The mean age of the patients was 43 ± 17 with a range of 6 - 76 years. Implanted sizes of the CarboMedics AV prosthesis in 22 patients were 19 and 21 mm, and in 44 patients were 23 and 25 mm. Eleven patients had moderate PPM (IEOA < 0.85 cm(2)/m(2)) and 55 of them did not have PPM (IEOA ≥ 0.85 cm(2)/m(2)). There were no statistically significant differences between the two groups in the echocardiographic trans-aortic pressure gradients (35.6 ± 19 vs. 23.2 ± 16 mmHg; P = 0.061) and the mean NYHA functional classification (1.10 ± 0.3 vs. 1.01 ± 0.10; P = 0.074) after AVR in the mid-term follow up.

Conclusions: Moderate PPM has no negative effect on echocardiographic trans-aortic pressure gradients or the patients' NYHA functional status after AVR with a CarboMedics prosthesis in the mid-term follow up.
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http://dx.doi.org/10.5812/cardiovascmed.29038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4756227PMC
May 2016

Early and Mid-Term Outcome of Pediatric Congenital Mitral Valve Surgery.

Res Cardiovasc Med 2015 Aug 1;4(3):e28724. Epub 2015 Aug 1.

Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran.

Background: Congenital lesions of the mitral valve are relatively rare and are associated with a wide spectrum of cardiac malformations. The surgical management of congenital mitral valve malformations has been a great challenge.

Objectives: The aim of this study was to evaluate the early and intermediate-term outcome of congenital mitral valve (MV) surgery in children and to identify the predictors for poor postoperative outcomes and death.

Patients And Methods: In this retrospective study, 100 consecutive patients with congenital MV disease undergoing mitral valve surgery were reviewed in 60-month follow-up (mean, 42.4 ± 16.4 months) during 2008 - 2013. Twenty-six patients (26%) were under one-year old. The mean age and weight of the patients were 41.63 ± 38.18 months and 11.92 ± 6.12 kg, respectively. The predominant lesion of the mitral valve was MV stenosis (MS group) seen in 21% and MR (MR group) seen in 79% of the patients. All patients underwent preoperative two-dimensional echocardiography and then every six months after surgery.

Results: Significant improvement in degree of MR was noted in all patients with MR during postoperative and follow-up period in both patients with or without atrioventricular septal defect (AVSD) (P = 0.045 in patients with AVSD and P = 0.008 in patients without AVSD). Decreasing trend of mean gradient (MG) in MS group was statistically significant (P = 0.005). In patients with MR, the mean pulmonary artery pressure (PAP) had improved postoperatively (P < 0.001). Although PAP in patients with MV stenosis was reduced, this reduction was not statistically significant (P = 0.17). In-hospital mortality was 7%. Multivariate analysis demonstrated that age (P < 0.001), weight (P < 0.001), and pulmonary stenosis (P = 0.03) are strong predictors for mortality. Based on the echocardiography report at the day of discharge from hospital, surgical results were optimal (up to moderate degree for MR group and up to mild degree for MS group) in 85.7% of patients with MS and in 76.6% of patients with MR. Age (P = 0.002) and weight (P = 0.003) of patients are strong predictors for surgical success in multivariate analysis.

Conclusions: Surgical repair of the congenital MV disease yields acceptable early and intermediate-term satisfactory valve function and good survival at intermediate-term follow-up. Strong predictors for poor surgical outcome and death were age smaller than 1 year, weight smaller or equal than 6 kg, and associated cardiac anomalies such as pulmonary stenosis.
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http://dx.doi.org/10.5812/cardiovascmed.28724v2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4592526PMC
August 2015

Anesthetic Management in a Patient With Type A Aortic Dissection and Superior Vena Cava Syndrome.

Res Cardiovasc Med 2015 Aug 1;4(3):e27424. Epub 2015 Aug 1.

Department of Radiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran.

