Logistic regression analysis of the risk factors of anastomotic fistula after radical resection of esophageal‐cardiac cancer

PubMed Central

Huang, Jinxi; Wang, Chenghu; Yuan, Weiwei; Zhang, Zhandong; Chen, Beibei; Zhang, Xiefu

2017-01-01

Background This study was conducted to investigate the risk factors of anastomotic fistula after the radical resection of esophageal‐cardiac cancer. Methods Five hundred and forty‐four esophageal‐cardiac cancer patients who underwent surgery and had complete clinical data were included in the study. Fifty patients diagnosed with postoperative anastomotic fistula were considered the case group and the remaining 494 subjects who did not develop postoperative anastomotic fistula were considered the control. The potential risk factors for anastomotic fistula, such as age, gender, diabetes history, smoking history, were collected and compared between the groups. Statistically significant variables were substituted into logistic regression to further evaluate the independent risk factors for postoperative anastomotic fistulas in esophageal‐cardiac cancer. Results The incidence of anastomotic fistulas was 9.2% (50/544). Logistic regression analysis revealed that female gender (P < 0.05), laparoscopic surgery (P < 0.05), decreased postoperative albumin (P < 0.05), and postoperative renal dysfunction (P < 0.05) were independent risk factors for anastomotic fistulas in patients who received surgery for esophageal‐cardiac cancer. Of the 50 anastomotic fistulas, 16 cases were small fistulas, which were only discovered by conventional imaging examination and not presenting clinical symptoms. All of the anastomotic fistulas occurred within seven days after surgery. Five of the patients with anastomotic fistulas underwent a second surgery and three died. Conclusion Female patients with esophageal‐cardiac cancer treated with endoscopic surgery and suffering from postoperative hypoproteinemia and renal dysfunction were susceptible to postoperative anastomotic fistula. PMID:28940985

Minimally invasive right lateral thoracotomy without aortic cross-clamping: an attractive alternative to repeat sternotomy for reoperative mitral valve surgery.

PubMed

Umakanthan, Ramanan; Petracek, Michael R; Leacche, Marzia; Solenkova, Nataliya V; Eagle, Susan S; Thompson, Annemarie; Ahmad, Rashid M; Greelish, James P; Ball, Stephen K; Hoff, Steven J; Absi, Tarek S; Balaguer, Jorge M; Byrne, John G

2010-03-01

The study aim was to determine the safety and benefits of minimally invasive mitral valve surgery without aortic cross-clamping for mitral valve surgery after previous cardiac surgery. Between January 2006 and August 2008, a total of 90 consecutive patients (38 females, 52 males; mean age 66 +/- 9 years) underwent minimally invasive mitral valve surgery after having undergone previous cardiac surgery. Of these patients, 80 (89%) underwent mitral valve replacement and 10 (11%) mitral valve repair utilizing a small (5 cm) right lateral thoracotomy along the 4th or 5th intercostal space under fibrillatory arrest (mean temperature 28 +/- 2 degrees C). The predicted mortality, calculated using the Society of Thoracic Surgeons (STS) algorithm, was compared to the observed mortality. The mean ejection fraction was 45 +/- 13%, mean NYHA class 3 +/- 1, while 66 patients (73%) had previous coronary artery bypass grafting and 37 (41%) had previous valve surgery. Twenty-six patients (29%) underwent non-elective surgery. Cardiopulmonary bypass was instituted through axillary (n = 19), femoral (n = 70) or direct use aortic (n = 1) cannulation. Operative mortality was 2% (2/90), lower than the STS-predicted mortality of 7%. Three patients (3%) developed acute renal failure postoperatively, one patient (1%) required new-onset hemodialysis, and one (1%) developed postoperative stroke. No patients developed postoperative myocardial infarction. The mean postoperative packed red blood cell transfusion requirement at 48 h was 2 +/- 3 units. Minimally invasive right thoracotomy without aortic cross-clamping is an excellent alternative to conventional redo-sternotomy for reoperative mitral valve surgery. The present study confirmed that this technique is safe and effective in reducing operative mortality in high-risk patients undergoing reoperative cardiac surgery.

Logistic regression analysis of the risk factors of anastomotic fistula after radical resection of esophageal-cardiac cancer.

PubMed

Huang, Jinxi; Zhou, Yi; Wang, Chenghu; Yuan, Weiwei; Zhang, Zhandong; Chen, Beibei; Zhang, Xiefu

2017-11-01

This study was conducted to investigate the risk factors of anastomotic fistula after the radical resection of esophageal-cardiac cancer. Five hundred and forty-four esophageal-cardiac cancer patients who underwent surgery and had complete clinical data were included in the study. Fifty patients diagnosed with postoperative anastomotic fistula were considered the case group and the remaining 494 subjects who did not develop postoperative anastomotic fistula were considered the control. The potential risk factors for anastomotic fistula, such as age, gender, diabetes history, smoking history, were collected and compared between the groups. Statistically significant variables were substituted into logistic regression to further evaluate the independent risk factors for postoperative anastomotic fistulas in esophageal-cardiac cancer. The incidence of anastomotic fistulas was 9.2% (50/544). Logistic regression analysis revealed that female gender (P < 0.05), laparoscopic surgery (P < 0.05), decreased postoperative albumin (P < 0.05), and postoperative renal dysfunction (P < 0.05) were independent risk factors for anastomotic fistulas in patients who received surgery for esophageal-cardiac cancer. Of the 50 anastomotic fistulas, 16 cases were small fistulas, which were only discovered by conventional imaging examination and not presenting clinical symptoms. All of the anastomotic fistulas occurred within seven days after surgery. Five of the patients with anastomotic fistulas underwent a second surgery and three died. Female patients with esophageal-cardiac cancer treated with endoscopic surgery and suffering from postoperative hypoproteinemia and renal dysfunction were susceptible to postoperative anastomotic fistula. © 2017 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.

Micro-RNA-208a, -208b, and -499 as Biomarkers for Myocardial Damage After Cardiac Surgery in Children.

PubMed

Bolkier, Yoav; Nevo-Caspi, Yael; Salem, Yishay; Vardi, Amir; Mishali, David; Paret, Gideon

2016-04-01

To test the hypothesis that cardiac-enriched micro-RNAs can serve as accurate biomarkers that reflect myocardial injury and to predict the postoperative course following pediatric cardiac surgery. Micro-RNAs have emerged as plasma biomarkers for many pathologic states. We aimed to quantify preoperative and postoperative plasma levels of cardiac-enriched micro-RNA-208a, -208b, and -499 in children undergoing cardiac surgery and to evaluate correlations between their levels, the extent of myocardial damage, and the postoperative clinical course. PICU. Thirty pediatric patients that underwent open heart surgery for the correction of congenital heart defects between January 2012 to July 2013. None. At 12 hours post surgery, the plasma levels of the micro-RNAs increased by 300- to 4,000-fold. At 24 hours, their levels decreased but remained significantly higher than before surgery. Micro-RNA levels were associated with troponin levels, longer cardiopulmonary bypass and aortic crossclamp times, maximal postoperative aspartate aminotransferase levels, and delayed hospital discharge. Circulating micro-RNA-208a, -208b, and -499 are detectable in the plasma of children undergoing cardiac surgery and may serve as novel biomarkers for monitoring and forecasting postoperative myocardial injury and recovery.

[Values of computed tomography angiogram in non-cardiac surgery planning and cardiac risk assessment of coronary atherosclerosis during perioperative period].

PubMed

Chang, Rui-ping; Ju, Hai-yue; Zhang, Xing-hua; Wu, Jian; Zhang, Fan; Mi, Wei-dong; Cao, Xiu-tang; Gao, Chang-qing; Yang, Li

2013-02-19

To explore the values of detecting coronary atherosclerosis by computed tomography angiogram (CTA) on non-cardiac surgery planning and cardiac risk assessment of coronary atherosclerosis during perioperative period. A total of 89 patients with suspected coronary heart disease (CHD) scheduled for non-cardiac surgery underwent coronary CTA to evaluate luminal stenosis and calculate calcification score. There were 56 males and 33 females with a mean age of 65.1 years. Operative sites included chests (n = 29), abdomens and pelvis (n = 26), large vessels (n = 3), bones and joints (n = 19) and other regions (n = 12). Reasons of abandoned or postponed surgery were documented to analyze the influence of CTA results on surgery planning. Cardiac events were recorded to assess the correlation with coronary atherosclerosis. Among them, 75 patients (84.27%) were diagnosed as atherosclerosis while 10 patients (11.24%) were negative; 2 patients had coronary artery bypass and another 2 had stent implantation. According to the results of CTA, 12 operations (13.48%) were canceled and 8 (8.98%) postponed after interventions. Severe stenosis of coronary lumen had significant effects on surgery planning (P = 0.003) while calcification score did not. In patients undergoing surgery as scheduled or after intervention, 1 had atrial fibrillation at post-operation. For the patients with suspected CHD scheduled for non-cardiac surgery, severity of coronary stenosis may greatly influence surgery planning. Preoperative coronary CTA may decrease the incidence of cardiac events during perioperative period.

Is presence of bacteria in preoperative microscopic urinalysis of the patients scheduled for cardiac surgery a reason for cancellation of elective operation?

PubMed

Soltanzadeh, Mansoor; Ebadi, Ahmad

2013-01-01

In some hospitals, urinalysis is done routinely for all patients scheduled for cardiac surgery. Occasionally pyuria or bacteria is reported in the microscopic urinalysis of these patients that are clinically asymptomatic for urinary tract infections. WE WERE SEEKING ANSWER TO THIS QUESTION: is the presence of a different number of bacteria in preoperative microscopic urinalysis of asymptomatic patients scheduled for cardiac surgery indicative of potential postoperative complications and as a result, a good reason to postpone the operation? We conducted a retrospective cross-sectional study based on the review of the medical records of 1165 patients who underwent open-heart surgery. One hundered and fifty one patients were eligible in our established criteria. There were no significant difference between their demographic characteristics and the same number of randomly selected patients with normal urinalysis who had underwent open-heart surgery. In the bacteriuria group, two patients, and in the control group, three patients had an infection at the operation sites in the post-operative period, which was not a significant finding between two groups (P = 0.503). We recommend that in the absence of symptoms of urinary tract infection, urinalysis is not necessary and not cost beneficial in the preoperative evaluation of patients scheduled for open-heart surgery.

Early biomarkers of acute kidney failure after heart angiography or heart surgery in patients with acute coronary syndrome or acute heart failure.

PubMed

Torregrosa, Isidro; Montoliu, Carmina; Urios, Amparo; Elmlili, Nisrin; Puchades, María Jesús; Solís, Miguel Angel; Sanjuán, Rafael; Blasco, Maria Luisa; Ramos, Carmen; Tomás, Patricia; Ribes, José; Carratalá, Arturo; Juan, Isabel; Miguel, Alfonso

2012-01-01

Acute kidney injury (AKI) is a common complication in cardiac surgery and coronary angiography, which worsens patients' prognosis. The diagnosis is based on the increase in serum creatinine, which is delayed. It is necessary to identify and validate new biomarkers that allow for early and effective interventions. To assess the sensitivity and specificity of neutrophil gelatinase-associated lipocalin in urine (uNGAL), interleukin-18 (IL-18) in urine and cystatin C in serum for the early detection of AKI in patients with acute coronary syndrome or heart failure, and who underwent cardiac surgery or catheterization. The study included 135 patients admitted to the intensive care unit for acute coronary syndrome or heart failure due to coronary or valvular pathology and who underwent coronary angiography or cardiac bypass surgery or valvular replacement. The biomarkers were determined 12 hours after surgery and serum creatinine was monitored during the next six days for the diagnosis of AKI. The area under the ROC curve (AUC) for NGAL was 0.983, and for cystatin C and IL-18 the AUCs were 0.869 and 0.727, respectively. At a cut-off of 31.9 ng/ml for uNGAL the sensitivity was 100% and the specificity was 91%. uNGAL is an early marker of AKI in patients with acute coronary syndrome or heart failure and undergoing cardiac surgery and coronary angiography, with a higher predictive value than cystatin C or IL-18.

Clinical utility of carotid duplex ultrasound prior to cardiac surgery.

PubMed

Lin, Judith C; Kabbani, Loay S; Peterson, Edward L; Masabni, Khalil; Morgan, Jeffrey A; Brooks, Sara; Wertella, Kathleen P; Paone, Gaetano

2016-03-01

Clinical utility and cost-effectiveness of carotid duplex examination prior to cardiac surgery have been questioned by the multidisciplinary committee creating the 2012 Appropriate Use Criteria for Peripheral Vascular Laboratory Testing. We report the clinical outcomes and postoperative neurologic symptoms in patients who underwent carotid duplex ultrasound prior to open heart surgery at a tertiary institution. Using the combined databases from our clinical vascular laboratory and the Society of Thoracic Surgery, a retrospective analysis of all patients who underwent carotid duplex ultrasound within 13 months prior to open heart surgery from March 2005 to March 2013 was performed. The outcomes between those who underwent carotid duplex scanning (group A) and those who did not (group B) were compared. Among 3233 patients in the cohort who underwent cardiac surgery, 515 (15.9%) patients underwent a carotid duplex ultrasound preoperatively, and 2718 patients did not (84.1%). Among the patients who underwent carotid screening vs no screening, there was no statistically significant difference in the risk factors of cerebrovascular disease (10.9% vs 12.7%; P = .26), prior stroke (8.2% vs 7.2%; P = .41), and prior transient ischemic attack (2.9% vs 3.3%; P = .24). For those undergoing isolated coronary artery bypass grafting (CABG), 306 (17.8%) of 1723 patients underwent preoperative carotid duplex ultrasound. Among patients who had carotid screening prior to CABG, the incidence of carotid disease was low: 249 (81.4%) had minimal or mild stenosis (<50%); 25 (8.2%) had unilateral moderate stenosis (50%-69%); 10 (3.3%) had bilateral moderate stenosis; 9 (2.9%) had unilateral severe stenosis (70%-99%); 5 (1.6%) had contralateral moderate stenosis; 2 (0.7%) had bilateral severe stenosis; 4 (1.3%) had unilateral occluded with contralateral less than 50% stenosis, 1 (0.3%) had unilateral occluded with contralateral (70%-99%) stenosis; and 1 had bilateral occluded carotid arteries. Primary outcomes of patients who underwent isolated CABG showed no difference in the perioperative mortality (2.9% vs 4.3%; P = .27) and stroke (2.9% vs 2.6%; P = .70) between patients undergoing preoperative duplex scanning and those who did not. Primary outcomes of patients who underwent open heart surgery also showed no difference in the perioperative mortality (5.1% vs 6.9%; P = .14) and stroke (2.6% vs 2.4%; P = .85) between patients undergoing preoperative duplex scanning and those who did not. Operative intervention of severe carotid stenosis prior to isolated CABG occurred in 2 of the 17 patients (11.8%) identified who underwent carotid endarterectomy with CABG. In this study, the correlation between preoperative duplex-documented high-grade carotid stenosis and postoperative stroke was low. Prudent use of preoperative carotid duplex ultrasound should be based on the presence of cerebrovascular symptoms and the type of open heart surgery. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Perceived learning needs of Syrian patients postcoronary artery bypass graft surgery.

PubMed

Omari, Ferdous; Al-Zaru, Ibtisam; Al-Yousef, Rasha H

2014-06-01

To describe the perceived learning needs of Syrian patients who underwent coronary artery bypass graft surgery before hospital discharge and to examine the differences in the mean scores of the categories (subscales) of the modified Cardiac Patients Learning Needs Inventory according to the demographic characteristics of the participants. Knowledge about the learning needs of patients who underwent coronary artery bypass graft surgery can help nurses in coronary care units to provide them with the information that they need. This might improve their quality of life through decreasing complications, length of stay in the hospital and hospital readmissions. A descriptive design was used for this study. A convenience sample of 135 patients participated in this study and completed the demographic form and the modified Cardiac Patients Learning Needs Inventory. Information about chest and leg wound care, complications, medication and physical activity was the most important learning needs. There were significant differences between patients' perceptions of learning needs and their age, chronic illnesses and their working status. Syrian patients who underwent coronary artery bypass graft surgery were able to identify their learning needs that should be the focus of nursing practice. Meeting the needs of patients who underwent coronary artery bypass graft surgery should be emphasised in nursing practice. Meeting these needs might enhance their self-care behaviours. © 2013 John Wiley & Sons Ltd.

Learning From Experience: Improving Early Tracheal Extubation Success After Congenital Cardiac Surgery.

PubMed

Winch, Peter D; Staudt, Anna M; Sebastian, Roby; Corridore, Marco; Tumin, Dmitry; Simsic, Janet; Galantowicz, Mark; Naguib, Aymen; Tobias, Joseph D

2016-07-01

The many advantages of early tracheal extubation following congenital cardiac surgery in young infants and children are now widely recognized. Benefits include avoiding the morbidity associated with prolonged intubation and the consequences of sedation and positive pressure ventilation in the setting of altered cardiopulmonary physiology. Our practice of tracheal extubation of young infants in the operating room following cardiac surgery has evolved and new challenges in the arena of postoperative sedation and pain management have appeared. Review our institutional outcomes associated with early tracheal extubation following congenital cardiac surgery. Inclusion criteria included all children less than 1 year old who underwent congenital cardiac surgery between October 1, 2010, and October 24, 2013. A total of 416 patients less than 1 year old were included. Of the 416 patients, 234 underwent tracheal extubation in the operating room (56%) with 25 requiring reintubation (10.7%), either immediately or following admission to the cardiothoracic ICU. Of the 25 patients extubated in the operating room who required reintubation, 22 failed within 24 hours of cardiothoracic ICU admission; 10 failures were directly related to narcotic doses that resulted in respiratory depression. As a result of this review, we have instituted changes in our cardiothoracic ICU postoperative care plans. We have developed a neonatal delirium score, and have adopted the "Kangaroo Care" approach that was first popularized in neonatal ICUs. This provision allows for the early parental holding of infants following admission to the cardiothoracic ICU and allows for appropriately selected parents to sleep in the same beds alongside their postoperative children.

[The project "Don Carlo Gnocchi Foundation--Cardio-Thoracic Department De Gasperis--Lombardy Region" for the care of children from socio-economically deprived areas affected by cardiac disease].

PubMed

Ferratini, Maurizio; Marianeschi, Stefano; Vitali, Ettore; Iorio, Fiore; Moraschi, Andrea; Pezzano, Antonio; Mauri, Luigi; Lorini, Saverio; Rambaldi, Roberto; Tersalvi, Carlo Alberto; Pesaresi, Marilena; Pllumi, Arketa; Santoro, Francesco

2007-08-01

In 2001 the Cardiac Rehabilitation Unit IRCCS S. Maria Nascente Center and the International Area of Don Carlo Gnocchi Foundation, in collaboration with the Cardiac Surgery Department "De Gasperis" of Niguarda Ca' Granda Hospital in Milan, planned a project to treat children from impoverished countries. The "Fondo Sanitario Regionale" of the Lombard Region cosponsored the program. From October 2001 to November 2006, 32 patients (25 from Zimbabwe and 7 from Albania) were selected and submitted to cardiac surgery: 22 patients were affected by acquired valvular heart disease in NYHA class III-IV, 10 by congenital heart disease. After surgery the patients admitted to our rehabilitation unit underwent a period of comprehensive cardiac rehabilitation. Afterwards, the patients were in the care of selected Italian families for about 3 months. In both populations the problems faced in the selection, management and surgical approach are discussed. At 21 months the survival of the whole study population was 93 % (2 valvular patients died during the follow-up); 2 patients who initially underwent mitral valve repair were submitted to valve replacement for late appearance of severe regurgitation. In 3 patients with mitral valve bioprosthesis a significant structural valve deterioration occurred in the follow-up and 2 of them underwent valve replacement. The advantage of the excellent performance in durability of mechanical prosthetic valves (with respect to the limited durability of porcine bioprostheses), the problems with long-term anticoagulation have to be taken into consideration in the management of patients coming from socio-economically deprived areas.

Influence of the timing of cardiac catheterization and amount of contrast media on acute renal failure after cardiac surgery.

PubMed

Sadeghi, Mohsen Mirmohammad; Gharipour, Mojgan; Nilforoush, Peiman; Shamsolkotabi, Hamid; Sadeghi, Hamid Mirmohammad; Kiani, Amjad; Sadeghi, Pouya Mirmohammad; Farahmand, Niloufar

2011-04-01

There is limited data about the influence of timing of cardiac surgery in relation to diagnostic angiography and/or the impact of the amount of contrast media used during angiography on the occurance of acute renal failure (ARF). Therefore, in the present study the effect of the time interval between diagnostic angiography and cardiac surgery and also the amount of contrast media used during the diagnostic procedure on the incidence of ARF after cardiac surgery was investigated. Data of 1177 patients who underwent different types of cardiac surgeries after cardiac catheterization were prospectively examined. The influence of time interval between cardiac catheterization and surgery as well as the amount of contrast agent on postoperative ARF were assessed using multivariable logistic regression. The patients who progressed to ARF were more likely to have received a higher dose of contrast agent compared to the mean dose. However, the time interval between cardiac surgery and last catheterization was not significantly different between the patients with and without ARF (p = 0.05). Overall, postoperative peak creatinine was highest on day 0, then decreased and remained significantly unchanged after this period. Overall prevalence of acute renal failure during follow-up period had a changeable trend and had the highest rates in days 1 (53.57%) and 6 (52.17%) after surgery. Combined coronary bypass and valve surgery were the strongest predictor of postoperative ARF (OR: 4.976, CI = 1.613-15.355 and p = 0.002), followed by intra-aortic balloon pump insertion (OR: 6.890, CI = 1.482-32.032 and p = 0.009) and usage of higher doses of contrast media agent (OR: 1.446, CI = 1.033-2.025 and p = 0.031). Minimizing the amount of contrast agent has a potential role in reducing the incidence of postoperative ARF in patients undergoing cardiac surgery, but delaying cardiac surgery after exposure to these agents might not have this protective effect.

Outcome of Cardiac Rehabilitation Following Off-Pump Versus On-Pump Coronary Bypass Surgery.

PubMed

Arefizadeh, Reza; Hariri, Seyed Yaser; Moghadam, Adel Johari

2017-06-15

A few studies have compared the cardiac rehabilitation (CR) outcome between those who undergo conventional on-pump bypass surgery and off-pump surgery. We compared this outcome among the patients differentiated by the On-pump and off-pump surgical procedures about cardiovascular variables and psychological status. This longitudinal study recruited 318 and 102 consecutive patients who had undergone CABG (on-pump surgery, n = 318 and off-pump surgery, n = 102) and been referred to the CR clinic. The off-pump surgery patients had more improvement in their metabolic equivalents (METs) value. The physical and mental components of health-related quality of life (QOL) (based on SF-36 questionnaire) as well as depression-anxiety (based on Costello-Comrey Depression and Anxiety Scale) were notably improved in the two study groups after the CR program, while changes in the QOL components scores and also depression-anxiety score were not different between the off-pump and on-pump techniques. Regarding QOL and psychological status, there were no differences in the CR outcome between those who underwent off-pump bypass surgery and those who underwent on-pump surgery; nevertheless, the off-pump technique was superior to the on-pump method on METs improvement following CR.

Non-cardiac surgery in patients with prosthetic heart valves: a 12 years experience.

