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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
Linköpings universitet, Institutionen för medicin och hälsa, Avdelningen för kardiovaskulär medicin. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Hjärt- och Medicincentrum, Thorax-kärlkliniken i Östergötland.ORCID-id: 0000-0003-3443-3392
2013 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

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.
Ort, förlag, år, upplaga, sidor
Linköping: Linköping University Electronic Press, 2013. , s. 70
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1375
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
URN: urn:nbn:se:liu:diva-97336ISBN: 978-91-7519-541-4 (tryckt)OAI: oai:DiVA.org:liu-97336DiVA, id: diva2:646936
Disputation
2013-09-27, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 09:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2013-09-10 Skapad: 2013-09-10 Senast uppdaterad: 2024-01-10Bibliografiskt granskad
Delarbeten
1. Mixed venous oxygen saturation is a prognostic marker after surgery for aortic stenosis
Öppna denna publikation i ny flik eller fönster >>Mixed venous oxygen saturation is a prognostic marker after surgery for aortic stenosis
2010 (Engelska)Ingår i: ACTA ANAESTHESIOLOGICA SCANDINAVICA, ISSN 0001-5172, Vol. 54, nr 5, s. 589-595Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

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.

Ort, förlag, år, upplaga, sidor
Blackwell Publishing Ltd, 2010
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:liu:diva-54873 (URN)10.1111/j.1399-6576.2009.02205.x (DOI)000276244700010 ()
Tillgänglig från: 2010-04-16 Skapad: 2010-04-16 Senast uppdaterad: 2024-01-10Bibliografiskt granskad
2. Mixed venous oxygen saturation predicts short- and long-term outcome after coronary artery bypass grafting surgery: a retrospective cohort analysis
Öppna denna publikation i ny flik eller fönster >>Mixed venous oxygen saturation predicts short- and long-term outcome after coronary artery bypass grafting surgery: a retrospective cohort analysis
2011 (Engelska)Ingår i: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 107, nr 3, s. 344-350Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

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.

Ort, förlag, år, upplaga, sidor
Oxford University Press (OUP), 2011
Nyckelord
assessment, patient outcomes, coronary artery bypass grafting, patient monitoring, postoperative complications, survival rates
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:liu:diva-70321 (URN)10.1093/bja/aer166 (DOI)000293910400008 ()
Anmärkning
Funding Agencies|Östergotlands Läns Landsting||Linköping University Hospital||Tillgänglig från: 2011-09-02 Skapad: 2011-09-02 Senast uppdaterad: 2024-01-10
3. Preoperative NT-proBNP independently predicts outcome in patients with acute coronary syndrome undergoing CABG
Öppna denna publikation i ny flik eller fönster >>Preoperative NT-proBNP independently predicts outcome in patients with acute coronary syndrome undergoing CABG
Visa övriga...
2013 (Engelska)Ingår i: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 47, nr 1, s. 28-35Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

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.

Ort, förlag, år, upplaga, sidor
Informa Healthcare, 2013
Nyckelord
acute coronary syndrome, coronary artery bypass grafting, natriuretic peptides
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:liu:diva-88661 (URN)10.3109/14017431.2012.731518 (DOI)000313678500004 ()
Anmärkning

Funding Agencies|Swedish Heart-Lung Foundation|20030595|Capio Research Foundation|2005-10212006-1203|Linkoping University||Ostergotlands Lans Landsting||

Tillgänglig från: 2013-02-14 Skapad: 2013-02-14 Senast uppdaterad: 2024-01-10Bibliografiskt granskad
4. EuroSCORE II and NT-proBNP for risk evaluation: an observational longitudinal study in patients undergoing CABG
Öppna denna publikation i ny flik eller fönster >>EuroSCORE II and NT-proBNP for risk evaluation: an observational longitudinal study in patients undergoing CABG
Visa övriga...
(Engelska)Manuskript (preprint) (Övrigt vetenskapligt)
Abstract [en]

BACKGROUND: Postoperative heart failure remains the major cause of death after cardiac surgery. As 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: 365 patients with acute coronary syndrome (ACS) undergoing isolated CABG were studied prospectively. Preoperative NT-proBNP and EuroSCORE II were evaluated with regard to severe circulatory failure postoperatively 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 Reciever Operating Chracateristics (ROC) analysis these cohorts were assessed with regard to preoperative NT-proBNP below or above 1028 ng/L. Follow-up time averaged 4.4 ± 0.7 years.

RESULTS: Preoperative NT-proBNP ≥ 1028 ng/L (OR 9.9, 95%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 postoperatively. In intermediate risk patients (EuroSCORE II 2.0 – 10.0) NT-proBNP ≥ 1028 ng/L 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 ICU stay (37±35 vs 27±38 hours; 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. NTproBNP may be particularly useful in patients at intermediate risk according to EuroSCORE II.

Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:liu:diva-97334 (URN)
Tillgänglig från: 2013-09-10 Skapad: 2013-09-10 Senast uppdaterad: 2024-01-10Bibliografiskt granskad

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