Introduction: Induction of general anesthesia in patients with superior vena cava (SVC) syndrome may cause airway obstruction and cardiovascular collapse.

Case Presentation: Herein, we introduced a patient with the diagnosis of dissecting aneurysm of the ascending aorta who was candidate for emergency surgery. He also had symptoms of SVC syndrome. To maintain airway patency during anesthetic management, we decided to perform femoro-femoral cardiopulmonary bypass followed by general anesthesia and tracheal intubation.

Conclusions: Femoro-femoral bypass prior to initiation of sternotomy is a safe and easy method in patients with aortic dissection and SVC syndrome in whom earlier endotracheal intubation may not be feasible.
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http://dx.doi.org/10.5812/cardiovascmed.27424v2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4588228PMC
August 2015

Comparison between Prothrombin Complex Concentrate (PCC) and Fresh Frozen Plasma (FFP) for the Urgent Reversal of Warfarin in Patients with Mechanical Heart Valves in a Tertiary Care Cardiac Center.

Iran J Pharm Res 2015 ;14(3):877-85

Department of Clinical Pharmacy, Pharmaceutical Sciences Branch, Islamic Azad University.

Fresh frozen plasma (FFP) and prothrombin complex concentrate (PCC) reverse oral anticoagulants such as Warfarin. We compared the standard dosage of FFP and PCC in terms of efficacy and safety for patients with mechanical heart valves undergoing interventional procedures while receiving Warfarin. Fifty patients were randomized (25 for each group) with mechanical heart valves [international normalized ratio (INR) >2.5]. FFP dosage was administered based on body weight (10-15 mL/Kg), while PCC dosage was administered based on both body weight and target INR. INR measurements were obtained at different time after PCC and FFP infusion. The mean ± SD of INR pre treatment was not significantly different between the PCC and FFP groups. However, over a 48-hour period following the administration of PCC and FFP, 76% of the patients in the PCC group and only 20% of the patients in the FFP group reached the INR target. Five (20%) patients in the PCC group received an additional dose of PCC, whereas 17 (68%) patients in the FFP group received a further dose of FFP (P=0.001). There was no significant difference between the two groups in Hb and Hct before and during a 48-hour period after PCC and FFP infusion. As regards safety monitoring and adverse drug reaction screening in the FFP group, the INR was high (INR > 2.5) in 86% of the patients. There was no report of hemorrhage in both groups. PCC reverses anticoagulation both effectively and safely while having the advantage of obviating the need to extra doses.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518116PMC
September 2015

A rare presentation of late right coronary artery spasm following aortic valve replacement.

ARYA Atheroscler 2015 Jan;11(1):50-3

Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.

Background: Coronary artery spasm (CAS) is defined as a reversible, sudden epicardial coronary artery stenosis that causes vessel occlusion or near occlusion.

Case Report: In this article, we present a clinical case of CAS in a 48-year-old woman undergoing elective aortic valve replacement surgery for aortic stenosis. On the 3rd post-operative day, the patient suffered from chest pain and dyspnea. Emergent coronary angiography demonstrated a significant spasm of the ostium portion of the right coronary artery.

Conclusion: This case shows that delayed coronary spasm should be considered as a cause of hemodynamic instability after valvular surgery.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4460353PMC
January 2015

Single Dose Corticosteroid Therapy After Surgical Repair of Fallot's Tetralogy; A Randomized Controlled Clinical Trial.

Res Cardiovasc Med 2015 Feb 20;4(1):e25500. Epub 2015 Feb 20.

Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran.

Background: Inflammatory reaction can produce several complications after cardiac surgery. Many attempts have been made to reduce these complications; perioperative corticosteroid therapy is one of the simplest methods.

Objectives: We conducted a randomized study to evaluate the efficacy of single dose methylprednisolone, prescribed after surgery, for reducing the complications. Repair of Tetralogy of Fallot was chosen as a homogenous large group for the study.