PubMed

Akhtar, Raja Parvez; Abid, Abdul Rehman; Zafar, Hasnain; Gardezi, Syed Javed Raza; Waheed, Abdul; Khan, Jawad Sajid

2007-10-01

To study patients with mechanical heart valves undergoing non-cardiac surgery and their anticoagulation management during these procedures. It was a cohort study. The study was conducted at the Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore and Department of Surgery, Services Institute of Medical Sciences, Lahore, from September 1994 to June 2006. Patients with mechanical heart valves undergoing non-cardiac surgical operation during this period, were included. Their anticoagulation was monitored and anticoagulation related complications were recorded. In this study, 507 consecutive patients with a mechanical heart valve replacement were followed-up. Forty two (8.28%) patients underwent non-cardiac surgical operations of which 24 (57.1%) were for abdominal and non-abdominal surgeries, 5 (20.8%) were emergency and 19 (79.2%) were planned. There were 18 (42.9%) caesarean sections for pregnancies. Among the 24 procedures, there were 7(29.1%) laparotomies, 7(29.1%) hernia repairs, 2 (8.3%) cholecystectomies, 2 (8.3%) hysterectomies, 1(4.1%) craniotomy, 1(4.1%) spinal surgery for neuroblastoma, 1(4.1%) ankle fracture and 1(4.1%) carbuncle. No untoward valve or anticoagulation related complication was seen during this period. Patients with mechanical valve prosthesis on life-long anticoagulation, if managed properly, can undergo any type of non-cardiac surgical operation with minimal risk.

Fungal infections in children in the early postoperative period after cardiac surgery for congenital heart disease: a single-centre experience.

PubMed

Jaworski, Radoslaw; Haponiuk, Ireneusz; Irga-Jaworska, Ninela; Chojnicki, Maciej; Steffens, Mariusz; Paczkowski, Konrad; Zielinski, Jacek

2016-09-01

Postoperative infections are still an important problem in cardiac surgery, especially in the paediatric population, and may influence the final outcome of congenital heart disease treatment. Postoperative infections with fungi are uncommon. The aetiology is poorly understood, and the proper diagnosis and treatment is unclear. In this single-centre study, the frequency of invasive fungal disease in children who underwent surgical management of congenital heart diseases was determined along with the risk factors for infection, treatment options and outcomes. All consecutive paediatric patients (<18 years of age) who underwent cardiac surgery for congenital heart disease between September 2008 and December 2015 in a paediatric cardiac centre in Poland were identified. Those who developed invasive fungal disease in the early postoperative period (30 days) were identified. Of the 1540 cardiosurgical procedures for congenital heart disease, 6 were complicated by fungal infection (0.39%). One patient had a high probability of fungal infection, but the diagnosis was unproved. Nevertheless, the patient was successfully treated with antifungal treatment. Five had proven invasive fungal disease. Of these, 3 were diagnosed with candidaemia. All had undergone cardiopulmonary bypass. Of the remaining 2 patients, 1 was a preterm newborn with complete atrioventricular septal defect who developed rib fungal invasion. The remaining patient had pulmonary atresia with ventricular septal defect and developed Fournier's gangrene after surgery. None of the patients died due to infection in the early postoperative period. However, the child with rib fungal invasion died 39 days after surgery as a result of multiorgan failure. Fungal infections in paediatric patients after cardiac surgery may markedly influence morbidity and mortality. Fungal infection prophylaxis in this specific group of children may reduce morbidity, whereas early empirical treatment followed by a targeted approach may improve outcomes. The 'hit fast, hit hard' treatment strategy may be the best rescue option for children who develop invasive fungal disease after cardiac surgery. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Assessment of Image Quality of Repeated Limited Transthoracic Echocardiography After Cardiac Surgery.

PubMed

Canty, David J; Heiberg, Johan; Tan, Jen A; Yang, Yang; Royse, Alistair G; Royse, Colin F; Mobeirek, Abdulelah; Shaer, Fayez El; Albacker, Turki; Nazer, Rakan I; Fouda, Muhammed; Bakir, Bakir M; Alsaddique, Ahmed A

2017-06-01

The use of limited transthoracic echocardiography (TTE) has been restricted in patients after cardiac surgery due to reported poor image quality. The authors hypothesized that the hemodynamic state could be evaluated in a high proportion of patients at repeated intervals after cardiac surgery. Prospective observational study. Tertiary university hospital. The study comprised 51 patients aged 18 years or older presenting for cardiac surgery. Patients underwent TTE before surgery and at 3 time points after cardiac surgery. Images were assessed offline using an image quality scoring system by 2 expert observers. Hemodynamic state was assessed using the iHeartScan protocol, and the primary endpoint was the proportion of limited TTE studies in which the hemodynamic state was interpretable at each of the 3 postoperative time points. Hemodynamic state interpretability varied over time and was highest before surgery (90%) and lowest on the first postoperative day (49%) (p<0.01). This variation in interpretability over time was reflected in all 3 transthoracic windows, ranging from 43% to 80% before surgery and from 2% to 35% on the first postoperative day (p<0.01). Image quality scores were highest with the apical window, ranging from 53% to 77% across time points, and lowest with the subcostal window, ranging from 4% to 70% across time points (p< 0.01). Hemodynamic state can be determined with TTE in a high proportion of cardiac surgery patients after extubation and removal of surgical drains. Copyright © 2017 Elsevier Inc. All rights reserved.

Impact of the viral respiratory season on postoperative outcomes in children undergoing cardiac surgery.

PubMed

Spaeder, Michael C; Carson, Kathryn A; Vricella, Luca A; Alejo, Diane E; Holmes, Kathryn W

2011-08-01

To compare postoperative outcomes in children undergoing cardiac surgery during the viral respiratory season and nonviral season at our institution. This was a retrospective cohort study and secondary matched case-control analysis. The setting was an urban academic tertiary-care children's hospital. The study was comprised of all patients <18 years of age who underwent cardiac surgery at Johns Hopkins Hospital from October 2002 through September 2007. Patients were stratified by season of surgery, complexity of cardiac disease, and presence or absence of viral respiratory infection. Measurements included patient characteristics and postoperative outcomes. The primary outcome was postoperative length of stay (LOS). A total of 744 patients were included in the analysis. There was no difference in baseline characteristics or outcomes, specifically, no difference in postoperative LOS, intensive care unit (ICU) LOS, and mortality, among patients by seasons of surgery. Patients with viral respiratory illness were more likely to have longer postoperative LOS (p < 0.01) and ICU LOS (p < 0.01) compared with matched controls. We identified no difference in postoperative outcomes based on season in patients undergoing cardiac surgery. Children with viral respiratory infection have significantly worse outcomes than matched controls, strengthening the call for universal administration of influenza vaccination and palivizumab to appropriate groups. Preoperative testing for respiratory viruses should be considered during the winter months for children undergoing elective cardiac surgery.

Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke.

PubMed

Barsic, Bruno; Dickerman, Stuart; Krajinovic, Vladimir; Pappas, Paul; Altclas, Javier; Carosi, Giampiero; Casabé, José H; Chu, Vivian H; Delahaye, Francois; Edathodu, Jameela; Fortes, Claudio Querido; Olaison, Lars; Pangercic, Ana; Patel, Mukesh; Rudez, Igor; Tamin, Syahidah Syed; Vincelj, Josip; Bayer, Arnold S; Wang, Andrew

2013-01-01

The timing of cardiac surgery after stroke in infective endocarditis (IE) remains controversial. We examined the relationship between the timing of surgery after stroke and the incidence of in-hospital and 1-year mortalities. Data were obtained from the International Collaboration on Endocarditis-Prospective Cohort Study of 4794 patients with definite IE who were admitted to 64 centers from June 2000 through December 2006. Multivariate logistic regression and Cox regression analyses were performed to estimate the impact of early surgery on hospital and 1-year mortality after adjustments for other significant covariates. Of the 857 patients with IE complicated by ischemic stroke syndromes, 198 who underwent valve replacement surgery poststroke were available for analysis. Overall, 58 (29.3%) patients underwent early surgical treatment vs 140 (70.7%) patients who underwent late surgical treatment. After adjustment for other risk factors, early surgery was not significantly associated with increased in-hospital mortality rates (odds ratio, 2.308; 95% confidence interval [CI], .942-5.652). Overall, probability of death after 1-year follow-up did not differ between 2 treatment groups (27.1% in early surgery and 19.2% in late surgery group, P = .328; adjusted hazard ratio, 1.138; 95% CI, .802-1.650). There is no apparent survival benefit in delaying surgery when indicated in IE patients after ischemic stroke. Further observational analyses that include detailed pre- and postoperative clinical neurologic findings and advanced imaging data (eg, ischemic stroke size), may allow for more refined recommendations on the optimal timing of valvular surgery in patients with IE and recent stroke syndromes.

Cardiac surgery in adults with high-surgical complexity CHD: results of a network collaborative programme.

PubMed

Gilad, Vered; Santoro, Francesco; Ribera, Elena; Calevo, Maria G; Cipriani, Adriano; Pasquè, Achille; Chierchia, Sergio L

2018-01-01

Adults with CHD often exhibit complex cardiac abnormalities, whose management requires specific clinical and surgical expertise. To enable easier access of these patients to highly specialised care, we implemented a collaborative programme that incorporates medical and surgical specialists belonging to both paediatric and adult cardiovascular institutions. The objective of this study was to review the experience gained and to analyse the surgical outcome of major cardiac surgery. We retrospectively reviewed all consecutive patients admitted for major cardiac surgery using our network between January, 2010 and December, 2013. Analysis of surgical outcome was performed in patients selected for major cardiac surgery with cardiopulmonary bypass. Early and late outcomes were evaluated. Out of a total of 433 inward patients, 86 were selected for surgery. The median age was 25.5 years, -64 patients (74.4%) had previously undergone heart surgery, and -55 patients (64%) had been subjected to at least one sternotomy. Abnormalities of the left ventricular and right ventricular outflow tract were the most frequent (37.2% and 30.2%, respectively), and despite high-surgical complexity only one death occurred (in-hospital mortality 1.1%). On a median follow-up time of 4 years no deaths and no heart-failure events have occurred; one patient underwent further cardiac surgery programmed at the time of discharge. Low mortality and morbidity rates can be obtained in high-surgical complexity adults with CHD populations when paediatric and adult cardiac specialists operate in the same multidisciplinary environment.

Increased Rate of Poor Laryngoscopic Views in Patients Scheduled for Cardiac Surgery Versus Patients Scheduled for General Surgery: A Propensity Score-Based Analysis of 21,561 Cases.

PubMed

Heinrich, Sebastian; Ackermann, Andreas; Prottengeier, Johannes; Castellanos, Ixchel; Schmidt, Joachim; Schüttler, Jürgen

2015-12-01

Former analyses reported an increased rate of poor direct laryngoscopy view in cardiac surgery patients; however, these findings frequently could be attributed to confounding patient characteristics. In most of the reported cardiac surgery cohorts, the rate of well-known risk factors for poor direct laryngoscopy view such as male sex, obesity, or older age, were increased compared with the control groups. Especially in the ongoing debate on anesthesia staff qualification for cardiac interventions outside the operating room a detailed and stratified risk analysis seems necessary. Retrospective, anonymous, propensity score-based, matched-pair analysis. Single-center study in a university hospital. No active participants. Retrospective, anonymous chart analysis. The anesthesia records of patients undergoing cardiac surgery in a period of 6 consecutive years were analyzed retrospectively. The results were compared with those of a control group of patients who underwent general surgery. Poor laryngoscopic view was defined as Cormack and Lehane classification grade 3 or 4. The records of 21,561 general anesthesia procedures were reviewed for the study. The incidence of poor direct laryngoscopic views in patients scheduled for cardiac surgery was significantly increased compared with those of the general surgery cohort (7% v 4.2%). Using propensity score-based matched-pair analysis, equal subgroups were generated of each surgical department, with 2,946 patients showing identical demographic characteristics. After stratifying for demographic characteristics, the rate of poor direct laryngoscopy view remained statistically significantly higher in the cardiac surgery group (7.5% v 5.7%). Even with stratification for demographic risk factors, cardiac surgery patients showed a significantly higher rate of poor direct laryngoscopic view compared with general surgery patients. These results should be taken into account for human resource management and distribution of difficult airway equipment, especially when cardiac interventional programs are implemented in remote hospital locations. Copyright © 2015 Elsevier Inc. All rights reserved.

Preoperative prediction of intensive care unit stay following cardiac surgery.

PubMed

De Cocker, Jeroen; Messaoudi, Nouredin; Stockman, Bernard A; Bossaert, Leo L; Rodrigus, Inez E R

2011-01-01

Following cardiac surgery, a great variety in intensive care unit (ICU) stay is observed, making it often difficult to adequately predict ICU stay preoperatively. Therefore, a study was conducted to investigate, which preoperative variables are independent risk factors for a prolonged ICU stay and whether a patient's risk of experiencing an extended ICU stay can be estimated from these predictors. The records of 1566 consecutive adult patients who underwent cardiac surgery at our institution were analysed retrospectively over a 2-year period. Procedures included in the analyses were coronary artery bypass grafting, valve replacement or repair, ascending and aortic arch surgery, ventricular rupture and aneurysm repair, septal myectomy and cardiac tumour surgery. For this patient group, ICU stay was registered and 57 preoperative variables were collected for analysis. Descriptives and log-rank tests were calculated and Kaplan-Meier curves drawn for all variables. Significant predictors in the univariate analyses were included in a Cox proportional hazards model. The definitive model was validated on an independent sample of 395 consecutive adult patients who underwent cardiac surgery at our institution over an additional 6-month period. In this patient group, the accuracy and discriminative abilities of the model were evaluated. Twelve independent preoperative predictors of prolonged ICU stay were identified: age at surgery>75 years, female gender, dyspnoea status>New York Heart Association class II (NYHA II), unstable symptoms, impaired kidney function (estimated glomerular filtration rate (eGFR)<60 ml min(-1)), extracardiac arterial disease, presence of arrhythmias, mitral insufficiency>colour flow mapping (CFM) grade II, inotropic support, intra-aortic balloon pumping (IABP), non-elective procedures and aortic surgery. The individual effect of every predictor on ICU stay was quantified and inserted into a mathematical algorithm (called the Morbidity Defining Cardiosurgical (MDC) index), making it possible to calculate a patient's risk of having an extended ICU stay. The model showed very good calibration and very good to excellent discriminative ability in predicting ICU stay >2, >5 and >7 days (C-statistic of 0.78; 0.82 and 0.85, respectively). Twelve independent preoperative risk factors for a prolonged ICU stay following cardiac surgery were identified and constructed into a proportional hazards model. Using this risk model, one can predict whether a patient will have a prolonged ICU stay or not. Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Wernicke's encephalopathy after cardiac surgery.

PubMed

Nishimura, Yoshiyuki

2018-05-01

A 76-year-old woman who had been on hemodialysis for 3 years developed ischemic mitral valve insufficiency, tricuspid insufficiency, and chronic atrial fibrillation, and underwent cardiac surgery. On the 4th postoperative day, she experienced a sudden disturbance of consciousness, aphasia, and limb ataxia. Brain computed tomography and magnetic resonance imaging showed no abnormalities. Wernicke's encephalopathy was suspected and the patient was given vitamin B1, whereupon her symptoms gradually improved. On the 42nd postoperative day, she was free of neurological symptoms and discharged.

[Cardiac surgery in octogenarian patients: evaluation of predictive factors of mortality, long-term outcome and quality of life].

PubMed

Viana-Tejedor, Ana; Domínguez, Francisco J; Moreno Yangüela, Mar; Moreno, Raúl; López de Sá, Esteban; Mesa, José M; López-Sendón, José

2008-10-04

Increasing life expectancy in Western countries in the last decades has resulted in a significant gradual increasing number of octogenarians referred for cardiac surgery. There is a need for a critical evaluation of the long-term surgical outcome and quality of life in the elderly. The aim of this study is to identify risk factors of mortality in octogenarians undergoing cardiac surgery and to assess the long term survival and quality of life. Data were reviewed on 150 patients aged over 80 years--mean age (standard deviation): 82.7 (2.5) years--who underwent cardiac surgery at our institution in the last 26 years. We analyzed clinical and epidemiological variables included in the European System for Cardiac Operative Risk Evaluation (euroSCORE), in-hospital morbidity and mortality, long term survival and quality of life after cardiac surgery. The 30-day mortality rate was 30.1%, with a mean hospital stay of 16.5 days (13-27). Emergent procedure, reparation of postinfarction ventricular ruptures, New York Heart Association functional class IV, chronic renal failure and previous myocardial infarction were independent predictors of in-hospital mortality. Mean follow up was 72.2 (9.9) months with survival rates of 87.3% and 57% at 1 and 5 years, respectively. Late postoperative quality of life in our 53 long-term survivors was significantly better than prior to surgery. New York Heart Association functional class improved from 2.52 to 1.48. Most survivors (97.7%) were satisfied with present quality of life Cardiac surgery in octogenarians is associated with increased in-hospital mortality rate and longer hospital stay. Our findings support that cardiac surgery can be performed in a selected elderly population with good long-term survival and quality of life.

Depression, anxiety disorders and Type D personality as risk factors for delirium after cardiac surgery.

PubMed

Tully, Phillip J; Baker, Robert A; Winefield, Helen R; Turnbull, Deborah A

2010-11-01

To determine the prognostic risk of incident delirium after cardiac surgery attributable to preoperative affective disorders and Type D personality. Patients awaiting elective coronary revascularization surgery (N = 158; 20.9% female; 11.4% concomitant valve surgery; age M = 64.7, SD = 10.6) underwent the structured MINI International Neuropsychiatric Interview and completed a measure of Type D personality. Postoperative incident delirium was established prior to discharge from the index hospitalization with structured psychiatric interview. The prevalence of psychiatric disorders before cardiac surgery was 17.1% for major depression, 7.6% for panic disorder, 10.1% for generalized anxiety disorder, and 13.3% for Type D personality, while there were 49 (31% of total) cases of delirium after surgery. After adjustment for sex, older age, cross-clamp time, haemoglobin (Hb) and psychotropic drug use, major depression was significantly associated with delirium, odds ratio (OR) = 3.86 (95% confidence interval (CI) 1.42 to 10.52, p = 0.001). Adjustment for clinical covariates suggested that Type D personality was not significantly associated with delirium, OR = 2.85 (95%CI 0.97 to 8.38, p = 0.06). Major depression was significantly associated with incident delirium after cardiac surgery. These findings suggest that the risk of incident delirium attributable to major depression was not merely a reflection of common diagnostic features in prospectively examined cardiac surgery patients.

Kosovo’s Experience for Children with Feeding Difficulties after Cardiac Surgery for Congenital Heart Defect

PubMed Central

Bejiqi, Ramush; Retkoceri, Ragip; Bejiqi, Hana; Maloku, Arlinda; Vuçiterna, Armend; Zeka, Naim; Gerguri, Abdurrahim; Bejiqi, Rinor

2017-01-01

BACKGROUND: A feeding disorder in infancy and during childhood is a complex condition involving different symptoms such as food refusal and faddiest, both leading to a decreased food intake. AIM: We aimed to assess the prevalence and predictor factors of feeding difficulties in children who underwent cardiac open heart surgery in neonatal period and infancy. We address selected nutritional and caloric requirements for children after cardiac surgery and explore nutritional interdependence with other system functions. METHODS: This was a retrospective study in a tertiary referral hospital, and prior approval from the institutional ethics committee was obtained. Information for 78 children (42 male and 36 female) was taken from patients charts. Data were analysed with descriptive statistics and logistic regression. RESULTS: From a cohort of analysed children with feeding problems we have occurred in 23% of such cases. At the time of the study, refusal to eat or poor appetite was reported as a significant problem in 19 children and subnormal height and weight were recorded in 11 children. Early neonatal intervention and reoperation were identified as risk factors for latter feeding difficulties or inadequate intake. Children with feeding problems also tended to eat less than children without feeding problems. There was a trend towards more feeding problems in patients with chromosomal abnormalities or other associated anomalies. CONCLUSION: Feeding disorder is often and a frequent long-term sequel in children after neonatal or early infancy heart surgery. Patients with chromosomal and associated anomalies who underwent multiple cardiac surgeries are at risk of developing feeding difficulties. PMID:29362619

Cardiac Surgery in Patients Infected with Human Immunodeficiency Virus

PubMed Central

Abad, Cipriano; Cárdenes, Miguel Angel; Jiménez, Pedro Conrado; Armas, Mario-Vicente; Betancor, Pedro

2000-01-01

From January 1991 through December 1999, 5 consecutive patients who were infected with human immunodeficiency virus presented in need of cardiac surgery. All were men; the median age was 44 years. Two of them presented with mitral and aortic infectious valve endocarditis, 1 with tricuspid endocarditis, 1 with prosthetic valve endocarditis, and 1 with pericarditis and pericardial tamponade. Under cardiopulmonary bypass, the 4 patients with endocarditis underwent these procedures: mitral and aortic valve replacement (2), tricuspid valve replacement (1), and aortic valve replacement (reoperation) and concomitant repair of a mycotic ascending aortic aneurysm (1). In the patient who had pericardial effusion, subxifoid pericardiostomy and drainage were performed, and a pericardial window was created. There was no intraoperative mortality. The patient with pericardial effusion died 8 days after surgery; he was in septic shock and had multiple organ failure. Two deaths occurred at 2 and 63 months, due to hemoptysis and sudden death, respectively. The 2 patients who underwent double valve replacement are alive and in good condition after a median follow-up of 71 months. Cardiac surgery is indicated in selected patients infected by the human immunodeficiency virus. These patients are frequently drug abusers or homosexual. Valvular endocarditis is the most common finding. Hospital morbidity and mortality rates are higher than usual in this group of patients. PMID:11198308

The crystalloid cardioplegia: advantages with a word of caution.

PubMed

Angeli, E

2011-05-01

Technical success and absence of iatrogenic injury from inadequate myocardial protection are the foremost targets of every cardiac surgical procedure. The current trends of pediatric cardiac surgery are aimed to achieve definitive repair of complex cardiac defects at birth as to avoid the risks related with palliative surgery and to reduce the long term impact of the untreated defect on the cardiac function. Thus, even newborn patients are exposed to a prolonged time of myocardial ischemia. The aim of this paper is to describe the impact of crystalloid HKT Custodiol cardioplegia infusion on myocardial protection in the early and late outcome of newborn patients who underwent arterial switch operation (ASO) for transposition of the great arteries (TGA). Copyright © 2011 Elsevier Masson SAS. All rights reserved.

Outcome of Cardiac Rehabilitation Following Off-Pump Versus On-Pump Coronary Bypass Surgery

PubMed Central

Arefizadeh, Reza; Hariri, Seyed Yaser; Moghadam, Adel Johari

2017-01-01

BACKGROUND: A few studies have compared the cardiac rehabilitation (CR) outcome between those who undergo conventional on-pump bypass surgery and off-pump surgery. We compared this outcome among the patients differentiated by the On-pump and off-pump surgical procedures about cardiovascular variables and psychological status. METHODS: This longitudinal study recruited 318 and 102 consecutive patients who had undergone CABG (on-pump surgery, n = 318 and off-pump surgery, n = 102) and been referred to the CR clinic. RESULTS: The off-pump surgery patients had more improvement in their metabolic equivalents (METs) value. The physical and mental components of health-related quality of life (QOL) (based on SF-36 questionnaire) as well as depression-anxiety (based on Costello-Comrey Depression and Anxiety Scale) were notably improved in the two study groups after the CR program, while changes in the QOL components scores and also depression-anxiety score were not different between the off-pump and on-pump techniques. CONCLUSIONS: Regarding QOL and psychological status, there were no differences in the CR outcome between those who underwent off-pump bypass surgery and those who underwent on-pump surgery; nevertheless, the off-pump technique was superior to the on-pump method on METs improvement following CR. PMID:28698744

Follow-Up After Cardiac Surgery Should be Extended to at Least 120 Days When Benchmarking Cardiac Surgery Centers.