Patients And Methods: One hundred children who underwent total repair of Tetralogy of Fallot were enrolled in this study. After the surgery, all patients were transferred to pediatric ICU and were randomized (in a double-blind fashion) in 2 groups (A and B); a single dose of methylprednisolone (30 mg/kg of body weight) was injected to participants of group "A" just at the time of ICU entrance. Group "B" received no drug. Then, clinical outcomes and laboratory data were compared between the two groups.

Results: The only significant differences were lower incidence of bacteremia and higher incidence of hyperglycemia in the group who were used methylprednisolone.

Conclusions: Using a single postsurgical dose of methylprednisolone does not significantly alter the clinical outcome after repairing Tetralogy of Fallot.
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http://dx.doi.org/10.5812/cardiovascmed.25500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4350157PMC
February 2015

Impact of vitamin C supplementation on post-cardiac surgery ICU and hospital length of stay.

Anesth Pain Med 2015 Feb 19;5(1):e25337. Epub 2015 Feb 19.

Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.

Background: Prolonged intensive care unit (ICU) and hospital stay after cardiac surgery is vitally important and is influenced by both intraoperative and postoperative factors.

Objectives: This randomized clinical trial study was designed to assess whether vitamin C supplementation could reduce the length of ICU and hospital stay in post-cardiac surgery patients.

Patients And Methods: Two hundred and ninety patients scheduled for adult cardiac surgery including coronary, valve and congenital operations were randomized into two groups: an intervention group, who received 2 g of vitamin C (ascorbic acid) intravenously, immediately before surgery in the operating theatre, followed by 1 g daily oral doses for the first 4 postoperative days; and a placebo group, who received an equal number of identical tablets in the same shape and size.

Results: Hospital length of stay was significantly different between the two groups (10.17 ± 4.63 days in the intervention group vs. 12 ± 4.51 days in the placebo group; P = 0.01), while there was no significant difference in the ICU stay between the groups (3.42 ± 1.06 days in intervention group vs. 3.43 ± 1.09 days in the placebo group; P = 0.88). There were significant differences in the intubation time and the drainage volume in the ICU and the first 24 postoperative hours between the two groups (P for both = 0.003).

Conclusions: Vitamin C can decrease the length of hospital stay, drainage volume in the ICU and in the first 24 postoperative hours, intubation time and some complications in patients after cardiac surgery; perhaps by decreasing inflammatory factors.
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http://dx.doi.org/10.5812/aapm.25337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4350190PMC
February 2015

Factors influencing prolonged ICU stay after open heart surgery.

Res Cardiovasc Med 2014 Nov 14;3(4):e20159. Epub 2014 Oct 14.

Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran.

Background: There are different risk factors that affect the intensive care unit (ICU) stay after cardiac surgery.

Objectives: The aim of this study was to evaluate possible risk factors influencing prolonged ICU stay in a large referral hospital.

Patients And Methods: We conducted a case-control study to determinate causes of prolonged ICU stay in 280 adult patients undergoing cardiac surgery in a tertiary care center for cardiovascular patients, Tehran, Iran. These patients were divided into two groups according to ICU stay ≤ 96 and > 96 hours. We evaluated perioperative risk factors of ICU stay > 96 hours.

Results: Among the 280 patients studied, 184 (65.7%) had stayed ≤ 96 hours and 96 (34.3%) had stayed > 96 hours in ICU. Frequency of prolonged ICU stay was 34.2% in patients undergoing coronary artery bypass graft (CABG), 30.8% in patients with valve surgery, and 44.8% in patients with CABG plus valve surgery. Patients with > 96 hours of ICU stay received more blood transfusion and intravenous inotropes. They also had longer anesthesia, cardiopulmonary bypass, and postoperative intubation time. There were higher incidence of postoperative tamponade, re-exploration, re-intubation, hemodialysis, and hypotension in this group (P < 0.05 for all comparisons).

Conclusions: In this study, about one-third of patients had prolonged ICU stay. Factors influencing prolonged ICU stay were medical and some non-medical factors. In the present study, up to 30% of the patients had a prolonged ICU stay of > 96 hours. Additional data from well-designed investigations are needed for further assessment of the factors influencing prolonged ICU stay after cardiac surgery.
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http://dx.doi.org/10.5812/cardiovascmed.20159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4347792PMC
November 2014

Blood transfusion practice in a referral cardiovascular center in tehran, iran: a critical point of view.

Res Cardiovasc Med 2014 Nov 14;3(4):e21772. Epub 2014 Oct 14.

Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran.

Background: Unnecessary perioperative transfusions are likely to be related to increased morbidity and additional costs in cardiac surgery.

Objectives: The aim of this study was to evaluate the blood transfusion practice during and after adult cardiac surgery in a referral university hospital in Iran.

Patients And Methods: In a descriptive study, we collected data from 153 adult patients underwent cardiac surgery at Rajaie Cardiovascular Medical and Research Center, Tehran, Iran from January to March 2013. The variables were patients' demographic, operative and post-operative data and the numbers of transfused packed red blood cell (PC) units and fresh frozen plasma (FFP) during and after cardiac surgery. Then we evaluated patients' and physicians' related causes of relatively increased transfusion rate in our patients and compared them with literature.

Results: Of 153 patients, 96.8% received PC and 54.9% transfused FFP during or after surgery. Most of the transfusions were done after operation in intensive care unit (ICU). Also, 20% and 17% of the patients underwent transfusion of more than 6 units of PC and FFP, respectively. The mean left ventricular ejection fraction of the patients was 42.5 ± 10.9%. A significant number of patients had anemia (especially women) or received anticoagulants or antiplatelet agents preoperatively. Thirteen percent of the patients underwent emergency operations and 12.3% had re-exploration.

Conclusions: The results of this study demonstrate that the cardiac surgery patients receive a relatively greater number of PC or FFP units during and after the operation in our center. This finding may be explained to some extent by the fact that the sicker and more co-morbid patients referred to our center and such patients are more anemic and undergoing more emergent and complex procedures. Moreover, Transfusion strategy or protocol should be updated, especially after the operation in ICU.
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http://dx.doi.org/10.5812/cardiovascmed.21772DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4347724PMC
November 2014

Predictors of prolonged mechanical ventilation after open heart surgery.

J Cardiovasc Thorac Res 2014 30;6(4):211-6. Epub 2014 Dec 30.

Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Introduction: Due to the importance of prolonged mechanical ventilation (PMV) as a postoperative complication, predicting "high-risk" patients by identifying predisposing risk factors is of important issue. The present study was aimed to identify perioperative variables associated with PMV in patients undergoing open heart surgery.

Methods: A total of 743 consecutive patients, American Society of Anesthesiologists (ASA) physical status class III, who were scheduled to undergo open heart surgery using cardiopulmonary bypass were included in this observational study. Perioperative variables were compared between the patients with and without PMV, as defined by an extubation time of >48 h.

Results: PMV occurred in 45 (6.1%) patients. On univariate analysis, pre-operative variables; including gender, history of chronic obstructive pulmonary disease (COPD); chronic kidney disease and endocarditis, intra-operative variables; including type of surgery, operation time, pump time, transfusion in operating room and postoperative variables; including bleeding and inotrope-dependency were significantly different between patients with and without PMV (all P<0.001, except for COPD and transfusion in operating room; P=0.004 and P=0.017, respectively).

Conclusion: Our findings reinforce that risk stratification for predicting delayed extubation should be an important aspect of preoperative clinical evaluation in all anesthesiology settings.
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http://dx.doi.org/10.15171/jcvtr.2014.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4291598PMC
January 2015

Tracheal Stenosis and Cuff Pressure: Comparison of Minimal Occlusive Volume and Palpation Techniques.