PubMed

Hansen, Laura S; Sloth, Erik; Hjortdal, Vibeke E; Jakobsen, Carl-Johan

2015-08-01

Short-term (30 days) mortality frequently is used as an outcome measure after cardiac surgery, although it has been proposed that the follow-up period should be extended to 120 days to allow for more accurate benchmarking. The authors aimed to evaluate whether mortality rates 120 days after surgery were comparable to general mortality and to compare causes of death between the cohort and the general population. A multicenter descriptive cohort study using prospectively entered registry data. University hospital. The cohort was obtained from the Western Denmark Heart Registry and matched to the Danish National Hospital Register as well as the Danish Register of Causes of Death. A weighted, age-matched general population consisting of all Danish patients who died within the study period was identified through the central authority on Danish statistics. A total of 11,988 patients (>15 years) who underwent cardiac-surgery at Aarhus, Aalborg and Odense University Hospitals from April 1, 2006 to December 31, 2012 were included. Coronary artery bypass grafting, valve surgery and combinations. Mortality after cardiac surgery matches with mortality in the general population after 140 days. Mortality curves run almost parallel from this point onwards, regardless of The European system for cardiac operative risk evaluation (EuroSCORE) and intervention. The causes of death in the cohort differed statistically significantly from the background population (p<0.0001; one-sample t-test) throughout the first postoperative year. The leading cause of death in the cohort was cardiac (38%); 53% of which was categorized as heart failure. A total of 54% of these patients were assessed preoperatively as having normal or mildly impaired heart function (EuroSCORE). This study supported an extended follow-up period after cardiac surgery when benchmarking cardiac surgery centers. Regardless of preoperative heart function, heart failure was the consistent leading cause of death. Copyright © 2015 Elsevier Inc. All rights reserved.

N-Terminal Pro-B-type Natriuretic Peptide Is Useful to Predict Cardiac Complications Following Lung Resection Surgery

PubMed Central

Lee, Chang Young; Bae, Mi Kyung; Lee, Jin Gu; Kim, Kwan-Wook; Park, In Kyu

2011-01-01

Background Cardiovascular complications are major causes of morbidity and mortality following non-cardiac thoracic operations. Recent studies have demonstrated that elevation of N-Terminal Pro-B-type natriuretic peptide (NT-proBNP) levels can predict cardiac complications following non-cardiac major surgery as well as cardiac surgery. However, there is little information on the correlation between lung resection surgery and NT-proBNP levels. We evaluated the role of NT-proBNP as a potential marker for the risk stratification of cardiac complications following lung resection surgery. Material and Methods Prospectively collected data of 98 patients, who underwent elective lung resection from August 2007 to February 2008, were analyzed. Postoperative adverse cardiac events were categorized as myocardial injury, ECG evidence of ischemia or arrhythmia, heart failure, or cardiac death. Results Postoperative cardiac complications were documented in 9 patients (9/98, 9.2%): Atrial fibrillation in 3, ECG-evidenced ischemia in 2 and heart failure in 4. Preoperative median NT-proBNP levels was significantly higher in patients who developed postoperative cardiac complications than in the rest (200.2 ng/L versus 45.0 ng/L, p=0.009). NT-proBNP levels predicted adverse cardiac events with an area under the receiver operating characteristic curve of 0.76 [95% confidence interval (CI) 0.545~0.988, p=0.01]. A preoperative NT-proBNP value of 160 ng/L was found to be the best cut-off value for detecting postoperative cardiac complication with a positive predictive value of 0.857 and a negative predictive value of 0.978. Other factors related to cardiac complications by univariate analysis were a higher American Society of Anesthesiologists grade, a higher NYHA functional class and a history of hypertension. In multivariate analysis, however, high preoperative NT-proBNP level (>160 ng/L) only remained significant. Conclusion An elevated preoperative NT-proBNP level is identified as an independent predictor of cardiac complications following lung resection surgery. PMID:22263123

Circulating S100B and Adiponectin in Children Who Underwent Open Heart Surgery and Cardiopulmonary Bypass.

PubMed

Varrica, Alessandro; Satriano, Angela; Frigiola, Alessandro; Giamberti, Alessandro; Tettamanti, Guido; Anastasia, Luigi; Conforti, Erika; Gavilanes, Antonio D W; Zimmermann, Luc J; Vles, Hans J S; Li Volti, Giovanni; Gazzolo, Diego

2015-01-01

S100B protein, previously proposed as a consolidated marker of brain damage in congenital heart disease (CHD) newborns who underwent cardiac surgery and cardiopulmonary bypass (CPB), has been progressively abandoned due to S100B CNS extra-source such as adipose tissue. The present study investigated CHD newborns, if adipose tissue contributes significantly to S100B serum levels. We conducted a prospective study in 26 CHD infants, without preexisting neurological disorders, who underwent cardiac surgery and CPB in whom blood samples for S100B and adiponectin (ADN) measurement were drawn at five perioperative time-points. S100B showed a significant increase from hospital admission up to 24 h after procedure reaching its maximum peak (P < 0.01) during CPB and at the end of the surgical procedure. Moreover, ADN showed a flat pattern and no significant differences (P > 0.05) have been found all along perioperative monitoring. ADN/S100B ratio pattern was identical to S100B alone with the higher peak at the end of CPB and remained higher up to 24 h from surgery. The present study provides evidence that, in CHD infants, S100B protein is not affected by an extra-source adipose tissue release as suggested by no changes in circulating ADN concentrations.

Reversible preoperative renal dysfunction does not add to the risk of postoperative acute kidney injury after cardiac valve surgery

PubMed Central

Xu, Jia-Rui; Zhuang, Ya-Min; Liu, Lan; Shen, Bo; Wang, Yi-Mei; Luo, Zhe; Teng, Jie; Wang, Chun-Sheng; Ding, Xiao-Qiang

2017-01-01

Objective To evaluate the impact of the renal dysfunction (RD) type and change of postoperative cardiac function on the risk of developing acute kidney injury (AKI) in patients who underwent cardiac valve surgery. Method Reversible renal dysfunction (RRD) was defined as preoperative RD in patients who had not been initially diagnosed with chronic kidney disease (CKD). Cardiac function improvement (CFI) was defined as postoperative left ventricular ejection function – preoperative left ventricular ejection function (ΔEF) >0%, and cardiac function not improved (CFNI) as ΔEF ≤0%. Results Of the 4,805 (94%) cardiac valve surgery patients, 301 (6%) were RD cases. The AKI incidence in the RRD group (n=252) was significantly lower than in the CKD group (n=49) (36.5% vs 63.3%, P=0.018). The AKI and renal replacement therapy incidences in the CFI group (n=174) were significantly lower than in the CFNI group (n=127) (33.9% vs 50.4%, P=0.004; 6.3% vs 13.4%, P=0.037). After adjustment for age, gender, and other confounding factors, CKD and CKD + CFNI were identified as independent risk factors for AKI in all patients after cardiac valve surgery. Multivariate logistic regression analysis showed that the risk factors for postoperative AKI in preoperative RD patients were age, gender (male), hypertension, diabetes, chronic heart failure, cardiopulmonary bypass time (every 1 min added), and intraoperative hypotension, while CFI after surgery could reduce the risk. Conclusion For cardiac valve surgery patients, preoperative CKD was an independent risk factor for postoperative AKI, but RRD did not add to the risk. Improved postoperative cardiac function can significantly reduce the risk of postoperative AKI. PMID:29184415

Comparison of Transcutaneous Electrical Nerve Stimulation and Parasternal Block for Postoperative Pain Management after Cardiac Surgery

PubMed Central

Ozturk, Nilgun Kavrut; Baki, Elif Dogan; Kavakli, Ali Sait; Sahin, Ayca Sultan; Ayoglu, Raif Umut; Karaveli, Arzu; Emmiler, Mustafa; Inanoglu, Kerem; Karsli, Bilge

2016-01-01

Background. Parasternal block and transcutaneous electrical nerve stimulation (TENS) have been demonstrated to produce effective analgesia and reduce postoperative opioid requirements in patients undergoing cardiac surgery. Objectives. To compare the effectiveness of TENS and parasternal block on early postoperative pain after cardiac surgery. Methods. One hundred twenty patients undergoing cardiac surgery were enrolled in the present randomized, controlled prospective study. Patients were assigned to three treatment groups: parasternal block, intermittent TENS application, or a control group. Results. Pain scores recorded 4 h, 5 h, 6 h, 7 h, and 8 h postoperatively were lower in the parasternal block group than in the TENS and control groups. Total morphine consumption was also lower in the parasternal block group than in the TENS and control groups. It was also significantly lower in the TENS group than in the control group. There were no statistical differences among the groups regarding the extubation time, rescue analgesic medication, length of intensive care unit stay, or length of hospital stay. Conclusions. Parasternal block was more effective than TENS in the management of early postoperative pain and the reduction of opioid requirements in patients who underwent cardiac surgery through median sternotomy. This trial is registered with Clinicaltrials.gov number NCT02725229. PMID:27445610

Predictors of early and late stroke following cardiac surgery

PubMed Central

Whitlock, Richard; Healey, Jeff S.; Connolly, Stuart J.; Wang, Julie; Danter, Matthew R.; Tu, Jack V.; Novick, Richard; Fremes, Stephen; Teoh, Kevin; Khera, Vikas; Yusuf, Salim

2014-01-01

Background: Much is known about the short-term risks of stroke following cardiac surgery. We examined the rate and predictors of long-term stroke in a cohort of patients who underwent cardiac surgery. Methods: We obtained linked data for patients who underwent cardiac surgery in the province of Ontario between 1996 and 2006. We analyzed the incidence of stroke and death up to 2 years postoperatively. Results: Of 108 711 patients, 1.8% (95% confidence interval [CI] 1.7%–1.9%) had a stroke perioperatively, and 3.6% (95% CI 3.5%–3.7%) had a stroke within the ensuing 2 years. The strongest predictors of both early and late stroke were advanced age (≥ 65 year; adjusted hazard ratio [HR] for all stroke 1.9, 95% CI 1.8–2.0), a history of stroke or transient ischemic attack (adjusted HR 2.1, 95% CI 1.9–2.3), peripheral vascular disease (adjusted HR 1.6, 95% CI 1.5–1.7), combined coronary bypass grafting and valve surgery (adjusted HR 1.7, 95% CI 1.5–1.8) and valve surgery alone (adjusted HR 1.4, 95% CI 1.2–1.5). Preoperative need for dialysis (adjusted odds ratio [OR] 2.1, 95% CI 1.6–2.8) and new-onset postoperative atrial fibrillation (adjusted OR 1.5, 95% CI 1.3–1.6) were predictors of only early stroke. A CHADS2 score of 2 or higher was associated with an increased risk of stroke or death compared with a score of 0 or 1 (19.9% v. 9.3% among patients with a history of atrial fibrillation, 16.8% v. 7.8% among those with new-onset postoperative atrial fibrillation and 14.8% v. 5.8% among those without this condition). Interpretation: Patients who had cardiac surgery were at highest risk of stroke in the early postoperative period and had continued risk over the ensuing 2 years, with similar risk factors over these periods. New-onset postoperative atrial fibrillation was a predictor of only early stroke. The CHADS2 score predicted stroke risk among patients with and without atrial fibrillation. PMID:25047983

Effects of preoperative aspirin on cardiocerebral and renal complications in non-emergent cardiac surgery patients: a sub-group and cohort study.

PubMed

Cao, Longhui; Silvestry, Scott; Zhao, Ning; Diehl, James; Sun, Jianzhong

2012-01-01

Postoperative cardiocerebral and renal complications are a major threat for patients undergoing cardiac surgery. This study was aimed to examine the effect of preoperative aspirin use on patients undergoing cardiac surgery. An observational cohort study was performed on consecutive patients (n = 1879) receiving cardiac surgery at this institution. The patients excluded from the study were those with preoperative anticoagulants, unknown aspirin use, or underwent emergent cardiac surgery. Outcome events included were 30-day mortality, renal failure, readmission and a composite outcome--major adverse cardiocerebral events (MACE) that include permanent or transient stroke, coma, perioperative myocardial infarction (MI), heart block and cardiac arrest. Of all patients, 1145 patients met the inclusion criteria and were divided into two groups: those taking (n = 858) or not taking (n = 287) aspirin within 5 days preceding surgery. Patients with aspirin presented significantly more with history of hypertension, diabetes, peripheral arterial disease, previous MI, angina and older age. With propensity scores adjusted and multivariate logistic regression, however, this study showed that preoperative aspirin therapy (vs. no aspirin) significantly reduced the risk of MACE (8.4% vs. 12.5%, odds ratio [OR] 0.585, 95% CI 0.355-0.964, P = 0.035), postoperative renal failure (2.6% vs. 5.2%, OR 0.438, CI 0.203-0.945, P = 0.035) and dialysis required (0.8% vs. 3.1%, OR 0.230, CI 0.071-0.742, P = 0.014), but did not significantly reduce 30-day mortality (4.1% vs. 5.8%, OR 0.744, CI 0.376-1.472, P = 0.396) nor it increased readmissions in the patients undergoing cardiac surgery. Preoperative aspirin therapy is associated with a significant decrease in the risk of MACE and renal failure and did not increase readmissions in patients undergoing non-emergent cardiac surgery.

Task-related changes in degree centrality and local coherence of the posterior cingulate cortex after major cardiac surgery in older adults.

PubMed

Browndyke, Jeffrey N; Berger, Miles; Smith, Patrick J; Harshbarger, Todd B; Monge, Zachary A; Panchal, Viral; Bisanar, Tiffany L; Glower, Donald D; Alexander, John H; Cabeza, Roberto; Welsh-Bohmer, Kathleen; Newman, Mark F; Mathew, Joseph P

2018-02-01

Older adults often display postoperative cognitive decline (POCD) after surgery, yet it is unclear to what extent functional connectivity (FC) alterations may underlie these deficits. We examined for postoperative voxel-wise FC changes in response to increased working memory load demands in cardiac surgery patients and nonsurgical controls. Older cardiac surgery patients (n = 25) completed a verbal N-back working memory task during MRI scanning and cognitive testing before and 6 weeks after surgery; nonsurgical controls with cardiac disease (n = 26) underwent these assessments at identical time intervals. We measured postoperative changes in degree centrality, the number of edges attached to a brain node, and local coherence, the temporal homogeneity of regional functional correlations, using voxel-wise graph theory-based FC metrics. Group × time differences were evaluated in these FC metrics associated with increased N-back working memory load (2-back > 1-back), using a two-stage partitioned variance, mixed ANCOVA. Cardiac surgery patients demonstrated postoperative working memory load-related degree centrality increases in the left dorsal posterior cingulate cortex (dPCC; p < .001, cluster p-FWE < .05). The dPCC also showed a postoperative increase in working memory load-associated local coherence (p < .001, cluster p-FWE < .05). dPCC degree centrality and local coherence increases were inversely associated with global cognitive change in surgery patients (p < .01), but not in controls. Cardiac surgery patients showed postoperative increases in working memory load-associated degree centrality and local coherence of the dPCC that were inversely associated with postoperative global cognitive outcomes and independent of perioperative cerebrovascular damage. © 2017 Wiley Periodicals, Inc.

Circulating S100B and Adiponectin in Children Who Underwent Open Heart Surgery and Cardiopulmonary Bypass

PubMed Central

Varrica, Alessandro; Satriano, Angela; Frigiola, Alessandro; Giamberti, Alessandro; Tettamanti, Guido; Conforti, Erika; Gavilanes, Antonio D. W.; Zimmermann, Luc J.; Vles, Hans J. S.; Li Volti, Giovanni

2015-01-01

Background. S100B protein, previously proposed as a consolidated marker of brain damage in congenital heart disease (CHD) newborns who underwent cardiac surgery and cardiopulmonary bypass (CPB), has been progressively abandoned due to S100B CNS extra-source such as adipose tissue. The present study investigated CHD newborns, if adipose tissue contributes significantly to S100B serum levels. Methods. We conducted a prospective study in 26 CHD infants, without preexisting neurological disorders, who underwent cardiac surgery and CPB in whom blood samples for S100B and adiponectin (ADN) measurement were drawn at five perioperative time-points. Results. S100B showed a significant increase from hospital admission up to 24 h after procedure reaching its maximum peak (P < 0.01) during CPB and at the end of the surgical procedure. Moreover, ADN showed a flat pattern and no significant differences (P > 0.05) have been found all along perioperative monitoring. ADN/S100B ratio pattern was identical to S100B alone with the higher peak at the end of CPB and remained higher up to 24 h from surgery. Conclusions. The present study provides evidence that, in CHD infants, S100B protein is not affected by an extra-source adipose tissue release as suggested by no changes in circulating ADN concentrations. PMID:26417594

[Changes in whole blood ionized magnesium concentration during cardiac surgery employing St. Thomas' cardioplegic solution].

PubMed

Chang, Kyung-ho; Bougaki, Masahiko; Kubota, Ryou; Tsubaki, Kumiko; Matsuo, Hideki; Hanaoka, Kazuo

2003-04-01

Although there is growing evidence to suggest that magnesium supplementation to patients undergoing cardiac surgery is beneficial, the way to administer magnesium is not established. Moreover in Japan St Thomas' cardioplegic solution, containing a high level of magnesium is widely used and the effect of such magnesium-rich cardioplegic solutions on blood magnesium concentration has not been well defined. We measured ionized magnesium concentrations (iMg) during cardiac surgery employing St Thomas' solution. Patients were divided into four groups. Group 1 patients were adults and group 2 were children, both of whom received St. Thomas' solution. Group 3 patients underwent cardiopulmonary bypass but did not receive any cardioplegic solution. Group 4 patients underwent off-pump coronary artery bypass grafting. In cardioplegia group (group 1 and 2) iMg was higher than the normal reference range at periods of rewarming, immediately postbypass, and at the end of the operation. iMg at immediately postbypass was related to the total amount of cardioplegic solution. In non-cardioplegia group (group 3 and 4) progressive decrease of iMg was observed throughout the operation. Because magnesium in cardioplegic solutions has substantial effect on perioperative iMg, it is crucial to measure iMg to avoid overdose of magnesium when magnesium-rich cardioplegic solutions are employed.

Cardiac surgery in systemic lupus erythematosus patients: Clinical characteristics and outcomes.

PubMed

Tejeda-Maldonado, Javier; Quintanilla-González, Lauro; Galindo-Uribe, Jaime; Hinojosa-Azaola, Andrea

2017-03-11

To study the clinical characteristics and outcomes in systemic lupus erythematosus (SLE) patients who underwent cardiac surgery. Retrospective analysis of 30 SLE patients who underwent cardiac surgery at a single center. Demographics, comorbidities, clinical and serologic characteristics, cardiovascular risk scores and treatment were recorded. Type of surgery, postoperative complications, mortality and histology were analyzed. Disease duration at surgery was 2 years. Valve replacement was the procedure most frequently performed (53%), followed by pericardial window (37%). At least one postoperative complication developed in 63% (mainly infections). An aortic cross-clamp time≥76minutes was associated with at least one postoperative complication (OR 6.4, 95% CI 1.1-35.4, p=.03). Early death occurred in 5 patients (17%) and late in 3 (10%); main causes were sepsis and heart failure. Disease activity was associated with pericardial window (OR 12.6, 95% CI 1.9-79, p=.007); lymphopenia≤1.200 (OR 10.1, 95% CI 1.05-97, p=.04); age≤30 years (OR 7.7, 95% CI 1.2-46.3, p=.02); and New York Heart Association class III (OR 7.0, 95% CI 1.1-42, p=.03). Postoperative infection was associated with length of hospital stay≥2 weeks (OR 54.9, 95% CI 5.0-602.1, p=.001); intensive care unit stay≥10 days (OR 20, 95% CI 1.6-171.7, p=.01); duration of mechanical ventilation≥5 days (OR 16.9, 95% CI 1.5-171.7, p=.01); and pulmonary artery systolic pressure≥50mmHg (OR 7.8, 95% CI 1.4-41.2, p=.01). Cardiac surgery in SLE confers high morbidity and mortality. SLE-specific preoperative risk scores should be designed to identify prognostic factors. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.

Predictors of operating room extubation in adult cardiac surgery.

PubMed

Subramaniam, Kathirvel; DeAndrade, Diana S; Mandell, Daniel R; Althouse, Andrew D; Manmohan, Rajan; Esper, Stephen A; Varga, Jeffrey M; Badhwar, Vinay

2017-11-01

The primary objective of the study was to identify perioperative factors associated with successful immediate extubation in the operating room after adult cardiac surgery. The secondary objective was to derive a simplified predictive scoring system to guide clinicians in operating room extubation. All 1518 patients in this retrospective cohort study underwent standardized fast-track cardiac anesthetic protocol during adult cardiac surgery. Perioperative variables between patients who had successful extubation in the operating room versus in the intensive care unit were retrospectively analyzed using both univariate and multivariable logistic regression analyses. A predictive score of successful operating room extubation was constructed from the multivariable results of 800 patients (derivation set), and the scoring system was further tested using a validation set of 398 patients. Younger age, lower body mass index, higher preoperative serum albumin, absence of chronic lung disease and diabetes, less-invasive surgical approach, isolated coronary bypass surgery, elective surgery, and lower doses of intraoperative intravenous fentanyl were independently associated with higher probability of operating room extubation. The extubation prediction score created in a derivation set of patients performed well in the validation set. Patient scores less than 0 had a minimal probability of successful operating room extubation. Operating room extubation was highly predicted with scores of 5 or greater. Perioperative factors that are independently associated with successful operating room extubation after adult cardiac operations were identified, and an operating room extubation prediction scoring system was validated. This scoring system may be used to guide safe operating room extubation after cardiac operations. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Inspiratory Muscle Training and Functional Capacity in Patients Undergoing Cardiac Surgery.

PubMed

Cordeiro, André Luiz Lisboa; de Melo, Thiago Araújo; Neves, Daniela; Luna, Julianne; Esquivel, Mateus Souza; Guimarães, André Raimundo França; Borges, Daniel Lago; Petto, Jefferson

2016-04-01

Cardiac surgery is a highly complex procedure which generates worsening of lung function and decreased inspiratory muscle strength. The inspiratory muscle training becomes effective for muscle strengthening and can improve functional capacity. To investigate the effect of inspiratory muscle training on functional capacity submaximal and inspiratory muscle strength in patients undergoing cardiac surgery. This is a clinical randomized controlled trial with patients undergoing cardiac surgery at Instituto Nobre de Cardiologia. Patients were divided into two groups: control group and training. Preoperatively, were assessed the maximum inspiratory pressure and the distance covered in a 6-minute walk test. From the third postoperative day, the control group was managed according to the routine of the unit while the training group underwent daily protocol of respiratory muscle training until the day of discharge. 50 patients, 27 (54%) males were included, with a mean age of 56.7±13.9 years. After the analysis, the training group had significant increase in maximum inspiratory pressure (69.5±14.9 vs. 83.1±19.1 cmH2O, P=0.0073) and 6-minute walk test (422.4±102.8 vs. 502.4±112.8 m, P=0.0031). We conclude that inspiratory muscle training was effective in improving functional capacity submaximal and inspiratory muscle strength in this sample of patients undergoing cardiac surgery.

Novel Method of Infection Prophylaxis in Heart Transplantation by Retrosternal Gentamycin Sponge Application.

PubMed

Urbanowicz, T; Straburzyńska-Migaj, E; Buczkowski, P; Grajek, S; Jemielity, M

2015-01-01

Surgical wound infections are more frequent in patients undergoing heart transplantation than in other heart surgery patients. There is a wide spread of sternal wound infection incidence in transplant patients ranging from 4% to 40%. It is first study describing local gentamicin sponge application during heart transplantation procedure. We enrolled 75 patients in a retrospective, single-center study, including 25 patients who underwent orthotopic heart transplantation (heart transplant group) and 50 in the cardiac surgery group. They were in mean age of 49 ± 12 years and 51 ± 13 years in heart transplantation and cardiac surgery group, respectively. A gentamicin sponge was inserted intraoperatively between sternal borders before chest closure in all heart transplantation patients. There was 1 early death (4%) on postoperative day 7 owing to Clostridium difficile infection in the heart transplant group. There was 1 death (2%) in the cardiac surgery group owing to multiorgan failure secondary to perioperative heart ischemia. There was neither bacterial sternal wound infection nor sternal instability in the heart transplant group. None of the patients who had gentamicin sponge applied had wound healing problems. Two patients (4%) had a deep sternal wound infection in the cardiac surgery group, who had no sponge application; 1 (2%) was treated by surgical debridement and active drainage and 1 (2%) by vacuum therapy. There were 11 patients (44%) discharged on insulin therapy in the heart transplant group and 21 (21%) in the cardiac surgery group. Mean overall postoperative hospital stay was 35 ± 19 days in the heart transplant group and 10 ± 4 days in the cardiac surgery group. Gentamicin sponge is an effective local infection prophylaxis in heart transplant patients. Copyright © 2015 Elsevier Inc. All rights reserved.

Additional effects of topical tranexamic acid in on-pump cardiac surgery.

PubMed

Taksaudom, Noppon; Siwachat, Sophon; Tantraworasin, Apichat

2017-01-01

Objective Postoperative bleeding after cardiac surgery is commonly associated with hyperfibrinolysis. This study was designed to evaluate the efficacy of topical tranexamic acid in addition to intravenous tranexamic acid in reducing bleeding in cardiac surgery cases. Methods From July 1, 2014 to September 30, 2015, 82 patients who underwent elective on-pump cardiac surgery were randomized into a tranexamic acid group and a placebo group. In the tranexamic acid group, 1 g of tranexamic acid dissolved in 100 mL of normal saline solution was poured into the pericardium during sternal closure; the placebo group had 100 mL of saline only. Two patients were excluded from the study due to obvious surgical bleeding. The primary endpoint was total blood loss 24 h after surgery. Repeated measures with mixed models was used to analyze bleeding over time. Results There was no significant difference in demographic and intraoperative data except for a significantly lower platelet count preoperatively in the tranexamic acid group ( p = 0.030). There was no significant difference in postoperative drainage volumes at 8, 16, and 24 h, postoperative bleeding over time (coefficient = 0.713, p = 0.709), or blood product transfusion between the groups. There were no serious complications. Conclusions Topical tranexamic acid is safe but it adds no additional efficacy to the intravenous application in reducing postoperative blood loss. Intravenous tranexamic acid administration alone is sufficient antifibrinolytic treatment to enhance the hemostatic effects during on-pump cardiac surgery.

Analysis of steps adapted protocol in cardiac rehabilitation in the hospital phase

PubMed Central

Winkelmann, Eliane Roseli; Dallazen, Fernanda; Bronzatti, Angela Beerbaum Steinke; Lorenzoni, Juliara Cristina Werner; Windmöller, Pollyana

2015-01-01

Objective To analyze a cardiac rehabilitation adapted protocol in physical therapy during the postoperative hospital phase of cardiac surgery in a service of high complexity, in aspects regarded to complications and mortality prevalence and hospitalization days. Methods This is an observational cross-sectional, retrospective and analytical study performed by investigating 99 patients who underwent cardiac surgery for coronary artery bypass graft, heart valve replacement or a combination of both. Step program adapted for rehabilitation after cardiac surgery was analyzed under the command of the physiotherapy professional team. Results In average, a patient stays for two days in the Intensive Care Unit and three to four days in the hospital room, totalizing six days of hospitalization. Fatalities occurred in a higher percentage during hospitalization (5.1%) and up to two years period (8.6%) when compared to 30 days after hospital discharge (1.1%). Among the postoperative complications, the hemodynamic (63.4%) and respiratory (42.6%) were the most prevalent. 36-42% of complications occurred between the immediate postoperative period and the second postoperative day. The hospital discharge started from the fifth postoperative day. We can observe that in each following day, the patients are evolving in achieving the Steps, where Step 3 was the most used during the rehabilitation phase I. Conclusion This evolution program by steps can to guide the physical rehabilitation at the hospital in patients after cardiac surgery. PMID:25859866

Analysis of steps adapted protocol in cardiac rehabilitation in the hospital phase.

PubMed

Winkelmann, Eliane Roseli; Dallazen, Fernanda; Bronzatti, Angela Beerbaum Steinke; Lorenzoni, Juliara Cristina Werner; Windmöller, Pollyana

2015-01-01

To analyze a cardiac rehabilitation adapted protocol in physical therapy during the postoperative hospital phase of cardiac surgery in a service of high complexity, in aspects regarded to complications and mortality prevalence and hospitalization days. This is an observational cross-sectional, retrospective and analytical study performed by investigating 99 patients who underwent cardiac surgery for coronary artery bypass graft, heart valve replacement or a combination of both. Step program adapted for rehabilitation after cardiac surgery was analyzed under the command of the physiotherapy professional team. In average, a patient stays for two days in the Intensive Care Unit and three to four days in the hospital room, totalizing six days of hospitalization. Fatalities occurred in a higher percentage during hospitalization (5.1%) and up to two years period (8.6%) when compared to 30 days after hospital discharge (1.1%). Among the postoperative complications, the hemodynamic (63.4%) and respiratory (42.6%) were the most prevalent. 36-42% of complications occurred between the immediate postoperative period and the second postoperative day. The hospital discharge started from the fifth postoperative day. We can observe that in each following day, the patients are evolving in achieving the Steps, where Step 3 was the most used during the rehabilitation phase I. This evolution program by steps can to guide the physical rehabilitation at the hospital in patients after cardiac surgery.

Effect of magnesium on arrhythmia incidence in patients undergoing coronary artery bypass grafting.

PubMed

Mohammadzadeh, Alireza; Towfighi, Farshad; Jafari, Naser

2018-06-01

Cardiac arrhythmia after coronary artery bypass grafting (CABG) surgery is a common complication of cardiac surgery. The effect of serum magnesium, hypomagnesaemia treatment and prophylactic administration of magnesium in the development and prevention of arrhythmias is controversial and there are many different ideas. This study evaluates the therapeutic effects of magnesium in cardiac arrhythmia after CABG surgery. The clinical trial enrolled 250 patients who underwent CABG. Based on the initial serum levels of magnesium, patients were divided into two groups: hypomagnesium and normomagnesium. Based on bioethics committee requirements, patients in the hypo-magnesium group received magnesium treatments until they attained normal magnesium blood levels. Both groups underwent CABG with normal blood levels of magnesium. After surgery, each group was randomly divided into two subgroups: one subgroup received a bolus dose of magnesium sulphate (30 mg/kg in 5 min) and the other subgroup received a placebo. Subgroups were under observation in the intensive care unit for 3 days and arrhythmias were recorded. Data from all four subgroups were analysed statistically and interpreted. The results of this study showed that the occurrence of arrhythmia was not significantly different among subgroups (P > 0.05). There was no significant relationship between blood levels of magnesium and arrhythmia during the 3 days post-surgery (P > 0.05). The results of this study showed that magnesium sulphate administration did not significantly improve the incidence of arrhythmias in hypo- and normo-magnesium patients after CABG. There was no significant correlation between post-operative serum levels of magnesium and arrhythmia during 3 days. © 2017 Royal Australasian College of Surgeons.

Surgery for atrial fibrillation.

PubMed

Viganò, M; Graffigna, A; Ressia, L; Minzioni, G; Pagani, F; Aiello, M; Gazzoli, F

1996-01-01

The mechanisms of atrial fibrillation arc multiple reentry circuits spinning around the atrial surface, and these baffle any attempt to direct surgical interruption. The purpose of this article is to report the surgical experience in the treatment of isolated and concomitant atrial fibrillation at the Cardiac Surgical Institute of the University of Pavia. In cases of atrial fibrillation secondary to mitral/valve disease, surgical isolation of the left atrium at the time of mitral valve surgery can prevent atrial fibrillation from involving the right atrium, which can exert its diastolic pump function on the right ventricle. Left atrial isolation was performed on 205 patients at the time of mitral valve surgery. Atrial partitioning ("maze operation") creates straight and blind atrial alleys so that non-recentry circuits can take place. Five patients underwent this procedure. In eight-cases of atrial fibrillation secondary to atrial septal defect, the adult patients with atrial septal defect and chronic or paroxysmal atrial fibrillation underwent surgical isolation of the right atrium associated which surgical correction of the defect, in order to let sinus rhythm govern the left atrium and the ventricles. "Lone" atrial fibrillation occurs in hearts with no detectable organic disease. Bi-atrial isolation with creation of an atrial septal internodal "corridor" was performed on 14 patients. In cases of atrial fibrillation secondary to mitral valve disease, left atrial isolation was performed on 205 patients at the time of mitral valve surgery with an overall sinus rhythm recovery of 44%. In the same period, sinus rhythm was recovered and persisted in only 19% of 252 patients who underwent mitral valve replacement along (P < 0.001). Sinus rhythm was less likely to recover in patients with right atriomegaly requiring tricuspid valve annuloplasty: 59% vs 84% (P < 0.001). Restoration of the right atrial function raised the cardiac index from 2.25 +/- 0.55 1/min per m2 during atrial fibrillation to 2.54 +/- 0.58 1/min per m2, with a mean percentage increase in cardiac index of 13.5% (P < 0.00018). Atrial partitioning ("maze operation") was performed on five patients with an immediate sinus rhythm recovery of 100%, but with two patients requiring pacemaker implant. Seven out of eight patients (87.5%), with atrial fibrillation secondary to atrial septal defect, who underwent surgical isolation of the right atrium at the time of surgery were free from atrial fibrillation and without medications. 2-52 months after operation. Thirteen of 14 patients with "lone" atrial fibrillation who underwent corridor procedure remained in sinus rhythm with a sinus rhythm recovery rate of 92%. Different surgical options can be chosen for different cases of atrial fibrillation, according to the underlying cardiac disease.

American College of Cardiology/American Heart Association preoperative assessment guidelines reduce resource utilization before aortic surgery.

PubMed

Froehlich, James B; Karavite, Dean; Russman, Pamela L; Erdem, Nurum; Wise, Chris; Zelenock, Gerald; Wakefield, Thomas; Stanley, James; Eagle, Kim A

2002-10-01

Methods used for evaluation of cardiac risk before noncardiac surgery vary widely. We evaluated the effect over time on practice and resource utilization of implementing the American College of Cardiology/American Heart Association Guidelines on Preoperative Risk Assessment. We compared 102 historical control patients who underwent elective abdominal aortic surgery (from January 1993 to December 1994) with 94 consecutive patients after guideline implementation (from July 1995 to December 1996) and 104 patients in a late after guideline implementation (from July 1, 1997, to September 30, 1998). Resource use (testing, revascularization, and costs) and outcomes (perioperative death and myocardial infarction) were examined. Patients with and without clinical markers of risk for perioperative cardiac complications were compared. The use of preoperative stress testing (88% to 47%; P <.00001), cardiac catheterization (24% to 11%; P <.05), and coronary revascularization (25% to 2%; P <.00001) decreased between control and postguideline groups, respectively. These changes persisted in the late postguideline group. Mean preoperative evaluation costs also fell ($1087 versus $171; P <.0001). Outcomes of death (4% versus 3% versus 2%) and myocardial infarction (7% versus 3% versus 5%) were not significantly different between control, postguideline, and late postguideline groups, respectively. Stress test rates were similar for patients at low risk versus high risk in the historical control group (84% versus 91%; P =.29) but lower for patients at low risk after guideline implementation (31% versus 61%; P =.003). Implementation of the American College of Cardiology/American Heart Association cardiac risk assessment guidelines appropriately reduced resource use and costs in patients who underwent elective aortic surgery without affecting outcomes. This effect was sustained 2 years after guideline implementation.

External Validation of European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) for Risk Prioritization in an Iranian Population

PubMed Central

Atashi, Alireza; Amini, Shahram; Tashnizi, Mohammad Abbasi; Moeinipour, Ali Asghar; Aazami, Mathias Hossain; Tohidnezhad, Fariba; Ghasemi, Erfan; Eslami, Saeid

2018-01-01

Introduction The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) is a prediction model which maps 18 predictors to a 30-day post-operative risk of death concentrating on accurate stratification of candidate patients for cardiac surgery. Objective The objective of this study was to determine the performance of the EuroSCORE II risk-analysis predictions among patients who underwent heart surgeries in one area of Iran. Methods A retrospective cohort study was conducted to collect the required variables for all consecutive patients who underwent heart surgeries at Emam Reza hospital, Northeast Iran between 2014 and 2015. Univariate and multivariate analysis were performed to identify covariates which significantly contribute to higher EuroSCORE II in our population. External validation was performed by comparing the real and expected mortality using area under the receiver operating characteristic curve (AUC) for discrimination assessment. Also, Brier Score and Hosmer-Lemeshow goodness-of-fit test were used to show the overall performance and calibration level, respectively. Results Two thousand five hundred eight one (59.6% males) were included. The observed mortality rate was 3.3%, but EuroSCORE II had a prediction of 4.7%. Although the overall performance was acceptable (Brier score=0.047), the model showed poor discriminatory power by AUC=0.667 (sensitivity=61.90, and specificity=66.24) and calibration (Hosmer-Lemeshow test, P<0.01). Conclusion Our study showed that the EuroSCORE II discrimination power is less than optimal for outcome prediction and less accurate for resource allocation programs. It highlights the need for recalibration of this risk stratification tool aiming to improve post cardiac surgery outcome predictions in Iran. PMID:29617500

Lung Transplantation From Donors After Previous Cardiac Surgery: Ideal Graft in Marginal Donor?

PubMed

Palleschi, A; Mendogni, P; Tosi, D; Montoli, M; Carrinola, R; Mariolo, A V; Briganti, F; Nosotti, M

2017-05-01

Lung transplantation is a limited by donor pool shortage. Despite the efforts to extend the graft acceptability with recurrent donor criteria reformulations, previous cardiothoracic surgery is still considered a contraindication. A donor who underwent cardiac surgery could potentially provide an ideal lung but high intraoperative risks and intrinsic technical challenges are expected during the graft harvesting. The purpose of this study is to present our dedicated protocol and four clinical cases of successful lung procurements from donors who had a previous major cardiac surgery. One donor had ascending aortic root (AAR) substitution, another had mitral valve substitution, and two had coronary artery bypass surgery. The others' eligibility criteria for organ allocation, such as ABO compatibility, PaO 2 /FiO 2 ratio, absence of aspiration, or sepsis were respected. In one of the cases with previous coronary bypass grafting, the donor had a veno-arterial extracorporeal membrane oxygenation support. Consequently, the grafts required an ex vivo lung perfusion evaluation. We report the technical details of procurement and postoperative courses of recipients. All procurements were uneventful, without lung damage or waste of abdominal organs related to catastrophic intraoperative events. All recipients had a successful clinical outcome. We believe that successful transplantation is achievable even in a complicated setting, such as cases involving donors with previous cardiac surgery frequently are. Facing lung donor shortage, we strongly support any effort to avoid the loss of possible acceptable lungs. In particular, previous major cardiac surgery does not strictly imply a poor quality of lungs as well as unsustainable graft procurement. Copyright © 2017 Elsevier Inc. All rights reserved.

Peri-operative heart-type fatty acid binding protein is associated with acute kidney injury after cardiac surgery

PubMed Central

Schaub, Jennifer A.; Garg, Amit X.; Coca, Steven G.; Testani, Jeffrey M.; Shlipak, Michael G.; Eikelboom, John; Kavsak, Peter; McArthur, Eric; Shortt, Colleen; Whitlock, Richard; Parikh, Chirag R.

2015-01-01

Acute Kidney Injury (AKI) is a common complication after cardiac surgery and is associated with worse outcomes. Since heart fatty acid binding protein (H-FABP) is a myocardial protein that detects cardiac injury, we sought to determine if plasma H-FABP was associated with AKI in the TRIBE-AKI cohort; a multi-center cohort of 1219 patients at high risk for AKI who underwent cardiac surgery. The primary outcomes of interest were any AKI (Acute Kidney Injury Network (AKIN) stage 1 or higher) and severe AKI (AKIN stage 2 or higher). The secondary outcome was long-term mortality after discharge. Patients who developed AKI had higher levels of H-FABP pre- and post-operatively than patients who did not have AKI. In analyses adjusted for known AKI risk factors, first post-operative log(H-FABP) was associated with severe AKI (adjusted OR 5.39 [95% CI, 2.87-10.11] per unit increase), while pre-operative log(H-FABP) was associated with any AKI (2.07 [1.48-2.89]) and mortality (1.67 [1.17-2.37]). These relationships persisted after adjustment for change in serum creatinine (for first postoperative log(H-FABP)) and biomarkers of cardiac and kidney injury, including brain natriuretic peptide, cardiac troponin-I, interleukin-18, liver fatty acid binding protein, kidney injury molecule-1, and neutrophil gelatinase associated lipocalin. Thus, peri-operative plasma H-FABP levels may be used for risk-stratification of AKI and mortality following cardiac surgery. PMID:25830762

Giant cardiac hydatid cyst with rare adhesions.

PubMed

Poorzand, Hoorak; Teshnizi, Mohammad Abbasi; Baghini, Vahid Shojaei; Gifani, Mehrnoosh; Gholoobi, Arash; Zirak, Nahid

2014-01-01

We present a 29-year-old woman who was admitted to the emergency department with shortness of breath. Using echocardiography, a giant multi-cystic mass was detected in the right ventricle, attached to the septal leaflet of the tricuspid valve and basal portion of the interventricular septum. Serologic tests (hydatid cyst antibody) confirmed Echinococcus infection. Lung computed tomography with intravenous contrast showed involvement of the pulmonary vasculature. The patient underwent cardiac surgery and the large cardiac cyst and the one in the right pulmonary artery branch were both removed. The tricuspid valve was also replaced by a bioprosthetic one. Albendazole was started preoperatively and was continued for six months after surgery. The patient recovered uneventfully and was followed up for one year. This is a report of a rare case of a very large cardiac hydatid cyst complicated by pulmonary embolism with attachments to both the tricuspid valve and interventricular septum.

The Effect of Previous Coronary Artery Revascularization on the Adverse Cardiac Events Ninety days After Total Joint Arthroplasty.

PubMed

Feng, Bin; Lin, Jin; Jin, Jin; Qian, Wenwei; Cao, Shiliang; Weng, Xisheng

2018-01-01

Although coronary artery revascularization therapies are effective for treating coronary artery disease (CAD), these patients may be more susceptible to adverse cardiac events during later non-cardiac surgeries. The purpose of this study is to evaluate post-operative 90-day complications of total joint arthroplasty (TJA) in CAD patients with a history of CAD and to study the risk factors for cardiac complications. We performed a retrospective analysis of TJA patients between 2005 and 2015 at our institute by summarizing the history of CAD, cardiac revascularization, and cardiac complications within 90 days after the operation. Multivariate logistic regression was performed to identify the factors that predicted cardiac complications within 90 days after the operation. A total of 4414 patients were included; of these, 64 underwent cardiac revascularization and 201 CAD patients underwent medical therapy other than revascularization. All the revascularization had history of myocardial infarction (MI). The rate of cardiac complications within 90 days for the CAD with revascularization was 18.7%, 18.4% for the CAD without revascularization, and 2.0% for the non-CAD group. A history of CAD and revascularization, bilateral TJA, general anesthesia, body mass index ≥30 kg/m 2 , and history of MI were associated with a higher risk of cardiac complications. Patients who underwent TJA within 2 years after cardiac revascularization had a significantly higher cardiac complication rate, and the risk decreased with time. There is an increased risk of cardiac complications within 90 days after the operation among TJA patients with a history of CAD. Revascularization cannot significantly reduce the risk of cardiac complications after TJA for CAD patients. However, the risk decreased as the interval between revascularization and TJA increased. Copyright © 2017 Elsevier Inc. All rights reserved.

Management of LVAD Patients for Noncardiac Surgery: A Single-Institution Study.

PubMed

Nelson, Eric W; Heinke, Timothy; Finley, Alan; Guldan, G J; Gaddy, Parker; Matthew Toole, J; Mims, Ryan; Abernathy, J H

2015-08-01

To describe the experience regarding the perioperative management of patients with left ventricular assist devices (LVADs) who require anesthesia while undergoing noncardiac surgery (NCS) at a single medical center. Retrospective chart review Academic medical center Patients with LVADs Medical records from April 1, 2009 through January 31, 2014 were reviewed for patients who underwent Heartmate II LVAD placement at this facility. Individual records were reviewed for NCS after LVAD placement, specifically investigating perioperative and anesthetic management. Seventy-one patients underwent LVAD placement during this time period. Thirty-five patients (49%) underwent a total of 101 NCS procedures. Arterial catheters were placed in 19 patients (19%), and 33 patients (33%) were intubated for their procedure. No complications or perioperative mortality occurred related to the NCS. Noncardiac surgery is becoming more common in patients with LVADs. Anesthetic management of these patients outside of the cardiac operating room is limited. Patients with Heartmate II LVADs can safely undergo noncardiac surgery. Copyright © 2015 Elsevier Inc. All rights reserved.

[Mortality following cardiac surgery in the National Health Service Hospitals of the Community of Valencia in 2007: a descriptive analysis].

PubMed

Vicente, R; Pajares, A; Vicente, J L; Aparicio, R; Loro, J M; Moreno, I; Soria, A; López, A; Porta, J; de la Fuente, C; Herrera, P; Tur, A; Osseyran, F; Guillén, A; Martí, F; Llagunes, J; Mateo, E; Aguar, F; Peña, J J; Marqués, J I; Ripoll, A; Reina, C; Ferrandis, P; Muedra, V; Llopis, E; Cantó, M; García, C

2010-02-01

To analyze clinical records of cardiac surgery patients in an attempt to identify factors associated with mortality in the postoperative critical care units of the public health service hospitals in the Community of Valencia, Spain, in 2007. Retrospective study of cases from January 1, 2007 to December 31, 2007. The charts of all patients who underwent cardiac surgery with or without extracorporeal circulation were reviewed. A data collection protocol was followed to obtain information on age, sex, body mass index (BMI), presurgical risk factors, type of surgery, duration of extracorporeal circulation, duration of ischemia, cause of death, and length of stay in the postoperative critical care unit. The study population consisted of 2113 patients at 5 public hospitals; 124 patients (70 men, 54 women) died. The mean (SD) age was 70 (9.43) years (range, 36-91 years). The mean BMI was 28.19 kg/m2 (maximum, 42 kg/m2). The mean Euroscore was 21.92 (maximum, 94.29). Hypertension was present as a preoperative risk factor in most patients (74.2%); dyslipidemia was present in 51.6%, diabetes mellitus in 38.7%, stroke in 73%, and renal failure in 2.4%. It was noteworthy was that the group who underwent coronary revascularization had the highest mortality rate (nearly 35% of the 124 patients). The next highest mortality rate (19.4%) was in patients who had combined procedures (valve repair or substitution plus coronary revascularization). Mortality was 18.5% in the group undergoing aortic valve surgery and 11.3% in those undergoing mitral valve surgery. The mean duration of extracorporeal circulation was 148.63 minutes. The mean duration of myocardial ischemia was 94.91 minutes. The most frequent cause of death was cardiogenic shock (54.8%). This was followed by distributive shock (29.8%) and hemorrhagic shock (8.9%). The mean length of stay in the postoperative critical care unit was 13.6 days. Overall mortality was 5.87%. The highest mortality rate among cardiac surgery patients in postoperative critical care units in hospitals in the Community of Valencia in 2007 was in patients who underwent coronary revascularization. The most prevalent preoperative risk factor was hypertension. Cardiogenic shock and distributive shock were the most frequent causes of death in these patients. A system for classifying risk is needed in order to predict mortality in critical care units and improve perioperative care.