Tanaffos 2015 ;14(4):252-6

Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Tracheal stenosis, which has received more emphasis recently, is a common post intubation complication and may develop due to different reasons. One important reason is the endotracheal tube cuff pressure. Therefore, this study sought to examine the accuracy of diagnostic test for palpation and minimal occlusive volume techniques to measure the endotracheal tube cuff pressure.

Materials And Methods: In this cross sectional study, the accuracy of diagnostic tests for palpation and minimal occlusive volume techniques to measure the endotracheal tube cuff pressure was assessed in 101 patients aged over 18 years who had undergone open heart surgery and post-surgical mechanical ventilation in the ICU.

Results: In the palpation technique, the cuff pressure of 27 patients (26.7%) was reported to be out of the permissible range and for the rest of them (74 patients, 73.3%) it was within the permissible range. Then, the cuff pressure was checked by the standard method using a manometer and after comparing the results it was found that the cuff pressure of 92 patients (91.1%) was not in the permissible range and only nine patients (8.9%) had a cuff pressure within the permissible range (20-30 cm H2O). In minimal occlusive volume method compared with the standard method, 22 patients (21.7%) had cuff pressure within the permissible range of 20-30 cm H2O, and 79 of them (78.2%) had cuff pressure out of the permissible range and higher than the upper limit.

Conclusion: This study recommends that the best way to measure the endotracheal tube cuff pressure is to use a cuff manometer, and when it is not available, the minimal occlusive volume would be a better alternative compared to the palpation technique to keep the cuff pressure within a proper range to avoid tracheotomy complications such as tracheal stenosis.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4841992PMC
April 2016

Hemodynamic changes following endotracheal intubation with glidescope(®) video-laryngoscope in patients with untreated hypertension.

Res Cardiovasc Med 2014 May 1;3(2):e17598. Epub 2014 Apr 1.

Pain Clinic, Tehran University of Medical Sciences, Tehran, IR Iran.

Background: Tracheal intubation can be associated with considerable hemodynamic changes, particularly in patients with uncontrolled hypertension. The GlideScope(®) video-laryngoscope (GVL) is a novel video laryngoscope that does not need direct exposure of the vocal cords, and it can also produce lower hemodynamic changes due to lower degrees of trauma and stimuli to the oropharynx than a Macintosh direct laryngoscope (MDL).

Objectives: The aim of this clinical trial was to compare hemodynamic alterations following tracheal intubation with a GVL and MDL in patients with uncontrolled hypertension.

Patients And Methods: Sixty patients who had uncontrolled hypertension and scheduled for elective surgery requiring tracheal intubation, were randomly assigned to receive intubated with either a GVL (n = 30) or a MDL (n = 30). Intubation time, heart rate, rate pressure product (RPP), and mean arterial blood pressure (MAP), were compared between the two groups at; baseline, following induction of anesthesia, after intubation, and at one minute intervals for 5 minutes.

Results: A total of 59 patients finished the study. Intubation time was longer in the GVL group (9.80 ± 1.27 s) than in the MDL group (8.20 ± 1.17 s) (P < 0.05). MAP, pulse rate, and RPP were lower in the GVL than the MDL group after endotracheal intubation (P < 0.05). MAP, heart rate, and RPP returned to pre-intubation values at 3 and 4 minutes after intubation in the GVL and MDL groups, respectively (P < 0.05).

Conclusions: Hemodynamic fluctuations in patients with uncontrolled hypertension after endotracheal intubation were lower with the GVL than the MDL technique.
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http://dx.doi.org/10.5812/cardiovascmed.17598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4253794PMC
May 2014

Safety and efficacy of caproamin fides and tranexamic Acid versus placebo in patients undergoing coronary artery revascularization.

J Cardiovasc Thorac Res 2014 30;6(3):197-202. Epub 2014 Sep 30.

Rasoul-e-Akram General Hospital, Iran University of Medical Sciences, Tehran, Iran.