Ulinastatin administration is associated with a lower incidence of acute kidney injury after cardiac surgery: a propensity score matched study.

PubMed

Wan, Xin; Xie, Xiangcheng; Gendoo, Yasser; Chen, Xin; Ji, Xiaobing; Cao, Changchun

2016-02-17

Systemic inflammation is involved in the development of acute kidney injury (AKI) after cardiac surgery with cardiopulmonary bypass (CPB). Ulinastatin, a urinary trypsin inhibitor (UTI), possesses a variety of anti-inflammatory effects. Therefore, we hypothesized that the administration of ulinastatin would reduce the occurrence of AKI in patients undergoing cardiac surgery with CPB. A retrospective propensity score matched analysis was used to evaluate the effect of ulinastatin on the development of AKI in patients undergoing first documented cardiac surgery with CPB between January 2008 and December 2012 in our hospital. Multiple logistic regression models were also employed to identify the association between UTI administration and development of AKI. A total of 2072 patients who underwent cardiac surgery with CPB met the inclusion criteria. Before propensity score matching, variables such as age, baseline creatinine, CPB duration, red blood cells transfused, and hematocrit were statistically different between the ulinastatin (UTI) group and the control group. On the basis of propensity scores, 409 UTI patients were successfully matched to the 409 patients from among those 1663 patients without UTI administration. After propensity score matching, no statistically significant differences in the baseline characteristics were found between the UTI group and the control group. The propensity score matched cohort analysis revealed that AKI and the need for renal replacement therapy occurred more frequently in the control group than in the UTI group (40.83% vs. 30.32%, P = 0.002; 2.44% vs. 0.49%, P = 0.02, respectively). However, there were no significant differences in mortality, length of intensive care unit stay, and length of hospital stay between the UTI group and the control group. Using multivariate logistic regression analysis, we found ulinastatin played a protective role in the development of AKI after cardiac surgery (odds ratio 0.71, 95% confidence interval 0.56-0.90, P = 0.005). This study shows that ulinastatin was associated with a lower incidence of AKI after cardiac surgery, suggesting that the administration of ulinastatin may be favorable for those patients undergoing cardiac surgery with CPB.

Comparison of outcome in Jehovah's Witness patients in cardiac surgery: an Australian experience.

PubMed

Bhaskar, B; Jack, R K; Mullany, D; Fraser, J

2010-11-01

Despite the advances in modern medicine, cardiac surgery remains associated with significant amounts of blood transfusion and is responsible for nearly 20% of all transfusions in Australasia. Progressive advances in perfusion technology and perioperative supportive management have made it possible for members of the Jehovah's Witnesses (JW) religious group to undergo open cardiac operations with remarkable safety. This study systematically compares the operative mortality and early clinical outcome after cardiac surgery in JWs. Data was obtained from the cardiac surgery and intensive care unit databases from January 2002 to December 2005. A total of 5353 patients who underwent cardiac surgical procedures including coronary artery bypass grafting with cardiopulmonary bypass (n=4041) and valvular heart surgery (n=2287) were assessed in this study. Of the 5353 patients 49 patients refused blood and blood products because of their religious beliefs. Models were constructed to determine the association between JWs and non-JWs and three outcomes: (1) operative mortality, (2) postoperative variables and (3) length of stay in intensive care unit. Propensity scores were computed from these models and used to match JWs with non-JWs. There were minimal differences in the baseline patient demographic characteristics between the two groups. Haemoglobin and haematocrit levels were higher in JWs both before (13.7g/dL vs 12.8g/dL; P=0.01, and 40.0% vs 39.2%; P=0.08) and after (10.8g/dL vs 9.9g/dL; P=.003, and 34.0% vs 30.9%; P=.001) surgery. Jehovah's Witnesses experienced significantly less bleeding, almost half compared to the control group, with P<0.001. No differences were found in the adjusted and unadjusted operative mortality or intensive care unit and postoperative length of stay between the two groups. This study concurs with the international published data that outcomes for JW patients who undergo cardiac surgery are similar to those who receive transfusion. Every appropriate opportunity to reduce the use of allogeneic blood products. Copyright © 2010 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. All rights reserved.

Bariatric Surgery Is Gaining Ground as Treatment of Obesity After Heart Transplantation: Report of Two Cases.

PubMed

Tsamalaidze, Levan; Elli, Enrique F

2017-11-01

Experience with bariatric surgery in patients after orthotopic heart transplantation (OHT) is still limited. We performed a retrospective review of patients who underwent bariatric surgery after OHT from January 1, 2010 to December 31, 2016. Two post-OHT patients with BMI of 37.5 and 36.2 kg/m² underwent laparoscopic robotic-assisted Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy, respectively. Quality of life substantially improved for both patients. Bariatric surgery is safe and feasible in OHT patients, despite numerous risk factors. Careful selection of patients is required with proper preoperative management and overall care. Due to the complexity of treatment and perioperative care in this specific population, these operations should be done in high-volume centers with multidisciplinary teams composed of bariatric, cardiac transplant surgeons and critical care physicians. Bariatric surgery can be highly effective for treatment of obesity after OHT.

Outcomes of surgical intervention for anomalous aortic origin of a coronary artery: A large contemporary prospective cohort study.

PubMed

Mery, Carlos M; De León, Luis E; Molossi, Silvana; Sexson-Tejtel, S Kristen; Agrawal, Hitesh; Krishnamurthy, Rajesh; Masand, Prakash; Qureshi, Athar M; McKenzie, E Dean; Fraser, Charles D

2018-01-01

The purpose of this study was to prospectively analyze the outcomes of patients with anomalous aortic origin of a coronary artery undergoing surgical intervention according to a standardized management algorithm. All patients aged 2 to 18 years undergoing surgical intervention for anomalous aortic origin of a coronary artery between December 2012 and April 2017 were prospectively included. Patients underwent stress nuclear perfusion imaging, stress cardiac magnetic resonance imaging, and retrospectively electrocardiogram-gated computed tomography angiography preoperatively. Patients were cleared for exercise at 3 months postoperatively if asymptomatic and repeat stress nuclear perfusion imaging, stress cardiac magnetic resonance imaging, and computed tomography angiography showed normal results. A total of 44 patients, with a median age of 14 years (8-18 years), underwent surgical intervention: 9 (20%) for the anomalous left coronary artery and 35 (80%) for the anomalous right coronary artery. Surgical procedures included unroofing in 35 patients (80%), translocation in 7 patients (16%), ostioplasty in 1 patient (2%), and side-side-anastomosis in 1 patient (2%). One patient who presented with aborted sudden cardiac death from an anomalous left coronary and underwent unroofing presented 1 year later with a recurrent episode and was found to have an unrecognized myocardial bridge and persistent compression of the coronary requiring reintervention. At last follow-up, 40 patients (91%) are asymptomatic and 4 patients have nonspecific chest pain; 42 patients (95%) have returned to full activity, and 2 patients are awaiting clearance. Surgical treatment for anomalous aortic origin of a coronary artery is safe and should aim to associate the coronary ostium with the correct sinus, away from the intercoronary pillar. After surgery, the majority of patients are cleared for exercise and remain asymptomatic. Longer follow-up is needed to assess the true efficacy of surgery in the prevention of sudden cardiac death. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Black box warning: is ketorolac safe for use after cardiac surgery?

PubMed

Oliveri, Lisa; Jerzewski, Katie; Kulik, Alexander

2014-04-01

In 2005, after the identification of cardiovascular safety concerns with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), the FDA issued a black box warning recommending against the use of NSAIDs following cardiac surgery. The goal of this study was to assess the postoperative safety of ketorolac, an intravenously administered NSAID, after cardiac surgery. Retrospective observational study. Single center, regional hospital. A total of 1,309 cardiac surgical patients (78.1% coronary bypass, 28.0% valve) treated between 2006 and 2012. A total of 488 of these patients received ketorolac for postoperative analgesia within 72 hours of surgery. Ketorolac-treated patients were younger, had better preoperative renal function, and underwent less complex operations compared with non-ketorolac patients. Ketorolac was administered, on average, 8.7 hours after surgery (mean doses: 3.1). Postoperative outcomes for ketorolac-treated patients were similar to those expected using Society of Thoracic Surgery database risk-adjusted outcomes. In unadjusted analysis, patients who received ketorolac had similar or better postoperative outcomes compared with patients who did not receive ketorolac, including gastrointestinal bleeding (1.2% v 1.3%; p = 1.0), renal failure requiring dialysis (0.4% v 3.0%; p = 0.001), perioperative myocardial infarction (1.0% v 0.6%; p = 0.51), stroke or transient ischemic attack (1.0% v 1.7%; p = 0.47), and death (0.4% v 5.8%; p<0.0001). With adjustment in a multivariate model, treatment with ketorolac was not a predictor for adverse outcome in this cohort (odds ratio: 0.72; p = 0.23). Ketorolac appears to be well-tolerated for use when administered selectively after cardiac surgery. Although a black box warning exists, the data highlights the need for further research regarding its perioperative administration. Copyright © 2014 Elsevier Inc. All rights reserved.

Biofeedback assisted control of respiratory sinus arrhythmia as a biobehavioral intervention for depressive symptoms in patients after cardiac surgery: a preliminary study.

PubMed

Patron, Elisabetta; Messerotti Benvenuti, Simone; Favretto, Giuseppe; Valfrè, Carlo; Bonfà, Carlotta; Gasparotto, Renata; Palomba, Daniela

2013-03-01

The current study investigated whether biofeedback training aimed at increasing respiratory sinus arrhythmia (RSA), a measure of cardiac vagal modulation, can reduce depressive symptoms in patients after cardiac surgery. This randomized controlled study enrolled 26 patients after first-time cardiac surgery. The patients were randomly assigned to an RSA-biofeedback group (N = 13) or to a treatment as usual group (N = 13). The biofeedback training consisted of five 45 min sessions designed to increase RSA. The outcome was assessed as changes in RSA and in the Centre for Epidemiologic Studies of Depression (CES-D) values from pre- to post-training. Both groups were comparable for demographic and biomedical characteristics. RSA increased significantly in patients who underwent RSA-biofeedback compared to controls. Moreover, the CES-D scores were reduced significantly from pre- to post-training in the RSA-biofeedback group compared to the controls. Changes in RSA were inversely related to changes in CES-D scores from pre- to post-training. These findings extend the effectiveness of RSA-biofeedback for increasing vagal modulation as well as for reducing depressive symptoms in post-surgical patients. Overall, the current study also suggests that this biobehavioral intervention may add to the efficacy of postoperative risk reduction programs and rehabilitation protocols in cardiac surgery patients.

Pulmonary hypertension: an important predictor of outcomes in patients undergoing non-cardiac surgery.

PubMed

Kaw, Roop; Pasupuleti, Vinay; Deshpande, Abhishek; Hamieh, Tarek; Walker, Esteban; Minai, Omar A

2011-04-01

Perioperative risk associated with pulmonary hypertension (PH) in patients undergoing non-cardiac surgery (NCS) remains poorly defined. We report perioperative outcomes in a large cohort of patients undergoing NCS, comparing those with and without PH. Patients undergoing NCS at our institution between January 2002 and December 2006, were cross matched with a Right Heart Catheterization (RHC) database for the same period. Patients were excluded if they were <18 years old and if they underwent cardiac surgery prior to NCS or minor procedures using local anesthesia or sedation. Controls were defined as patients who underwent similar NCS with mean pulmonary arterial pressure (MPAP) ≤ 25 mmHg. 173 patients underwent RHC and NCS during the specified period and were included in the analysis. Of these 96 (55%) had PH. Mean pulmonary arterial pressure (p = 0.001), American Association of Anesthesiology Class (p = 0.02), and chronic renal insufficiency (p = 0.03) were determined as independent risk factors for post-operative morbidity. Patients with PH were more likely to develop congestive heart failure (p < 0.001; OR: 11.9), hemodynamic instability (p < 0.002), sepsis (p < 0.0005), and respiratory failure (p < 0.004). Patients with PH needed longer ventilatory support (p < 0.002), stayed longer in the ICU (p < 0.04), and were more frequently readmitted to the hospital within 30 days (p < 008; OR 2.4). In addition to the traditionally known risk factors for outcomes after NCS such as coronary artery disease, diabetes mellitus, chronic renal insufficiency, American Society of Anesthesiology class, the presence of underlying PH can have a significant negative impact on perioperative outcomes. Copyright © 2010 Elsevier Ltd. All rights reserved.

Guillain-Barré Syndrome after Coronary Artery Bypass Graft Surgery: a Case Report.

PubMed

Hekmat, Manouchehr; Ghaderi, Hamid; Foroughi, Mahnoosh; Mirjafari, S Adeleh

2016-01-01

Guillain-Barre syndrome is a neurologic disorder that may appear after infection or major surgery. Guillain-Barré syndrome following cardiac surgery is rare and only based on case reports, and we review all of the published cases. A 52-year-old man after 5 months suffering from chest pain was referred to our hospital and underwent coronary artery bypass graft for 3 vessel disease. The patient was discharged without complication on the 5th postoperative day. He presented Guillain-Barré syndrome after 12 months. He has not completely recovered weakness of upper extremities grade 4/5 with atrophy of both upper extremities remains after 18 months. This disorder is similar to classic GBS. It is important to be alert to de novo autoimmune neurological disorders after cardiac surgery. These disorders are similar to classic autoimmune disease and treated with standard therapies.

Mini-extracorporeal circulation technology, conventional bypass and prime displacement in isolated coronary and aortic valve surgery: a propensity-matched in-hospital and survival analysis.

PubMed

Ariyaratnam, Priyadharshanan; Mclean, Lindsay A; Cale, Alexander; Chaudhry, Mubarak A; Vijayan, Ajith; Richards, Neil; Jarvis, Martin A; Haqzad, Yama; Ngaage, Dumbor; Cowen, Michael E; Loubani, Mahmoud

2018-02-14

Conventional cardiopulmonary bypass is the most commonly used means of artificial circulation in cardiac surgery. However, it suffers from the effects of haemodilution and activation of inflammatory/coagulation cascades. Prime displacement (PD) can offset haemodilution and Mini-Extracorporeal Technology (MIECT) can offset both. So far, no study has compared all of these modalities together; hence, we compared the outcomes of these 3 modalities at our institution. This was a retrospective analysis of our cardiac surgical database. A total of 9626 patients underwent conventional bypass (CB), 3125 patients underwent a modification of CB, called PD, and 904 underwent MIECT. A 1:1 propensity-matching algorithm was employed using IBM SPSS 24 to match (i) 813 MIECT patients with 813 CB patients and (ii) 717 MIECT patients with 717 PD patients. The patients included coronary artery bypass grafting and valve surgery. MIECT had significantly (P < 0.05) longer bypass and cross-clamp times compared to CB and PD. MIECT had significantly higher rates of postoperative atrial fibrillation associated with it compared to CB. The mean red cell blood transfusion was significantly lower in the MIECT group compared to the CB group as was the mean platelet transfusion and fresh frozen plasma transfusion. The overall 5-year survival was higher in the MIECT group compared to the CB group (log-rank, P = 0.018). Between the MIECT and the PD groups, we found the incidence of renal failure and gastrointestinal complications to be significantly higher in the PD group compared to the MIECT group. MIECT has short-term advantages over CB and PD. However, due to the retrospective limitations of the study, including calendar time bias, a multicentre randomized controlled trial comparing all 3 modalities will be beneficial for the larger cardiac community. © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Perioperative hemoglobin area under the curve is an independent predictor of renal failure after cardiac surgery. Results from a Spanish multicenter retrospective cohort study

PubMed Central

Duque-Sosa, Paula; Iribarren, María Josefa; Rábago, Gregorio

2017-01-01

Perioperative anemia is an important risk factor for cardiac surgery-associated acute kidney injury (CSA-AKI). Nonetheless, the severity of the anemia and the time in the perioperative period in which the hemoglobin level should be considered as a risk factor is conflicting. The present study introduces the concept of perioperative hemoglobin area under the curve (pHb-AUC) as a surrogate marker of the evolution of perioperative hemoglobin concentration. Through a retrospective analysis of prospectively collected data, we assessed this new variable as a risk factor for the development of acute kidney injury after cardiac surgery in 966 adult patients who underwent cardiac surgery with cardiopulmonary bypass, at twenty-three academic hospitals in Spain. Exclusion criteria were patients on renal replacement therapy, who needed a reoperation because of bleeding and/or with missing perioperative hemoglobin or creatinine values. Using a multivariate regression analysis, we found that a pHb-AUC <19 g/dL was an independent risk factor for CSA-AKI even after adjustment for intraoperative red blood cell transfusion (OR 1.41, p <0.05). It was also associated with mortality (OR 2.48, p <0.01) and prolonged hospital length of stay (4.67 ± 0.99 days, p <0.001) PMID:28225801

Effect of Levosimendan on Renal Outcome in Cardiac Surgery Patients With Chronic Kidney Disease and Perioperative Cardiovascular Dysfunction: A Substudy of a Multicenter Randomized Trial.

PubMed

Zangrillo, Alberto; Alvaro, Gabriele; Belletti, Alessandro; Pisano, Antonio; Brazzi, Luca; Calabrò, Maria G; Guarracino, Fabio; Bove, Tiziana; Grigoryev, Evgeny V; Monaco, Fabrizio; Boboshko, Vladimir A; Likhvantsev, Valery V; Scandroglio, Anna M; Paternoster, Gianluca; Lembo, Rosalba; Frassoni, Samuele; Comis, Marco; Pasyuga, Vadim V; Navalesi, Paolo; Lomivorotov, Vladimir V

2018-02-26

Acute kidney injury (AKI) occurs frequently after cardiac surgery. Levosimendan might reduce the incidence of AKI in patients undergoing cardiac surgery. The authors investigated whether levosimendan administration could reduce AKI incidence in a high-risk cardiac surgical population. Post hoc analysis of a multicenter randomized trial. Cardiac surgery operating rooms and intensive care units of 14 centers in 3 countries. The study comprised 90 patients who underwent mitral valve surgery with an estimated glomerular filtration rate <60 mL/min/1.73 m 2 and perioperative myocardial dysfunction. Patients were assigned randomly to receive levosimendan (0.025-0.2 μg/kg/min) or placebo in addition to standard inotropic treatment. Forty-six patients were assigned to receive levosimendan and 44 to receive placebo. Postoperative AKI occurred in 14 (30%) patients in the levosimendan group versus 23 (52%) in the placebo group (absolute difference -21.8; 95% confidence interval -41.7 to -1.97; p = 0.035). The incidence of major complications also was lower (18 [39%]) in the levosimendan group versus that in the placebo group (29 [66%]) (absolute difference -26.8 [-46.7 to -6.90]; p = 0.011). A trend toward lower serum creatinine at intensive care unit discharge was observed in the levosimendan group (1.18 [0.99-1.49] mg/dL) versus that in the placebo group (1.39 [1.05-1.76] mg/dL) (95% confidence interval -0.23 [-0.49 to 0.01]; p = 0.07). Levosimendan may improve renal outcome in cardiac surgery patients with chronic kidney disease undergoing mitral valve surgery who develop perioperative myocardial dysfunction. Results of this exploratory analysis should be investigated in future properly designed randomized controlled trials. Copyright © 2018 Elsevier Inc. All rights reserved.

Preoperative Low Serum Bicarbonate Levels Predict Acute Kidney Injury After Cardiac Surgery.

PubMed

Jung, Su-Young; Park, Jung Tak; Kwon, Young Eun; Kim, Hyung Woo; Ryu, Geun Woo; Lee, Sul A; Park, Seohyun; Jhee, Jong Hyun; Oh, Hyung Jung; Han, Seung Hyeok; Yoo, Tae-Hyun; Kang, Shin-Wook

2016-03-01

Acute kidney injury (AKI) after cardiac surgery is a common and serious complication. Although lower than normal serum bicarbonate levels are known to be associated with consecutive renal function deterioration in patients with chronic kidney injury, it is not well-known whether preoperative low serum bicarbonate levels are associated with the development of AKI in patients who undergo cardiac surgery. Therefore, the clinical implication of preoperative serum bicarbonate levels on AKI occurrence after cardiac surgery was investigated. Patients who underwent coronary artery bypass or valve surgery at Yonsei University Health System from January 2013 to December 2014 were enrolled. The patients were divided into 3 groups based on preoperative serum bicarbonate levels, which represented group 1 (below normal levels) <23 mEq/L; group 2 (normal levels) 23 to 24 mEq/L; and group 3 (elevated levels) >24 mEq/L. The primary outcome was the predicated incidence of AKI 48 hours after cardiac surgery. AKI was defined according to Acute Kidney Injury Network criteria. Among 875 patients, 228 (26.1%) developed AKI within 48 hours after cardiac surgery. The incidence of AKI was higher in group 1 (40.9%) than in group 2 (26.5%) and group 3 (19.5%) (P < 0.001). In addition, the duration of postoperative stay in a hospital intensive care unit (ICU) was longer for AKI patients and for those in the low-preoperative-serum-bicarbonate-level groups. A multivariate logistic regression analysis showed that low preoperative serum bicarbonate levels were significantly associated with AKI even after adjustment for age, sex, hypertension, diabetes mellitus, operation type, preoperative hemoglobin, and estimated glomerular filtration rate. In conclusion, low serum bicarbonate levels were associated with higher incidence of AKI and prolonged ICU stay. Further studies are needed to clarify whether strict correction of bicarbonate levels close to normal limits may have a protective role in preventing further AKI development.

Robotic cardiac surgery in Brazil

PubMed Central

Toschi, Alisson P.; Pope, Renato B.; Montanhesi, Paola K.; Santos, Ricardo S.; Teruya, Alexandre; Hatanaka, Dina M.; Rusca, Gabriel F.; Fischer, Claudio H.; Vieira, Marcelo C.; Makdisse, Marcia R.

2017-01-01

Background Brazil, the largest country and economy in South America, is a major driving force behind the development of new medical technologies in the region. Robotic cardiac surgery (RCS) has been evolving rapidly since 2010, when the first surgery using the DaVinci® robotic system was performed in Latin America. The aim of this article is to evaluate short and mid-term results in patients undergoing robotic cardiac surgery in Brazil. Methods From March 2010 to December 2015, 39 consecutive patients underwent robotic cardiac surgery. Twenty-seven patients were male (69.2%), with the mean age of 51.3±17.9 years. Participants had a mean ejection fraction of 62±5%. The procedures included in this study were mitral valve surgery, surgical treatment of atrial fibrillation, atrial septal defect closure, resection of intra-cardiac tumors, totally endoscopic coronary artery bypass and pericardiectomy. Results The mean time spent on cardiopulmonary bypass (CPB) during RCS was 154.9±94.2 minutes and the mean aortic cross-clamp time was 114.48±75.66 minutes. Thirty-two patients (82%) were extubated in the operating room immediately after surgery. The median intensive care unit (ICU) length of stay was 1 day (ranging from 0 to 25) and the median hospital length of stay was 5 days (ranging from 3 to 25). For each type of procedure, endpoints were individually reported. There were no conversions to sternotomy and no intra-operative complications. Patient follow-up was complete in 100% of the participants, with two early deaths unrelated to the procedures and no re-operations at mid-term. Conclusions Despite the heterogeneity of this series, RCS appears to be feasible, safe and effective when used for the correction of various intra- and extra-cardiac pathologies. Adopting the robotic system has been a challenge in Brazil, where its limited clinical application may be related to the lack of specific training and the high cost of technology. PMID:28203537

Robotic cardiac surgery in Brazil.