Introduction: Excessive fibrinolysis contributes to post-cardiopulmonary bypass bleeding. Tranexamic Acid (TXA) and Caproamin Fides are synthetic lysine analogues that inhibit plasminogen-fibrin binding. The present study aimed to compare TXA and Caproamin Fides versus placebo in patients undergoing elective coronary artery revascularization.

Methods: We analyzed perioperative data of 300 adult patients undergoing coronary artery revascularization. Patients were randomly allocated to receive TXA (n=100), Caproamin Fides (n=100) or placebo (n=100) during perioperative time. Mediastinal bleeding during the first 24 hours post-operation, transfusion requirement and post-surgical complications were assessed.

Results: Most descriptive and intra-operative parameters were well comparable between the 3 study groups. Except for mean number of packed red blood cell (PRBC) units transfused during ICU stay (P=0.01), patients in the Caproamin Fides and TXA groups did not show any statistically significant differences regarding transfusion of blood products during peri-operative period. There was no evidence of a significant difference in mediastinal blood loss during the first 24 hours post-operation between the patients receiving TXA or placebo, while patients in the Caproamin Fides group had significantly lower mediastinal bleeding than the other 2 groups (Caproamin Fides vs. placebo, P=0.002, <0.001 and <0.001 at 6, 12 and 24 hours post-operation; Caproamin Fides vs. TXA, P=0.009, 0.003, <0.001 at 6, 12 and 24 hours post-operation). The incidence of postoperative complications were comparable between Caproamin Fides and TXA groups (P>0.05).

Conclusion: In conclusion, Caproamin Fides seems to be superior to TXA regarding the blood saving effects in patients undergoing coronary artery revascularization.
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http://dx.doi.org/10.15171/jcvtr.2014.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195972PMC
October 2014

Comparison of the Complications between Left Side and Right Side Subclavian Vein Catheter Placement in Patients Undergoing Coronary Artery Bypass Graft Surgery.

J Cardiovasc Thorac Res 2014 30;6(3):147-51. Epub 2014 Sep 30.

Department of Anesthesiology, Rajaei Heart Hospital, Iran University of Medical Sciences, Tehran, Iran.

Introduction: Percutaneous subclavian vein catheterization is one of the most common invasive procedures performed in cardiac surgery. The aim of this study was to compare left and right subclavian vein catheter placement via the infraclavicular approach in patients who undergo coronary artery bypass graft (CABG) surgery.

Methods: This prospective, randomized clinical trial was performed in193 patients. The technique applied for cannulation was infraclavicular approach for both the right and the left sides. Subclavian vein of other side was attempted only when catheterization at initial side was unsuccessful at two attempts. The success and complication rates were compared for the two sides.

Results: On193 patients, catheterization attempts were performed. Overall 177 catheterizations (91.7%) were successful during the first attempt, 105 (92.1%) on the right side and 72 (91.1%) on the left side. There was no significant difference between success rate and side of catheterization. Malposition of the catheter tip on the right side (9.6%) was significantly more than the left side (0%) (P= 0.003). The differences in other complications on two sides were statistically insignificant.

Conclusion: Compared with the right side, insertion of the cannula on the left side resulted in fewer catheter tip misplacements. Incidence of cannulation failure and other complications were similar on both sides.
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http://dx.doi.org/10.15171/jcvtr.2014.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195964PMC
October 2014

Electrocardiographic changes in mitral valve prolapse syndrome.

J Cardiovasc Thorac Res 2014 21;6(1):21-3. Epub 2014 Mar 21.

Rajaie Cardiovascular Medical & Research Center, Iran University of Medical Sciences, Tehran, Iran.

Introduction: Mitral valve prolapse syndrome (MVP) is the most common valvular abnormalityin the young and is correlated with increased frequency of cardiac dysrhythmias and sudden death.The aim of this study was to compare frequency of "early repolarization" in electrocardiogram(ECG) between MVP patients and healthy adults.