PubMed

Poffo, Robinson; Toschi, Alisson P; Pope, Renato B; Montanhesi, Paola K; Santos, Ricardo S; Teruya, Alexandre; Hatanaka, Dina M; Rusca, Gabriel F; Fischer, Claudio H; Vieira, Marcelo C; Makdisse, Marcia R

2017-01-01

Brazil, the largest country and economy in South America, is a major driving force behind the development of new medical technologies in the region. Robotic cardiac surgery (RCS) has been evolving rapidly since 2010, when the first surgery using the DaVinci ® robotic system was performed in Latin America. The aim of this article is to evaluate short and mid-term results in patients undergoing robotic cardiac surgery in Brazil. From March 2010 to December 2015, 39 consecutive patients underwent robotic cardiac surgery. Twenty-seven patients were male (69.2%), with the mean age of 51.3±17.9 years. Participants had a mean ejection fraction of 62±5%. The procedures included in this study were mitral valve surgery, surgical treatment of atrial fibrillation, atrial septal defect closure, resection of intra-cardiac tumors, totally endoscopic coronary artery bypass and pericardiectomy. The mean time spent on cardiopulmonary bypass (CPB) during RCS was 154.9±94.2 minutes and the mean aortic cross-clamp time was 114.48±75.66 minutes. Thirty-two patients (82%) were extubated in the operating room immediately after surgery. The median intensive care unit (ICU) length of stay was 1 day (ranging from 0 to 25) and the median hospital length of stay was 5 days (ranging from 3 to 25). For each type of procedure, endpoints were individually reported. There were no conversions to sternotomy and no intra-operative complications. Patient follow-up was complete in 100% of the participants, with two early deaths unrelated to the procedures and no re-operations at mid-term. Despite the heterogeneity of this series, RCS appears to be feasible, safe and effective when used for the correction of various intra- and extra-cardiac pathologies. Adopting the robotic system has been a challenge in Brazil, where its limited clinical application may be related to the lack of specific training and the high cost of technology.

Perioperative use of iloprost in cardiac surgery patients diagnosed with heparin-induced thrombocytopenia-reactive antibodies or with true HIT (HIT-reactive antibodies plus thrombocytopenia): An 11-year experience.

PubMed

Palatianos, George; Michalis, Alkiviadis; Alivizatos, Petros; Lacoumenda, Stavroula; Geroulanos, Stefanos; Karabinis, Andreas; Iliopoulou, Eugenia; Soufla, Giannoula; Kanthou, Chryso; Khoury, Mazen; Sfyrakis, Petros; Stavridis, George; Astras, George; Vassili, Maria; Antzaka, Christina; Marathias, Katerina; Kriaras, Ioannis; Tasouli, Androniki; Papadopoulos, Kyrillos; Katafygioti, Marina; Matoula, Nikoletta; Angelidis, Antonios; Melissari, Euthemia

2015-07-01

Thrombocytopenia and thromboembolism(s) may develop in heparin immune-mediated thrombocytopenia (HIT) patients after reexposure to heparin. At the Onassis Cardiac Surgery Center, 530 out of 17,000 patients requiring heart surgery over an 11-year period underwent preoperative HIT assessment by ELISA and a three-point heparin-induced platelet aggregation assay (HIPAG). The screening identified 110 patients with HIT-reactive antibodies, out of which 46 were also thrombocytopenic (true HIT). Cardiac surgery was performed in HIT-positive patients under heparin anticoagulation and iloprost infusion. A control group of 118 HIT-negative patients received heparin but no iloprost during surgery. For the first 20 patients, the dose of iloprost diminishing the HIPAG test to ≤5% was determined prior to surgery by in vitro titration using the patients' own plasma and donor platelets. In parallel, the iloprost "target dose" was also established for each patient intraoperatively, but before heparin administration. Iloprost was infused initially at 3 ng/kg/mL and further adjusted intraoperatively, until ex vivo aggregation reached ≤5%. As a close correlation was observed between the "target dose" identified before surgery and that established intraoperatively, the remaining 90 patients were administered iloprost starting at the presurgery identified "target dose." This process significantly reduced the number of intraoperative HIPAG reassessments needed to determine the iloprost target dose, and reduced surgical time, while maintaining similar primary clinical outcomes to controls. Therefore, infusion of iloprost throughout surgery, under continuous titration, allows cardiac surgery to be undertaken safely using heparin, while avoiding life-threatening iloprost-induced hypotension in patients diagnosed with HIT-reactive antibodies or true HIT. © 2015 Wiley Periodicals, Inc.

Factors associated with prolonged length of stay following cardiac surgery in a major referral hospital in Oman: a retrospective observational study.

PubMed

Almashrafi, Ahmed; Alsabti, Hilal; Mukaddirov, Mirdavron; Balan, Baskaran; Aylin, Paul

2016-06-08

Two objectives were set for this study. The first was to identify factors influencing prolonged postoperative length of stay (LOS) following cardiac surgery. The second was to devise a predictive model for prolonged LOS in the cardiac intensive care unit (CICU) based on preoperative factors available at admission and to compare it against two existing cardiac stratification systems. Observational retrospective study. A tertiary hospital in Oman. All adult patients who underwent cardiac surgery at a major referral hospital in Oman between 2009 and 2013. 30.5% of the patients had prolonged LOS (≥11 days) after surgery, while 17% experienced prolonged ICU LOS (≥5 days). Factors that were identified to prolong CICU LOS were non-elective surgery, current congestive heart failure (CHF), renal failure, combined coronary artery bypass graft (CABG) and valve surgery, and other non-isolated valve or CABG surgery. Patients were divided into three groups based on their scores. The probabilities of prolonged CICU LOS were 11%, 26% and 28% for group 1, 2 and 3, respectively. The predictive model had an area under the curve of 0.75. Factors associated with prolonged overall postoperative LOS included the body mass index, the type of surgery, cardiopulmonary bypass machine use, packed red blood cells use, non-elective surgery and number of complications. The latter was the most important determinant of postoperative LOS. Patient management can be tailored for individual patient based on their treatments and personal attributes to optimise resource allocation. Moreover, a simple predictive score system to enable identification of patients at risk of prolonged CICU stay can be developed using data that are routinely collected by most hospitals. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Society of Thoracic Surgeons 2008 cardiac risk models predict in-hospital mortality of heart valve surgery in a Chinese population: a multicenter study.

PubMed

Wang, Lv; Lu, Fang-Lin; Wang, Chong; Tan, Meng-Wei; Xu, Zhi-yun

2014-12-01

The Society of Thoracic Surgeons 2008 cardiac surgery risk models have been developed for heart valve surgery with and without coronary artery bypass grafting. The aim of our study was to evaluate the performance of Society of Thoracic Surgeons 2008 cardiac risk models in Chinese patients undergoing single valve surgery and the predicted mortality rates of those undergoing multiple valve surgery derived from the Society of Thoracic Surgeons 2008 risk models. A total of 12,170 patients underwent heart valve surgery from January 2008 to December 2011. Combined congenital heart surgery and aortal surgery cases were excluded. A relatively small number of valve surgery combinations were excluded. The final research population included the following isolated heart valve surgery types: aortic valve replacement, mitral valve replacement, and mitral valve repair. The following combined valve surgery types were included: mitral valve replacement plus tricuspid valve repair, mitral valve replacement plus aortic valve replacement, and mitral valve replacement plus aortic valve replacement and tricuspid valve repair. Evaluation was performed by using the Hosmer-Lemeshow test and C-statistics. Data from 9846 patients were analyzed. The Society of Thoracic Surgeons 2008 cardiac risk models showed reasonable discrimination and poor calibration (C-statistic, 0.712; P = .00006 in Hosmer-Lemeshow test). Society of Thoracic Surgeons 2008 models had better discrimination (C-statistic, 0.734) and calibration (P = .5805) in patients undergoing isolated valve surgery than in patients undergoing multiple valve surgery (C-statistic, 0.694; P = .00002 in Hosmer-Lemeshow test). Estimates derived from the Society of Thoracic Surgeons 2008 models exceeded the mortality rates of multiple valve surgery (observed/expected ratios of 1.44 for multiple valve surgery and 1.17 for single valve surgery). The Society of Thoracic Surgeons 2008 cardiac surgery risk models performed well when predicting the mortality for Chinese patients undergoing valve surgery. The Society of Thoracic Surgeons 2008 models were suitable for single valve surgery in a Chinese population; estimates of mortality for multiple valve surgery derived from the Society of Thoracic Surgeons 2008 models were less accurate. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Primary cardiac sarcoma complicated with cerebral infarction and brain metastasis: A case report and literature review.

PubMed

Sun, Yun-Peng; Wang, Xuan; Gao, Yong-Sheng; Zhao, Song; Bai, Yang

2017-12-12

In large autopsy series, the estimated frequency of primary tumors of the heart ranges from 0.0017% to 0.33%. Approximately 25% of primary cardiac tumors are malignant, and nearly 20% of these are sarcomas. To date, a completely feasible surgical resection remains the major treatment measure of cardiac sarcoma, especially for recurrent focal cardiac sarcoma and the recurrence of a restrictive metastasis. Although characteristically medical treatments are recommended, there is no consistent opinion for adjuvant radiotherapy and chemotherapy following an operation. Since these tumors usually undergo extensive spread by the time that the diagnosis is established, the prognosis of cardiac sarcoma remains poor. In this report, we described a case who underwent initial cardiac tumor resection, and was confirmed to be a pleomorphic undifferentiated sarcoma based on pathological findings. However, the patient complicated with cerebral infarction and subsequent brain metastasis sarcoma after the initial surgery, which was confirmed by brain tissue pathology. During the course of therapy, the patient underwent three surgical operations and refused to accept any chemotherapy and radiotherapy intervention. To the best of our knowledge, this is the first case report describing a primary cardiac sarcoma complicated with cerebral infarction and brain metastasis. The management of primary cardiac sarcoma is also discussed.

Preoperative nutritional status is associated with progression of postoperative cardiac rehabilitation in patients undergoing cardiovascular surgery.

PubMed

Arai, Yasuhiro; Kimura, Toru; Takahashi, Yuki; Hashimoto, Takashi; Arakawa, Mamoru; Okamura, Homare

2018-06-23

Progression of cardiac rehabilitation after cardiovascular surgery can be affected by frailty. The nutritional status of the patient has been proposed as an indicator of frailty. In this study, we aimed to evaluate the influence of preoperative nutritional status on the progress of postoperative cardiac rehabilitation. This study included 146 patients (82 males, 64 females, average age 71.9 ± 12.0 years) who underwent elective cardiovascular surgery. In-hospital mortality cases were excluded to focus on postoperative cardiac rehabilitation. We classified patients with a Geriatric Nutritional Risk Index of 92 or higher as the good nutrition group and those with a Geriatric Nutritional Risk Index less than 92 as the malnutrition group. Preoperative patient characteristics and postoperative cardiac rehabilitation progress were compared between the good nutrition (n = 93) and malnutrition (n = 53) groups. The patients in the good nutrition group had an earlier progression to walking after postoperative rehabilitation (p = 0.002), a shorter postoperative hospital stay (p = 0.004), and a higher rate of discharge home (p = 0.028) than those in the malnutrition group. Multivariable analysis demonstrated preoperative malnutrition to be an independent predictor for the day to 100 m walking (p = 0.010). Preoperative nutritional status was associated with progression of postoperative cardiac rehabilitation.

The efficacy of intraoperative atrial radiofrequency ablation for atrial fibrillation during concomitant cardiac surgery-the Surgical Atrial Fibrillation Suppression (SAFS) Study.

PubMed

Veasey, Rick A; Segal, Oliver R; Large, Janet K; Lewis, Michael E; Trivedi, Uday H; Cohen, Andrew S; Hyde, Jonathan A J; Sulke, A Neil

2011-10-01

Studies assessing radiofrequency ablation (RFA) for atrial fibrillation (AF) performed at the time of concomitant cardiac surgery have reported high success rates. The efficacy of this treatment has primarily been determined by a single electrocardiogram (ECG) or 24-h Holter monitor at follow-up. We sought to assess the true efficacy of this procedure using prolonged cardiac rhythm monitoring. One hundred patients with paroxysmal (n = 47) and persistent AF (n = 53) requiring cardiac surgery were enrolled. Patients were clinically reviewed 6 weeks post-operatively and were monitored with 7-day Holter with full disclosure, 6 months post-surgery. A cohort of 50 patients also underwent 7 day Holter monitoring preoperatively. AF recurrence was defined as >30 s of AF. At 6 months, 75% of patients were in sinus rhythm according to a single ECG. However, only 62% of patients were free from AF on 7-day Holter; all AF episodes in these patients were asymptomatic. The procedure resulted in a significant decrease in AF burden from 56.2% at baseline to 27.5% at 6 months follow-up, (p < 0.001). Predictors of AF recurrence were (1) pre-operative AF duration; (2) persistent compared with paroxysmal AF; (3) increasing left atrial diameter and (4) requirement for mitral valve surgery. Surgical RFA for the treatment of AF, during concomitant cardiac surgery, is a successful procedure and significantly reduces AF burden. However, 13% of patients have asymptomatic AF episodes only identified with continuous monitoring. This has important implications for post-operative anti-arrhythmic and anticoagulant management and for the definition of surgical AF ablation success.

Previous coronary stent implantation and cardiac events in patients undergoing noncardiac surgery.

PubMed

Cruden, Nicholas L M; Harding, Scott A; Flapan, Andrew D; Graham, Cat; Wild, Sarah H; Slack, Rachel; Pell, Jill P; Newby, David E

2010-06-01

Noncardiac surgery performed after coronary stent implantation is associated with an increased risk of stent thrombosis, myocardial infarction, and death. The influence of stent type and period of risk still have to be defined. We linked the Scottish Coronary Revascularisation Register with hospital admission data to undertake a Scotland-wide retrospective cohort study examining cardiac outcomes in all patients who received drug-eluting or bare-metal stents between April 2003 and March 2007 and subsequently underwent noncardiac surgery. Of 1953 patients, 570 (29%) were treated with at least 1 drug-eluting stent and 1383 (71%) with bare-metal stents only. There were no differences between drug-eluting and bare-metal stents in the primary end point of in-hospital mortality or ischemic cardiac events (14.6% versus 13.3%; P=0.3) or the secondary end points of in-hospital mortality (0.7% versus 0.6%; P=0.8) and acute myocardial infarction (1.2% versus 0.7%; P=0.3). Perioperative death and ischemic cardiac events occurred more frequently when surgery was performed within 42 days of stent implantation (42.4% versus 12.8% beyond 42 days; P<0.001), especially in patients revascularized after an acute coronary syndrome (65% versus 32%; P=0.037). There were no temporal differences in outcomes between the drug-eluting and bare-metal stent groups. Patients undergoing noncardiac surgery after recent coronary stent implantation are at increased risk of perioperative myocardial ischemia, myocardial infarction, and death, particularly after an acute coronary syndrome. For at least 2 years after percutaneous coronary intervention, cardiac outcomes after noncardiac surgery are similar for both drug-eluting and bare-metal stents.

Incidence and outcome of re-entry injury in redo cardiac surgery: benefits of preoperative planning.

PubMed

Imran Hamid, Umar; Digney, Ruairi; Soo, Lorraine; Leung, Samantha; Graham, Alastair N J

2015-05-01

Repeat sternotomy for redo cardiac surgery may be associated with catastrophic injuries to mediastinal structures. The purpose of this study was to determine the frequency of these injuries, associated outcome and if a preoperative computerized tomography (CT) scan reduces the risk of re-entry injury. Five hundred and forty-four patients who underwent redo cardiac surgery between 2001 and 2011 were identified by review of our unit's prospectively maintained cardiac surgery database. Demographic details, surgical strategy, re-entry injuries, hospital stay, in-hospital mortality and long-term survival were analysed. The mean age was 61 years; 326 were male, 218 were female. Four hundred and eighty six patients underwent first time redo surgery, while 58 patients had multiple previous operations. The median logistic EuroSCORE was 11, in-hospital mortality rate was 9.5% and observed to expected mortality rate was 0.8. Re-entry complications occurred in 15 cases (2.7%). These included injuries to the aorta (n = 2), right atrium (n = 1), innominate vein (n = 2), internal mammary artery (n = 2), pulmonary artery (n = 2), lung parenchyma (n = 1), saphenous vein graft (n = 2), right ventricle (n = 2) and ventricular fibrillation (n = 1). The mortality rate in patients with re-entry injury was 26% (n = 4) compared with 9% (n = 48) in those without re-entry complications. Preoperative planning by CT scan was performed in 162 cases and adherence of vital structures to the sternum was found in 60 cases; the right ventricle, innominate vein and bypass grafts in 41, 11 and 8, respectively. The incidence rate of re-entry injury was 0.6% in these patients vs 3.6% in those who did not have a preoperative CT scan (P = 0.046). Peripheral arterial cannulation was carried out in 35 patients (6.4%) to establish cardiopulmonary bypass (CPB) prior to sternotomy, and there were no mediastinal injuries observed in these cases. Multivariate logistic regression analysis revealed re-entry injury as one of the independent predictors of in-hospital mortality (P = 0.039). The incidence of re-entry injury during repeat sternotomy is low; however, it is associated with a significant increase in the risk of in-hospital mortality. Preoperative planning using CT scan reduces the risk by identifying adherent structures, and, in selected patients, establishing CPB prior to sternotomy is a safe strategy in redo cardiac surgery. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Prevalence of HCV Infection in Adults with Congenital Heart Disease and Treatment with Direct Antiviral Agents.

PubMed

Gade, Ajay Reddy; Patel, Manisha; West, Donna R; Abrams, Gary A

2018-03-01

Hepatitis C virus (HCV) infection affects >3% of the US population, which over time can lead to cirrhosis and hepatocellular carcinoma. The lack of a reliable screening method for HCV before 1992 resulted in a higher prevalence of the virus in adults with congenital heart disease who underwent corrective surgery that required blood transfusions. Direct-acting antiviral agents such as sofosbuvir/ledipasvir have significantly increased the efficacy of HCV therapy, although use of these medications in adults with congenital heart disease has not been described. Ours was a retrospective study of 188 adults with congenital heart conditions who had cardiac surgery before 1992. These patients were screened for HCV using HCV antibody followed by HCV RNA if the screening test was positive. Of the 188 adults, 116 (43% male patients, 24-70 years) were screened for the HCV antibody, demonstrating that 104 individuals were negative and 12 subjects were positive for the virus. Subsequently, further testing for the presence of HCV demonstrated 11 of 12 were infected, with an overall prevalence of 9.5%. Five individuals chose to be treated with sofosbuvir/ledipasvir and 5 of 5 have successfully cleared the virus and are considered cured. Adults with congenital heart disease who underwent cardiac surgery before 1992 warrant being screened for HCV, and, if testing positive, may be considered for therapy using direct-acting antiviral agents with close monitoring for cardiac complications.

Bariatric surgery modulates circulating and cardiac metabolites.

PubMed

Ashrafian, Hutan; Li, Jia V; Spagou, Konstantina; Harling, Leanne; Masson, Perrine; Darzi, Ara; Nicholson, Jeremy K; Holmes, Elaine; Athanasiou, Thanos

2014-02-07

Bariatric procedures such as the Roux-en-Y gastric bypass (RYGB) operation offer profound metabolic enhancement in addition to their well-recognized weight loss effects. They are associated with significant reduction in cardiovascular disease risk and mortality, which suggests a surgical modification on cardiac metabolism. Metabolic phenotyping of the cardiac tissue and plasma postsurgery may give insight into cardioprotective mechanisms. The aim of the study was to compare the metabolic profiles of plasma and heart tissue extracts from RYGB- and sham-operated Wistar rats to identify the systemic and cardiac signature of metabolic surgery. A total of 27 male Wistar rats were housed individually for a week and subsequently underwent RYGB (n = 13) or sham (n = 14) operation. At week 8 postoperation, a total of 27 plasma samples and 16 heart tissue samples (8 RYGB; 8 Sham) were collected from animals and analyzed using (1)H nuclear magnetic resonance (NMR) spectroscopy and ultra performance liquid chromatography (UPLC-MS) to characterize the global metabolite perturbation induced by RYGB operation. Plasma bile acids, phosphocholines, amino acids, energy-related metabolites, nucleosides and amine metabolites, and cardiac glycogen and amino acids were found to be altered in the RYGB operated group. Correlation networks were used to identify metabolite association. The metabolic phenotype of this bariatric surgical model inferred systematic change in both myocardial and systemic activity post surgery. The altered metabolic profile following bariatric surgery reflects an enhancement of cardiac energy metabolism through TCA cycle intermediates, cardiorenal protective activity, and biochemical caloric restriction. These surgically induced metabolic shifts identify some of the potential mechanisms that contribute toward bariatric cardioprotection through gut microbiota ecological fluxes and an enterocardiac axis to shield against metabolic syndrome of cardiac dysfunction.

Clinical, biochemical and genetic risk factors for 30-day and 5-year mortality in 518 adult patients subjected to cardiopulmonary bypass during cardiac surgery - the INFLACOR study.

PubMed

Kowalik, Maciej Michał; Lango, Romuald; Siondalski, Piotr; Chmara, Magdalena; Brzeziński, Maciej; Lewandowski, Krzysztof; Jagielak, Dariusz; Klapkowski, Andrzej; Rogowski, Jan

2018-04-25

There is increasing evidence that genetic variability influences patients' early morbidity after cardiac surgery performed using cardiopulmonary bypass (CPB). The use of mortality as an outcome measure in cardiac surgical genetic association studies is rare. We publish the 30-day and 5-year survival analyses with focus on pre-, intra-, postoperative variables, biochemical parameters, and genetic variants in the INFLACOR (INFLAmmation in Cardiac OpeRations) cohort. In a prospectively recruited cohort of 518 adult Polish Caucasians, who underwent cardiac surgery in which CPB was used, the clinical data, biochemical parameters, IL-6, soluble ICAM-1, TNFα, soluble E-selectin, and 10 single nucleotide polymorphisms were evaluated for their association with 30-day and 5-year mortality. The 30-day mortality was associated with: pre-operative prothrombin international normalized ratio, intra-operative blood lactate, postoperative serum creatine phosphokinase, and acute kidney injury requiring renal replacement therapy (AKI-RRT) in logistic regression. Factors that determined the 5-year survival included: pre-operative NYHA class, history of peripheral artery disease and severe chronic obstructive pulmonary disease, intra-operative blood transfusion; and postoperative peripheral hypothermia, myocardial infarction, infection, and AKI-RRT in Cox regression. Serum levels of IL-6 and ICAM-1 measured three hours after the operation were associated with 30-day and 5-year mortality, respectively. The ICAM1 rs5498 was associated with 30-day and 5-year survival with borderline significance. Different risk factors determined the early (30-day) and late (5-year) survival after adult cardiac surgery in which cardiopulmonary bypass was used. Future genetic association studies in cardiac surgical patients should account for the identified chronic and perioperative risk factors.

Cardiac Magnetic Resonance Imaging Predictors of Short-Term Outcomes after High Risk Coronary Surgery.