Methods: In this cross-sectional study, we compared ECG presentations of early repolarizationincluding notch in descending arm of QRS and J-point and/or ST segment changes in 100 patientswith MVP with 100 healthy individuals. MVP patients were referred to cardiology clinic withsymptoms of palpitation, chest pain or anxiety.

Results: The mean age in patients with MVP was significantly less than healthy subjects (29.5 ±9.3 years versus 31.0 ± 6.9 years in control group, P= 0.1967). We detected early repolarizationas a prevalent sign in ECG of patients which was a notch in descending arm of QRS and/or STsegment or J-point elevation seen in 74% of patients ( 51% in inferior leads and 23% in I and aVLleads) , whilst the same findings were seen in 8 men (8%) in control group (P= 0.0001).

Conclusion: Early repolarization in ECG presented as a notch in descending arm of QRS and/or ST segment or J-point elevation is more frequent in in young patients with MVP syndrome.
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http://dx.doi.org/10.5681/jcvtr.2014.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3992727PMC
April 2014

Long-term results of aortic valve replacement with posterior root enlargement.

Asian Cardiovasc Thorac Ann 2014 Nov 25;22(9):1059-65. Epub 2014 Mar 25.

Department of Cardiac Surgery, Rajaei Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.

Background: Posterior root enlargement provides the implantation of suitable-sized prosthetic valves in patients with a small aortic root. The aim of this study was to evaluate the long-term results of posterior root enlargement in patients undergoing aortic valve replacement.

Methods: Between 1997 and 2011, 103 patients with a small aortic annulus (indexed effective orifice area < 0.75 cm(-2) · m(-2)) underwent aortic valve replacement with posterior aortic root enlargement. Forty-six (44%) patients were male. The mean age was 28.62 ± 18.56 years. Survivors were followed up for a mean of 45.6 ± 32.4 months.

Results: Early mortality was 9.6%. The most common cause of early mortality was low cardiac output syndrome (6 patients). There were 2 (1.9%) late deaths due to cerebrovascular events. During the follow-up period, mild paravalvular leakage occurred in only one (1%) patient, and one suffered a malfunction of the prosthesis. A significant reduction was seen in the peak pressure gradients across the replaced aortic valves (p < 0.001). Moreover, a significant increase was noted in left ventricular ejection fraction (p = 0.001).

Conclusions: Aortic root enlargement using the Manouguian technique can be applied with acceptable safety. It effectively decreases postoperative gradients and increases left ventricular ejection fraction. Short- and long-term mortality and morbidity rates are satisfactory.
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http://dx.doi.org/10.1177/0218492314528923DOI Listing
November 2014

Pain location and intensity during the first week following coronary artery bypass graft surgery.

Anesth Pain Med 2014 Feb 26;4(1):e10386. Epub 2013 Dec 26.

Rajaei Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.

Background: Despite the advances in pain control following surgery, data on the location and distribution of pain following coronary artery bypass grafting (CABG) are lacking.

Objectives: This study was intended to investigate the location, distribution, and intensity of pain in patients undergoing CABG during their postoperative hospital stay from the operation to the end of the first postoperative week. Factors that could affect pain intensity and distribution were analyzed as well.

Patients And Methods: The present study was conducted on 138 patients who underwent CABG surgery at Rajaei cardiovascular, Medical and Research Center during May and July 2011. Location and intensity of pain were assessed using numeric rating scale (NRS) over time: every six hours after the operation on the first day (T1-T4, respectively), and on two (POD2), three (POD3), and seven days after the operation (POD7).

Results: Among 138 patients assessed in the study, the greatest severity of pain was reported on T2, with the mean severity of 3.4, followed by POD2 with the mean severity of 2.9 (P < 0.01). The location of the surgical incision had the most severity of pain in all patients (P < 0.01). On the site of surgical incision, a negative correlation was seen between the age and the severity of pain on T1 (P = 0.03, r = -0.180). Women experienced more severe pain compared to men at POD7. A significant correlation was seen between the severity of pain on POD7 and body mass index (BMI) (P < 0.01, r = 0.23). In patients who had the longer duration of cardiopulmonary bypass (CBD), the most pain intensity was reported on T1 (P < 0.01, r = 0.18). A significant correlation was seen on the pain intensity on T4 and chest tube drainage (P < 0.01, r = 0.24). The correlation between the pain severity pain and duration of admission in intensive care unit (ICU), was significant on T1 (P < 0.05, r = 0.18), T4 (P < 0.01, r = 0.29), POD2 (P < 0.01, r = 0.35) and POD7 (P < 0.05, r = 0.18).

Conclusions: Following CABG, the most severity of pain was reported at surgical incision on time T2. Pain began to decrease from the third day following the operation. Age, sex and BMI along with operation-related factors such as duration of CBP or chest tube drainage may affect the pain pattern following CABG surgery.
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http://dx.doi.org/10.5812/aapm.10386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3961017PMC
February 2014

Modified aortic root replacement technique in destructive ventricular-aortic discontinuity.

Ann Thorac Surg 2014 Jan;97(1):347-9

Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Science, Tehran, Iran.

We describe a simple technique for aortic root replacement in destructive prosthetic aortic valve endocarditis wherein the fragile aortic annulus tissue is not suitable for suture placement. Therefore, we first reconstructed the intervalvular part with a nontreated pericardial patch and then implanted the aortic composite graft on the aortic root through the roof of the left atrium and reconstructed the defect thus made with another pericardial patch. No complication was seen at 6-month follow up.
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http://dx.doi.org/10.1016/j.athoracsur.2013.06.066DOI Listing
January 2014

Hyperglycemia or high hemoglobin A1C: Which one is more associated with morbidity and mortality after coronary artery bypass graft surgery?

Ann Thorac Cardiovasc Surg 2014 10;20(3):223-8. Epub 2013 May 10.

Department of Cardiac Anesthesia, Rajaie Cardiovascular Medical & Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Propose: Our aim was to determine which criterion- hyperglycemia or high levels of glycosylated hemoglobin (HbA1C) is more associated with increased mortality and morbidity after coronary artery bypass graft (CABG).

Methods: Two hundred and sixteen patients who underwent elective CABG were enrolled in this prospective study. In order to compare postoperative outcomes regarding HbA1c and fasting blood sugar (FBS) levels, the patients were divided into two groups based on plasma HbA1c levels >7% or ≤7% and FBS >126 mg/dl or ≤126 mg/dl.

Results: Of 216 studied patients, 165 and 51 cases had levels of HbA1C ≤7% and HbA1c >7% respectively. Furthermore, 129 and 87 patients had levels of FBS of ≤126 mg/dl and FBS of >126 mg/dl respectively. Multivariate analyses revealed that patients with high HbA1C levels experienced significantly higher rates of postoperative re-intubation [P = 0.001, OR (95% CI) = 8.15 (2.88-23.09)], wound infection [P = 0.001, OR (95% CI) = 8.15 (2.88-23.09)] and bleeding [P = 0.027, OR (95% CI) = 2.18 (1.10-4.35)]. In addition, hyperglycemic patients had a higher frequency of arrhythmias [P = 0.001, OR (95% CI) = 3.07 (1.69-5.59)], atelectasis [P = 0.029, OR (95% CI) = 1.88 (1.07-3.30)] and wound infection [P = 0.001, OR (95% CI) = 8.75 (2.45-31.25)].

Conclusion: Higher levels of both HbA1C and FBS contribute to the increased risk of morbidity but not mortality rates in post-CABG surgery patients; yet further studies are required to distinguish "a better predictor" of postoperative adverse events.
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http://dx.doi.org/10.5761/atcs.oa.13.02282DOI Listing
February 2015