PubMed

Sheriff, Mohammed J; Mouline, Omar; Hsu, Chijen; Grieve, Stuart M; Wilson, Michael K; Bannon, Paul G; Vallely, Michael P; Puranik, Rajesh

2016-06-01

The euroSCORE II is a widely used pre-coronary artery bypass graft surgery (CAGS) risk score, but its predictive power lacks the specificity to predict outcomes in high-risk patients (16) and left ventricular (LV) dysfunction (<40%) based on 2D-echocardiography who underwent CAGS and in whom CMRI (1.5T) was performed preoperatively were retrospectively studied. Cardiac magnetic resonance imaging parameters were assessed in patients who either had complications immediately post-surgery (n=35), six weeks post-surgery (n=20) or were uncomplicated. The average age of patients recruited was 69±5 years with high euroSCORE II (22±4) and low 2D-echocardiography LV ejection fraction (38%±2%). Cardiac magnetic resonance imaging results demonstrated that those with immediate complications had higher LV scar/infarct burden as a proportion of LV mass (17±3% vs 10±3%; p=0.04) with lower circumferential relaxation index (2.5±0.46 vs 2.8±0.56; p=0.05) compared to those with no complications. Early mortality from surgery was 17% (n=9) and was associated with lower RV stroke volume (55±12 vs 68±18; p=0.03) and higher LV infarct scar/burden (18±2% vs 10±2%, p=0.04). Cardiac magnetic resonance imaging showed patients with complications at six weeks post-surgery had higher LV scar/infarct burden (14.5±2% vs 6.8±2%, p=0.03) compared to those without complications. Cardiac magnetic resonance imaging preoperative LV and RV parameters are valuable in assessing the likelihood of successful outcomes from CAGS in high-risk patients with LV dysfunction. Crown Copyright © 2016. Published by Elsevier B.V. All rights reserved.

The impact of congenital cardiovascular malformations on the assessment and surgical management of infants with cleft lip and/or palate.

PubMed

Harry, Brian L; TeBockhorst, Seth; Deleyiannis, Frederic W-B

2013-05-01

The purpose of this study was to assess the cardiac evaluation of cleft lip and/or palate patients, characterize their cardiovascular malformations, and determine the impact of cardiovascular malformations on surgical management. A single-institution retrospective study of 329 consecutive cleft patients was performed. Cardiovascular malformations were categorized according to involvement of cardiac septa, vasculature, and valves. Their impact on the need for cardiac surgery, timing of cleft repair, need for subacute bacterial endocarditis (SBE) prophylaxis, and the perioperative experience was evaluated. Ten percent (33/329) of cleft patients had a cardiovascular malformation, and 3% underwent cardiac surgery prior to cleft repair. Malformations of the septa, vasculature, and valves were present in 9%, 6%, and 2% of cleft infants, respectively. Murmur as a sign of structural cardiovascular disease was 79% sensitive and 97% specific. Cleft palate repair was delayed by 2 months in patients with a cardiovascular malformation (P = .001). Subacute bacterial endocarditis prophylaxis was recommended, not recommended, or not specified by cardiology in 18%, 33%, and 48% of cleft patients with a cardiovascular malformation, respectively. Postoperative stay and surgical complications were not associated with cardiovascular malformation. Even in the absence of a murmur, echocardiographic screening should be considered in infants with nonspecific signs of cardiovascular disease. Greater awareness of the guidelines for SBE prophylaxis is needed. Most cleft patients with a cardiovascular malformation do not require cardiac surgery and do not experience an increased rate of complications associated with cleft surgery.

Patients with single ventricle physiology undergoing noncardiac surgery are at high risk for adverse events.

PubMed

Brown, Morgan L; DiNardo, James A; Odegard, Kirsten C

2015-08-01

Patients with single ventricle physiology are at increased anesthetic risk when undergoing noncardiac surgery. To review the outcomes of anesthetics for patients with single ventricle physiology undergoing noncardiac surgery. This study is a retrospective chart review of all patients who underwent a palliative procedure for single ventricle physiology between January 1, 2007 and January 31, 2014. Anesthetic and surgical records were reviewed for noncardiac operations that required sedation or general anesthesia. Any noncardiac operation occurring prior to completion of a bidirectional Glenn procedure was included. Diagnostic procedures, including cardiac catheterization, insertion of permanent pacemaker, and procedures performed in the ICU, were excluded. During the review period, 417 patients with single ventricle physiology had initial palliation. Of these, 70 patients (16.7%) underwent 102 anesthetics for 121 noncardiac procedures. The noncardiac procedures included line insertion (n = 23); minor surgical procedures such as percutaneous endoscopic gastrostomy or airway surgery (n = 38); or major surgical procedures including intra-abdominal and thoracic operations (n = 41). These interventions occurred on median day 60 of life (1-233 days). The procedures occurred most commonly in the operating room (n = 79, 77.5%). Patients' median weight was 3.4 kg (2.4-15 kg) at time of noncardiac intervention. In 102 anesthetics, 26 patients had an endotracheal tube or tracheostomy in situ, 57 patients underwent endotracheal intubation, and 19 patients had a natural or mask airway. An intravenous induction was performed in 77 anesthetics, an inhalational induction in 17, and a combination technique in 8. The median total anesthetic time was 126 min (14-594 min). In 22 anesthetics (21.6%), patients were on inotropic support upon arrival; an additional 24 patients required inotropic support (23.5%), of which dopamine was the most common medication. There were 10 intraoperative adverse events (9.8%) including: arrhythmias requiring treatment (n = 4), conversion from sedation to a general anesthetic (n = 2), difficult airway (n = 1), inadvertent extubation with desaturation and bradycardia (n = 1), hypotension and desaturation (n = 1), and cardiac arrest (n = 1). Postoperative events (<48 h) included ST segment changes requiring cardiac catheterization (n = 1), and cardiorespiratory arrest (n = 1). Age, size, gender, type of cardiac palliation, patient location, procedure location, and type of procedure were not associated with adverse outcome. After 62 anesthetics (60.8%), patients went postoperatively to the cardiac ICU. There were no deaths at 48 h. We observed no mortality during or after noncardiac surgery in a high-risk subgroup of palliated cardiac patients with single ventricle physiology. However, 11.8% of patients had an adverse event associated with their anesthetic. © 2015 John Wiley & Sons Ltd.

The clinical significance of the atrial subendocardial smooth muscle layer and cardiac myofibroblasts in human atrial tissue with valvular atrial fibrillation.

PubMed

Park, Jae Hyung; Pak, Hui-Nam; Lee, Sak; Park, Han Ki; Seo, Jeong-Wook; Chang, Byung-Chul

2013-01-01

The existence of myofibroblasts (MFBs) and the role of subendocardial smooth muscle (SSM) layer of human atrial tissue in atrial fibrillation (AF) have not yet been elucidated. We hypothesized that the SSM layer and MFB play some roles in atrial structural remodeling and maintenance of valvular AF in patients who undergo cardiac surgery. We analyzed immunohistochemical staining of left atrial (LA) appendage tissues taken from 17 patients with AF and 15 patients remaining in sinus rhythm (SR) who underwent cardiac surgery (male 50.0%, 54.1 ± 14.2 years old, valve surgery 87.5%). SSM was quantified by α-smooth muscle actin (α-SMA) stain excluding vascular structure. MFB was defined as α-SMA+ cells with disorganized Connexin 43-positive gap junctions in Sirius red-positive fibrotic area. The SSM layer of atrium was significantly thicker in patients with AF than in those with SR (P=.0091). Patients with SSM layer ≥ 14 μm had a larger LA size (P=.0006) and greater fibrotic area (P=.0094) than those patients whose SSM layer <14 μm. MFBs were found in 7 of 17 (41.2%) patients with AF and 2 of 15 (13.3%) in SR group (P=.0456) in SSM area, colocalized with Periodic Acid-Schiff (PAS) stain-positive glycogen storage cells (95.5%). SSM layer was closely related to the existence of AF, degrees of atrial remodeling, and fibrosis in patients who underwent open heart surgery. We found that MFB does exist in SSM layer of human atrial tissue co-localized with PAS-positive cells. Crown Copyright © 2013. Published by Elsevier Inc. All rights reserved.

Study of High Sensitive C-Reactive Protein (HS-CRP) After Cardiac Rehabilitation Program in Patients Undergoing Isolated CABG.

PubMed

Johari Moghadam, Adel; Azizinejad, Saied

2016-12-01

Although cardiac rehabilitation is known as a tool to reduce the overall risk of cardiovascular complications, its specific role in the reduction of hs-CRP as a marker of inflammation and a proven marker of cardiovascular risk needs further investigation. The present study aims at elucidating the effects of a full course of conventional cardiac rehabilitation program for the period of eight weeks, on the levels of hs-CRP in patients who underwent isolated coronary artery bypass surgery. In this case study, 30 consecutive patients who underwent isolated coronary artery bypass surgery (isolated CABGS), and a full 8-week cardiac rehabilitation program in Tehran Heart Center, were investigated. A group of 30 similar patients, who enrolled in the same period of rehabilitation program but did not participate in practice, was considered as a control group. Serum levels of hs-CRP in both groups were measured retrospectively and in similar days before the start of rehabilitation program and at the end of it (or 8 weeks after initial registration for the control group). Levels of hs-CRP in the rehabilitation group and control group were 5.9 7.7 and 6.3 6.9 respectively before start of the program which was not statistically meaningful ( P -Value = 0.833). However, after the program, level of hs-CRP in the two tested groups changed to 2.3 5.1 and 5.7 6.1 respectively which showed a meaningful correlation ( P -Value = 0.023). These results also showed that decrease in hs-CRP level in the rehabilitated group but not in the control group was statistically meaningful (with P -Value of 0.037 and 0.0723 respectively). In patients undergoing coronary bypass surgery, participating in a full course of cardiac rehabilitation for 8 weeks has resulted in a significant reduction in hs-CRP levels as a marker of cardiovascular risk.

Nutrition Therapy in Critically Ill Patients Following Cardiac Surgery: Defining and Improving Practice.

PubMed

Rahman, Adam; Agarwala, Ravi; Martin, Claudio; Nagpal, Dave; Teitelbaum, Michael; Heyland, Daren K

2017-09-01

Malnutrition is a predictor of poor outcome following cardiac surgery. We define nutrition therapy after cardiac surgery to identify opportunities for improvement. International prospective studies in 2007-2009, 2011, and 2013 were combined. Sites provided institutional and patient characteristics from intensive care unit (ICU) admission to ICU discharge for a maximum of 12 days. Patients had valvular, coronary artery bypass graft (CABG) surgery, or combined procedures and were mechanically ventilated and staying in the ICU for ≥3 days. There were 787 patients from 144 ICUs. In total, 120 patients (15.2%) had valvular surgery, 145 patients (18.4%) had CABG, and 522 patients (66.3%) underwent a combined procedure. Overall, 60.1% of patients received artificial nutrition support. For these patients, 78% received enteral nutrition (EN) alone, 17% received a combination of EN and parenteral nutrition (PN), and 5% received PN alone. The remaining 314 patients (40%) received no nutrition. The mean (SD) time from ICU admission to EN initiation was 2.3 (1.8) days. The adequacy of calories was 32.4% ± 31.9% from EN and PN and 25.5% ± 27.9% for patients receiving only EN. In EN patients, 57% received promotility agents and 20% received small bowel feeding. There was no significant relationship between increased energy or protein provision and 60-day mortality. Postoperative cardiac surgery patients who stay in the ICU for 3 or more days are at high risk for inadequate nutrition therapy. Further studies are required to determine if targeted nutrition therapy may alter clinical outcomes.

The Brazilian Registry of Adult Patient Undergoing Cardiovascular Surgery, the BYPASS Project: Results of the First 1,722 Patients.

PubMed

Gomes, Walter J; Moreira, Rita Simone; Zilli, Alexandre Cabral; Bettiati, Luiz Carlos; Figueira, Fernando Augusto Marinho Dos Santos; D' Azevedo, Stephanie Steremberg Pires; Soares, Marcelo José Ferreira; Fernandes, Marcio Pimentel; Ardito, Roberto Vito; Bogdan, Renata Andrea Barberio; Campagnucci, Valquíria Pelisser; Nakasako, Diana; Kalil, Renato Abdala Karam; Rodrigues, Clarissa Garcia; Rodrigues, Anilton Bezerra; Cascudo, Marcelo Matos; Atik, Fernando Antibas; Lima, Elson Borges; Nina, Vinicius José da Silva; Heluy, Renato Albuquerque; Azeredo, Lisandro Gonçalves; Henrique, Odilon Silva; Mendonça, José Teles de; Silva, Katharina Kelly de Oliveira Gama; Pandolfo, Marcelo; Lima, José Dantas de; Faria, Renato Max; Santos, Jonas Pereira Dos; Paez, Rodrigo Pereira; Coelho, Guilherme Henrique Biachi; Pereira, Sergio Nunes; Senger, Roberta; Buffolo, Enio; Caputi, Guido Marco; Santo, José Amalth do Espírito; Oliveira, Juliana Aparecida Borges de; Berwanger, Otavio; Cavalcanti, Alexandre Biasi; Jatene, Fabio B

2017-01-01

To report the early results of the BYPASS project - the Brazilian registrY of adult Patient undergoing cArdiovaScular Surgery - a national, observational, prospective, and longitudinal follow-up registry, aiming to chart a profile of patients undergoing cardiovascular surgery in Brazil, assessing the data harvested from the initial 1,722 patients. Data collection involved institutions throughout the whole country, comprising 17 centers in 4 regions: Southeast (8), Northeast (5), South (3), and Center-West (1). The study population consists of patients over 18 years of age, and the types of operations recorded were: coronary artery bypass graft (CABG), mitral valve, aortic valve (either conventional or transcatheter), surgical correction of atrial fibrillation, cardiac transplantation, mechanical circulatory support and congenital heart diseases in adults. 83.1% of patients came from the public health system (SUS), 9.6% from the supplemental (private insurance) healthcare systems; and 7.3% from private (out-of -pocket) clinic. Male patients comprised 66%, 30% were diabetics, 46% had dyslipidemia, 28% previously sustained a myocardial infarction, and 9.4% underwent prior cardiovascular surgery. Patients underwent coronary artery bypass surgery were 54.1% and 31.5% to valve surgery, either isolated or combined. The overall postoperative mortality up to the 7th postoperative day was 4%; for CABG was 2.6%, and for valve operations, 4.4%. This first report outlines the consecution of the Brazilian surgical cardiac database, intended to serve primarily as a tool for providing information for clinical improvement and patient safety and constitute a basis for production of research protocols.

Nonbacterial Thrombotic Endocarditis in a Patient with Bowel Infarction due to Mesenteric Vein Thrombosis.

PubMed

Kim, Hyue Mee; Kim, Hack-Lyoung; Lee, Hak Seung; Jung, Ji-Hyun; Kim, Chee Hae; Oh, Sooyeon; Kim, Jung Ho; Zo, Joo-Hee

2014-05-01

Ante mortem cases of venous thrombosis in patients with nonbacterial thrombotic endocarditis (NBTE) have not yet been reported. We describe a rare case of NBTE in a patient with mesenteric vein thrombosis. A healthy 37-year-old man with abdominal pain and fever underwent emergency small bowel resection due to bowel ischemia resulting from mesenteric vein thrombosis. Transthoracic echocardiography revealed multiple mobile masses attached to the anterior leaflet of the mitral valves and their chordae tendineae. On suspicion of infective endocarditis, the cardiac masses were excised through open-heart surgery. However, pathologic reviews were compatible with NBTE. The patient was stable after the cardiac surgery and was treated with warfarin. Laboratory and imaging findings regarding his hypercoagulable condition were all negative.

Cardiac surgery for inmates in the Texas Department of Corrections.

PubMed

Bilfinger, T V; Conti, V R

1990-10-01

All Texas prison inmates requiring hospitalization since 1983 have been transferred to a separate prison hospital adjacent to a tertiary care university hospital. We reviewed and analyzed the data regarding one major tertiary care service, namely cardiac surgery, to describe the rate of utilization of this service and its results. From January 1, 1984, to June 30, 1988, 73 inmates underwent 74 cardiac operations, 50 of which were coronary revascularizations. The age-adjusted rates of utilization for coronary artery bypass grafting were substantially higher for inmates over age 45 than for that described for the general population, whereas the utilization rates for valve surgery were comparable. There were no perioperative or late deaths, and 86% of the inmate patients are currently employed within the Texas Department of Corrections system or were employed at the time of their release. The utilization rates and the results of this representative tertiary medical care service for the state's prison population are comparable to those achieved in the private sector, and may have a substantial beneficial effect on inmate rehabilitation.

[Effect of early postoperative use of ACEI/ARB or diuretics on the incidence of acute kidney injury after cardiac surgery in elderly patients].

PubMed

Hu, Peng-hua; Chen, Yuan-han; Liang, Xin-ling; Li, Rui-zhao; Li, Zhi-lian; Jiang, Fen; Shi, Wei

2013-07-01

To explore the influence of early postoperative use of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) or diuretics on acute kidney injury (AKI) after cardiac surgery in elderly patients. Data from elderly patients (age≥60 years old) who underwent cardiac surgery with extracorporeal circulation in Guangdong General Hospital between January 2007 and December 2010 were analyzed in this retrospective research. The primary endpoint was AKI as diagnosed according to the serum creatinine criteria of RIFLE (risk, injury, failure, loss, end stage renal disease). The baseline serum creatinine was defined as the latest serum creatinine level before cardiac surgery. Multivariate analysis by logistic regression was used to obtain the independent risk factors for AKI. Among 618 elderly patients, 76 (12.3%) patients received ACEI/ARB during early postoperative period, 491 (79.4%) patients were given diuretics during early postoperative period, and postoperative AKI occurred in 394 (63.8%) patients. The incidence of AKI was 46.1% in patients who received early postoperative ACEI/ARB, and 66.2% in patients who did not (P<0.001). Patients who received diuretics postoperatively were less likely to suffer from AKI compared with patients who did not (57.0% vs. 89.8%, P<0.001). After adjustment of other potential factors of postoperative AKI, logistic regression analysis showed that early postoperative use of ACEI/ARB [odds ratio (OR)=0.131, 95% confidence interval (95%CI) 0.033-0.517, P=0.004], and early postoperative use of diuretics (OR=0.149, 95%CI 0.076-0.291, P<0.001) independently predicted the occurrence of AKI. Early postoperative use of ACEI/ARB or diuretics is associated with a lower incidence of AKI after cardiac surgery with extracorporeal circulation in elderly patients.

Audit of Cardiac Surgery Outcomes for Low Birth Weight and Premature Infants.

PubMed

Alarcon Manchego, Peter; Cheung, Michael; Zannino, Diana; Nunn, Russell; D'Udekem, Yves; Brizard, Christian

2018-01-01

The burden of disease associated with cardiac surgery in preterm and low birth weight infants is increasing. This retrospective study aimed to compare the mortality and morbidity of cardiac surgery in low birth weight and preterm infants with that of a case-matched normal population. This was a single-center audit of cardiac surgery interventions at a tertiary pediatric center in Melbourne, Australia. Subjects underwent intervention in the first 3 months of life and were preterm (<37 weeks' gestation) or <2500 g at birth. Subjects were case-matched with 2 controls of term gestation and appropriate birth weight with the same primary diagnosis and intervention. Principal outcomes were mortality and complications in the 6 months following intervention. A total of 513 participants were included for analysis in the 13-year study period. There was an increased risk of mortality (odds ratio 6.26; 95% confidence interval (3.19, 12.3)) and rate of complications (odds ratio 2.29; 95% confidence interval (1.38, 3.78)) in low birth weight and premature infants compared with the control population. Patients who did not survive were more likely to have required extracorporeal membrane oxygenation (relative risk [RR] 6.6, P < 0.001), developed postoperative sepsis (RR 2.6, P = 0.012), and undergone unplanned reintervention (RR 2.3, P < 0.001) compared with survivors. Preterm and low birth weight patients had twice the RR of developing complications and 6 times the risk of mortality in the 6 months following cardiac intervention compared with a matched population. Observed trends suggest delaying surgery in clinically stable infants beyond 35 weeks corrected gestational age and 2500-g weight may result in improved survival. Copyright © 2018 Elsevier Inc. All rights reserved.

Virtual Surgery for Conduit Reconstruction of the Right Ventricular Outflow Tract.

PubMed

Ong, Chin Siang; Loke, Yue-Hin; Opfermann, Justin; Olivieri, Laura; Vricella, Luca; Krieger, Axel; Hibino, Narutoshi

2017-05-01

Virtual surgery involves the planning and simulation of surgical reconstruction using three-dimensional (3D) modeling based upon individual patient data, augmented by simulation of planned surgical alterations including implantation of devices or grafts. Here we describe a case in which virtual cardiac surgery aided us in determining the optimal conduit size to use for the reconstruction of the right ventricular outflow tract. The patient is a young adolescent male with a history of tetralogy of Fallot with pulmonary atresia, requiring right ventricle-to-pulmonary artery (RV-PA) conduit replacement. Utilizing preoperative magnetic resonance imaging data, virtual surgery was undertaken to construct his heart in 3D and to simulate the implantation of three different sizes of RV-PA conduit (18, 20, and 22 mm). Virtual cardiac surgery allowed us to predict the ability to implant a conduit of a size that would likely remain adequate in the face of continued somatic growth and also allow for the possibility of transcatheter pulmonary valve implantation at some time in the future. Subsequently, the patient underwent uneventful conduit change surgery with implantation of a 22-mm Hancock valved conduit. As predicted, the intrathoracic space was sufficient to accommodate the relatively large conduit size without geometric distortion or sternal compression. Virtual cardiac surgery gives surgeons the ability to simulate the implantation of prostheses of different sizes in relation to the dimensions of a specific patient's own heart and thoracic cavity in 3D prior to surgery. This can be very helpful in predicting optimal conduit size, determining appropriate timing of surgery, and patient education.

IL-1B rs16944 polymorphism is related to septic shock and death.

PubMed

Jiménez-Sousa, María Ángeles; Medrano, Luz M; Liu, Pilar; Almansa, Raquel; Fernández-Rodríguez, Amanda; Gómez-Sánchez, Esther; Rico, Lucía; Heredia-Rodríguez, María; Gómez-Pesquera, Estefanía; Tamayo, Eduardo; Resino, Salvador

2017-01-01

IL-1β is a primary mediator of systemic inflammatory response syndrome (SIRS) and it may lead to shock septic. Our aim was to analyse whether IL-1B rs16944 polymorphism is associated with the onset of septic shock and death after major surgery. We performed a case-control study on 467 patients who underwent major cardiac or abdominal surgery. Of them, 205 patients developed septic shock (cases, SS group) and 262 patients developed SIRS (controls, SIRS group). The primary outcome variables were the development of septic shock and death within 90 days after diagnosis of septic shock. The IL-1B rs16944 polymorphism was genotyped by Sequenom's MassARRAY platform. The association analysis was performed under a recessive genetic model (AA vs. GG/GC). The frequency of septic shock was higher in patients with IL-1B rs16944 AA genotype than in patients with IL-1B rs16944 GG/AG genotype when all patients were taken into account (63·6% vs. 41·8%; P = 0·006), cardiac surgery (52·2% vs. 33·3%; P = 0·072) and abdominal surgery (76·2% vs. 50·2%; P = 0·023). However, the IL-1B rs16944 AA genotype was only associated with higher likelihood of septic shock in the analysis of all population [adjusted odds ratio (aOR) = 2·26 (95%CI = 1·03; 4·97; P = 0·042], but not when it was stratified by cardiac surgery (P = 0·175) or abdominal surgery (P = 0·467). Similarly, IL-1B rs16944 AA genotype was also associated with higher likelihood of septic shock-related death in all population [aOR = 2·67 (95%CI = 1·07; 4·97); P = 0·035]. IL-1B rs16944 AA genotype seems to be related to the onset of septic shock and death in patients who underwent major surgery. © 2016 Stichting European Society for Clinical Investigation Journal Foundation.

Penicillin skin testing in cardiac surgery.

PubMed

Cook, David J; Barbara, David W; Singh, Karen E; Dearani, Joseph A

2014-06-01

Penicillin is the most commonly reported allergy in cardiac surgical patients and a history of penicillin allergy frequently results in the use of vancomycin for antibiotic prophylaxis. However, clinical history is unreliable and true allergy is rare. Penicillin allergy testing has the potential to reduce vancomycin use and indirectly the potential for selection of vancomycin-resistant organisms, a national priority. After the publication of the 2007 Society of Thoracic Surgeons practice guideline report, we initiated a penicillin allergy testing service for cardiac surgical patients in 2009. We sought to determine the true incidence of penicillin allergy in the tested population, whether testing availability reduced vancomycin use in those tested, and if vancomycin use was reduced in the entire cardiac surgical population as a whole. A total of 276 patients were skin tested for allergy to penicillin or cephalosporin. Testing recommended no penicillin use in 13.8% of those tested giving a true penicillin allergy incidence of 0.9%. Only 24 of the 276 patients tested (9%) received vancomycin. However, given the small percentage of the total population that underwent allergy testing, the overall use of vancomycin in the cardiac surgery practice was not reduced in the posttesting period. The true rate of contraindication to penicillin in a cardiac surgical population is very low. Penicillin allergy testing can reduce vancomycin use in the tested population, but better means of conducting the testing and making the results available are necessary to reduce unnecessary vancomycin use in a broader cardiac surgical population. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Predictive value of the model for end-stage liver disease score in patients undergoing left ventricular assist device implantation.

PubMed

Deo, Salil V; Daly, Richard C; Altarabsheh, Salah E; Hasin, Tal; Zhao, Yanjun; Shah, Ishan K; Stulak, John M; Boilson, Barry A; Schirger, John A; Joyce, Lyle D; Park, Soon J

2013-01-01

Axial flow left ventricular assist device (LVAD) implantation is an effective therapy for patients with advanced heart failure. As the preoperative hepatic and renal function play a critical role in determining adverse events after LVAD implantation, we analyzed the predictive role of the model for end-stage liver disease (MELD) score in determining in-hospital mortality after surgery. One hundred twenty-six patients underwent implant of an LVAD at our institution. Their individual preoperative MELD scores and perioperative total blood product usage (TBPU) were calculated. As LVAD implant as a reoperation is known to influence postoperative bleeding and mortality independently, the patients were divided into group I (first cardiac surgery) and group II (reoperative surgery). Group I: LVAD implantation was performed in 68/126 (54%) patients as their first cardiac surgery. The mean MELD score was 16.3 ± 6. Median TBPU for this group was 20.7 (0, 135) units. Inhospital mortality/30-day mortality was 4/68 (5.8%). Increasing MELD score (c-statistic = 0.88) and TBPU were found to be predictors of early mortality. An increasing MELD score was associated with more TBPU (p < 0.01) with a 10.9 ± 3 TBPU increase per a 10 unit rise in the MELD score. Group II: Of the 126 patients, 58 (46%) underwent LVAD implantation as a reoperation. Mean MELD score for these patients was 16 ± 5. Inhospital mortality/30-day mortality in this group was 12% and median TBPU was 30 (4,153) units. The MELD score was not predictive of inhospital mortality in these patients (p = 0.97). The MELD score is predictive of early mortality in patients undergoing LVAD implantation as their first cardiac surgery. Use of this score to select patients for LVAD implantation may be appropriate.

Kidney Outcomes 5 Years After Pediatric Cardiac Surgery

PubMed Central

Greenberg, Jason H.; Zappitelli, Michael; Devarajan, Prasad; Thiessen-Philbrook, Heather R.; Krawczeski, Catherine; Li, Simon; Garg, Amit X.; Coca, Steve; Parikh, Chirag R.

2017-01-01

IMPORTANCE Acute kidney injury (AKI) after pediatric cardiac surgery is associated with high short-term morbidity and mortality; however, the long-term kidney outcomes are unclear. OBJECTIVE To assess long-term kidney outcomes after pediatric cardiac surgery and to determine if perioperative AKI is associated with worse long-term kidney outcomes. DESIGN, SETTING, AND PARTICIPANTS This prospective multicenter cohort study recruited children between ages 1 month to 18 years who underwent cardiopulmonary bypass for cardiac surgery and survived hospitalization from 3 North American pediatric centers between July 2007 and December 2009. Children were followed up with telephone calls and an in-person visit at 5 years after their surgery. EXPOSURES Acute kidney injury defined as a postoperative serum creatinine rise from preoperative baseline by 50% or 0.3 mg/dL or more during hospitalization for cardiac surgery. MAIN OUTCOMES AND MEASURES Hypertension (blood pressure ≥95th percentile for height, age, sex, or self-reported hypertension), microalbuminuria (urine albumin to creatinine ratio >30 mg/g), and chronic kidney disease (serum creatinine estimated glomerular filtration rate [eGFR] <90 mL/min/1.73 m2 or microalbuminuria). RESULTS Overall, 131 children (median [interquartile range] age, 7.7 [5.9–9.9] years) participated in the 5-year in-person follow-up visit; 68 children (52%) were male. Fifty-seven of 131 children (44%) had postoperative AKI. At follow-up, 22 children (17%) had hypertension (10 times higher than the published general pediatric population prevalence), while 9 (8%), 13 (13%), and 1 (1%) had microalbuminuria, an eGFR less than 90 mL/min/1.73 m2, and an eGFR less than 60 mL/min/1.73 m2, respectively. Twenty-one children (18%) had chronic kidney disease. Only 5 children (4%) had been seen by a nephrologist during follow-up. There was no significant difference in renal outcomes between children with and without postoperative AKI. CONCLUSIONS AND RELEVANCE Chronic kidney disease and hypertension are common 5 years after pediatric cardiac surgery. Perioperative AKI is not associated with these complications. Longer follow-up is needed to ascertain resolution or worsening of chronic kidney disease and hypertension. PMID:27618162

Surgical Results and Outcomes After Reimplantation for the Management of Anomalous Aortic Origin of the Right Coronary Artery.

PubMed

Law, Timothy; Dunne, Ben; Stamp, Nikki; Ho, Kwok M; Andrews, David

2016-07-01

Anomalous aortic origin of the right coronary artery (AAORCA) has been reported to cause myocardial ischemia, leading to angina, dyspnea, and decreased exercise tolerance. Reimplantation is a repair technique devised to exclude the abnormal intramural portion of the anomalous artery and avoid the known late attrition of saphenous vein grafts. Our study aims to evaluate the medium-term clinical outcomes with this technique. A retrospective review was made of patients who underwent repair of AAORCA by reimplantation between 2002 and 2014 in two institutions in Western Australia. Follow-up computed tomography coronary angiography was used to assess the status of the reimplanted right coronary artery (RCA). Data on survival, freedom from symptoms, cardiac events, and cardiac interventions were also analyzed. Of the 16 patients (aged 17 to 70 years old), 14 (88%) were symptomatic before surgery, with angina (50%) and exertional dyspnea (56%) being the most common symptoms. Surgical reimplantation was successful in 15 patients (94%) without operative mortality. One patient required saphenous vein bypass grafting of the RCA intraoperatively after presumed failed repair and difficulty weaning from cardiopulmonary bypass. All patients who had successful reimplantation of AAORCA were symptom-free after surgery, and none had subsequent cardiac events attributable to the RCA or required further interventions. Ten patients (67%) had computed tomography coronary angiography after surgery; none had stenosis, kinking, or compression of the RCA by the pulmonary artery. Two further patients (including the patient who underwent saphenous vein grafting for presumed failed reimplantation) underwent conventional angiography, which demonstrated patent reimplantations. To the best of our knowledge, this is the largest reported series of anomalous RCA managed by surgical reimplantation. Our results suggest that this technique is safe and has excellent medium to long-term results regarding symptom-free survival. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Serum uric acid level predicts adverse outcomes after myocardial revascularization or cardiac valve surgery.

PubMed

Lazzeroni, Davide; Bini, Matteo; Camaiora, Umberto; Castiglioni, Paolo; Moderato, Luca; Bosi, Davide; Geroldi, Simone; Ugolotti, Pietro T; Brambilla, Lorenzo; Brambilla, Valerio; Coruzzi, Paolo

2018-01-01

Background High levels of serum uric acid have been associated with adverse outcomes in cardiovascular diseases such as myocardial infarction and heart failure. The aim of the current study was to evaluate the prognostic role of serum uric acid levels in patients undergoing cardiac rehabilitation after myocardial revascularization and/or cardiac valve surgery. Design We performed an observational prospective cohort study. Methods The study included 1440 patients with available serum uric acid levels, prospectively followed for 50 ± 17 months. Mean age was 67 ± 11 years; 781 patients (54%) underwent myocardial revascularization, 474 (33%) cardiac valve surgery and 185 (13%) valve-plus-coronary artery by-pass graft surgery. The primary endpoints were overall and cardiovascular mortality while secondary end-points were combined major adverse cardiac and cerebrovascular events. Results Serum uric acid level mean values were 286 ± 95 µmol/l and elevated serum uric acid levels (≥360 µmol/l or 6 mg/dl) were found in 275 patients (19%). Overall mortality (hazard ratio = 2.1; 95% confidence interval: 1.5-3.0; p < 0.001), cardiovascular mortality (hazard ratio = 2.0; 95% confidence interval: 1.2-3.2; p = 0.004) and major adverse cardiac and cerebrovascular events rate (hazard ratio = 1.5; 95% confidence interval: 1.0-2.0; p = 0.019) were significantly higher in patients with elevated serum uric acid levels, even after adjustment for age, gender, arterial hypertension, diabetes, glomerular filtration rate, atrial fibrillation and medical therapy. Moreover, strong positive correlations between serum uric acid level and probability of overall mortality ( p < 0.001), cardiovascular mortality ( p < 0.001) and major adverse cardiac and cerebrovascular events ( p = 0.003) were found. Conclusions Serum uric acid levels predict mortality and adverse cardiovascular outcome in patients undergoing myocardial revascularization and/or cardiac valve surgery even after the adjustment for age, gender, arterial hypertension, diabetes, glomerular filtration rate and medical therapy.

Prognostic Value of Negative Coronary CT Angiography in Severely Obese Patients Prior to Bariatric Surgery: a Follow-Up After 6 Years.

PubMed

Messerli, Michael; Maywald, Céline; Wälti, Stephan; Warschkow, René; Wildermuth, Simon; Alkadhi, Hatem; Leschka, Sebastian; Schiesser, Marc

2017-08-01

This study aims to determine the long-term prognostic value of coronary CT angiography (CCTA) prior to bariatric surgery in severely obese patients with a body mass index (BMI) ≥35 kg/m 2 . Seventy consecutive patients undergoing cardiac CT for coronary assessment prior to bariatric surgery were prospectively included. Images were analysed for the presence of coronary calcification and for non-obstructive (<50%) or obstructive (>50% stenosis) coronary artery disease (CAD). A median clinical follow-up of 6.1 years in 54 patients was obtained for major adverse cardiovascular events (MACEs), defined as death, non-fatal myocardial infarction or coronary revascularisation. Weight loss and BMI decrease following bariatric surgery were recorded. The median BMI prior to surgery was 46.9 kg/m 2 . The median percentage of excess BMI loss after surgery was 75%. CT showed coronary calcification in 26 (48%) patients, whereas 28 (52%) patients had no calcification. CCTA revealed normal coronaries in 47 (87%) and non-obstructive CAD in 7 (13%) patients. No obstructive CAD was found. All patients successfully underwent bariatric surgery, and no MACE occurred neither perioperatively nor in the follow-up period. The negative predictive value of CCTA was 100% (95% confidence interval of 90.1-100.0%). In severely obese patients, the absence of obstructive CAD in cardiac CT prior to bariatric surgery with subsequently marked weight reduction has strong long-term prognostic implications for ruling out major adverse cardiac events in the postoperative period.

Application of the Transtheoretical Model to Exercise Behavior and Physical Activity in Patients after Open Heart Surgery.

PubMed

Huang, Hsin-Yi; Lin, Yu-Shan; Chuang, Yi-Cheng; Lin, Wei-Hsuan; Kuo, Li Ying; Chen, Jui Chun; Hsu, Ching Ling; Chen, Bo Yan; Tsai, Hui Yu; Cheng, Fei Hsin; Tsai, Mei-Wun

2015-05-01

To assess exercise behavior and physical activity levels after open heart surgery. This prospective cohort study included 130 patients (70.8% male, aged 61.0 ± 12.2 years, 53.8% coronary bypass grafting) who underwent open heart surgery. The exercise behavior and physical activity of these patients were assessed at the 3- and 6-month follow-up appointments. Additional interviews were also conducted to further assess exercise behavior. Physical activity duration and metabolic equivalents were calculated from self-reported questionnaire responses. Moreover, possible related demographic factors, clinical features, participation in cardiac rehabilitation programs, and physical activity levels were additionally evaluated. Six months after hospital discharge, most patients were in the action (39.2%) and maintenance (37.7%) stages. Other subjects were in the precontemplation (11.5%), contemplation (5.4%), and preparation (6.2%) stages. The average physical activity level was 332.6 ± 377.1 min/week and 1198.1 ± 1396.9 KJ/week. Subjects in the action and maintenance stages exercised an average of 399.4 ± 397.6 min/week, significantly longer than those in other stages (116.2 ± 176.2 min/week, p = 0.02). Subjects that participated in outpatient cardiac rehabilitation programs after discharge may have the better exercise habit. Gender had no significant effect on exercise behavior 6 months after hospital discharge. Most subjects following open heart surgery may maintain regular exercise behavior at 6 months after hospital discharge. Physical activity levels sufficient for cardiac health were achieved by subjects in the active and maintenance stages. Outpatient cardiac rehabilitation programs are valuable for encouraging exercise behavior after heart surgery. Exercise behavior; Open heart surgery; Physical activity; Transtheoretical model.

The Incidence of Postoperative Pneumonia in Various Surgical Subspecialties: A Dual Database Analysis.

PubMed

Chughtai, Morad; Gwam, Chukwuweike U; Khlopas, Anton; Newman, Jared M; Curtis, Gannon L; Torres, Pedro A; Khan, Rafay; Mont, Michael A

2017-07-25

Pneumonia is the third most common postoperative complication. However, its epidemiology varies widely and is often difficult to assess. For a better understanding, we utilized two national databases to determine the incidence of postoperative pneumonia after various surgical procedures. Specifically, we used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and the Nationwide Inpatient Sample (NIS) to determine the incidence and yearly trends of postoperative pneumonia following orthopaedic, urologic, otorhinolaryngologic, cardiothoracic, neurosurgery, and general surgeries. The NIS and NSQIP databases from 2009-2013 were utilized. The Clinical Classification Software (CCS) for International Classification of Diseases, 9th edition (ICD-9) codes provided by the NIS database was used to identify all surgical subspecialty procedures. The incidence of postoperative pneumonia was identified as the total number of cases under each identifying CCS code that also had ICD-9 codes for postoperative pneumonia. In the NSQIP database, the surgical subspecialties were selected using the following identifying string variables provided by NSQIP: 1) "Orthopedics", 2) "Otolaryngology (ENT)", 3) "Urology", 4) "Neurosurgery", 5) "General Surgery", and 6) "Cardiac Surgery" and "Thoracic Surgery". Cardiac and thoracic surgery was merged to create the variable "Cardiothoracic Surgery". Postoperative pneumonia cases were extracted utilizing the available NSQIP nominal variables. All variables were used to isolate the incidences of postoperative pneumonia stratified by surgical specialty. A subsequent trend analysis was conducted to assess the associations between operative year and incidence of postoperative pneumonia. For all NIS surgeries, the incidence of postoperative pneumonia was 0.97% between 2009 and 2013. The incidence was highest among patients who underwent cardiothoracic surgery (3.3%) and urologic surgery (1.73%). Patients who underwent general surgery, neurosurgery, spine surgery, orthopaedic surgery, and ENT surgery had a postoperative pneumonia incidence of 1.1%, 0.6%, 0.5%, 0.5%, and 0.4%, respectively. Overall trend analysis demonstrated a statistically significant decrease in postoperative pneumonia incidence (p <0.001), which paralleled in each specialty as well. In NSQIP, the incidence of postoperative pneumonia for all surgeries that occurred between 2009 and 2013 was 1.3%. The incidences of postoperative pneumonia were highest among patients who underwent cardiothoracic surgery (5.3%), general surgery (1.4%), and neurosurgery (1.4%). The incidences of postoperative pneumonia in patients who underwent ENT surgery, orthopedic surgery, and urologic surgery were 0.7%, respectively. Overall trend analysis demonstrated a statistically significant increase in postoperative pneumonia incidence for patients undergoing cardiothoracic surgery (p <0.001). There were no notable trends for the other surgical subspecialties. The incidence of postoperative pneumonia differs between the two national databases. Furthermore, the incidences differed among the various surgical subspecialties; however, cardiothoracic surgery had the highest incidence in both databases. Furthermore, cardiothoracic surgery appeared to have an increasing trend in incidence. Standardizing and implementing accurate coding methodologies for this complication are needed for a more accurate assessment of this burdensome complication. Future studies should assess interventions, such as oral cleansing and suctioning, incentive spirometry, as well as designated institution-based pneumonia prevention programs and protocols to help prevent and mitigate the occurrence of this complication.

Patient body image, self-esteem, and cosmetic results of minimally invasive robotic cardiac surgery.

PubMed

İyigün, Taner; Kaya, Mehmet; Gülbeyaz, Sevil Özgül; Fıstıkçı, Nurhan; Uyanık, Gözde; Yılmaz, Bilge; Onan, Burak; Erkanlı, Korhan

2017-03-01

Patient-reported outcome measures reveal the quality of surgical care from the patient's perspective. We aimed to compare body image, self-esteem, hospital anxiety and depression, and cosmetic outcomes by using validated tools between patients undergoing robot-assisted surgery and those undergoing conventional open surgery. This single-center, multidisciplinary, randomized, prospective study of 62 patients who underwent cardiac surgery was conducted at Hospital from May 2013 to January 2015. The patients were divided into two groups: the robotic group (n = 33) and the open group (n = 29). The study employed five different tools to assess body image, self-esteem, and overall patient-rated scar satisfaction. There were statistically significant differences between the groups in terms of self-esteem scores (p = 0.038), body image scores (p = 0.026), overall Observer Scar Assessment Scale (p = 0.013), and overall Patient Scar Assessment Scale (p = 0.036) scores in favor of the robotic group during the postoperative period. Robot-assisted surgery protected the patient's body image and self-esteem, while conventional open surgery decreased these levels but without causing pathologies. Preoperative depression and anxiety level was reduced by both robot-assisted surgery and conventional open surgery. The groups did not significantly differ on Patient Satisfaction Scores and depression/anxiety scores. The results of this study clearly demonstrated that a minimally invasive approach using robotic-assisted surgery has advantages in terms of body image, self-esteem, and cosmetic outcomes over the conventional approach in patients undergoing cardiac surgery. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Preoperative Red Cell Distribution Width and 30-day mortality in older patients undergoing non-cardiac surgery: a retrospective cohort observational study.

PubMed

Abdullah, H R; Sim, Y E; Sim, Y T; Ang, A L; Chan, Y H; Richards, T; Ong, B C

2018-04-18

Increased red cell distribution width (RDW) is associated with poorer outcomes in various patient populations. We investigated the association between preoperative RDW and anaemia on 30-day postoperative mortality among elderly patients undergoing non-cardiac surgery. Medical records of 24,579 patients aged 65 and older who underwent surgery under anaesthesia between 1 January 2012 and 31 October 2016 were retrospectively analysed. Patients who died within 30 days had higher median RDW (15.0%) than those who were alive (13.4%). Based on multivariate logistic regression, in our cohort of elderly patients undergoing non-cardiac surgery, moderate/severe preoperative anaemia (aOR 1.61, p = 0.04) and high preoperative RDW levels in the 3rd quartile (>13.4% and ≤14.3%) and 4th quartile (>14.3%) were significantly associated with increased odds of 30-day mortality - (aOR 2.12, p = 0.02) and (aOR 2.85, p = 0.001) respectively, after adjusting for the effects of transfusion, surgical severity, priority of surgery, and comorbidities. Patients with high RDW, defined as >15.7% (90th centile), and preoperative anaemia have higher odds of 30-day mortality compared to patients with anaemia and normal RDW. Thus, preoperative RDW independently increases risk of 30-day postoperative mortality, and future risk stratification strategies should include RDW as a factor.

Theophylline Population Pharmacokinetics and Dosing in Children Following Congenital Heart Surgery With Cardiopulmonary Bypass.

PubMed

Frymoyer, Adam; Su, Felice; Grimm, Paul C; Sutherland, Scott M; Axelrod, David M

2016-09-01

Children undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) frequently develop acute kidney injury due to renal ischemia. Theophylline, which improves renal perfusion via adenosine receptor inhibition, is a potential targeted therapy. However, children undergoing cardiac surgery and CPB commonly have alterations in drug pharmacokinetics. To help understand optimal aminophylline (salt formulation of theophylline) dosing strategies in this population, a population-based pharmacokinetic model was developed using nonlinear mixed-effects modeling (NONMEM) from 71 children (median age 5 months; 90% range 1 week to 10 years) who underwent cardiac surgery requiring CPB and received aminophylline as part of a previous randomized controlled trial. A 1-compartment model with linear elimination adequately described the pharmacokinetics of theophylline. Weight scaled via allometry was a significant predictor of clearance and volume. In addition, allometric scaled clearance increased with age implemented as a power maturation function. Compared to prior reports in noncardiac children, theophylline clearance was markedly reduced across age. In the final population pharmacokinetic model, optimized empiric dosing regimens were developed via Monte Carlo simulations. Doses 50% to 75% lower than those recommended in noncardiac children were needed to achieve target serum concentrations of 5 to 10 mg/L. © 2016, The American College of Clinical Pharmacology.

Bard Denali inferior vena cava filter fracture and embolization resulting in cardiac tamponade: a device failure analysis.

PubMed

Kuo, William T; Robertson, Scott W

2015-01-01

A 46-year-old woman underwent inferior vena cava filter placement before bariatric surgery and returned within 6 months for routine removal. She complained of a 1-week history of severe chest pain, and during retrieval, two fractured filter components were identified including one arm in the right ventricle. The filter body and one fragment were successfully retrieved, but the fragment in the right ventricle was refractory to percutaneous retrieval. During open-heart surgery, the fragment was found traversing through the ventricular wall resulting in cardiac tamponade. Electron microscopic fragment analysis revealed high-cycle metal fatigue indicating the filter design failed to withstand this patient's natural inferior vena cava biomechanical motions. Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.

The Brazilian Registry of Adult Patient Undergoing Cardiovascular Surgery, the BYPASS Project: Results of the First 1,722 Patients

PubMed Central

Gomes, Walter J.; Moreira, Rita Simone; Zilli, Alexandre Cabral; Bettiati Jr, Luiz Carlos; Figueira, Fernando Augusto Marinho dos Santos; D'Azevedo, Stephanie Steremberg Pires; Soares, Marcelo José Ferreira; Fernandes, Marcio Pimentel; Ardito, Roberto Vito; Bogdan, Renata Andrea Barberio; Campagnucci, Valquíria Pelisser; Nakasako, Diana; Kalil, Renato Abdala Karam; Rodrigues, Clarissa Garcia; Rodrigues Junior, Anilton Bezerra; Cascudo, Marcelo Matos; Atik, Fernando Antibas; Lima, Elson Borges; Nina, Vinicius José da Silva; Heluy, Renato Albuquerque; Azeredo, Lisandro Gonçalves; Henrique Junior, Odilon Silva; de Mendonça, José Teles; Silva, Katharina Kelly de Oliveira Gama; Pandolfo, Marcelo; de Lima Júnior, José Dantas; Faria, Renato Max; dos Santos, Jonas Pereira; Paez, Rodrigo Pereira; Coelho, Guilherme Henrique Biachi; Pereira, Sergio Nunes; Senger, Roberta; Buffolo, Enio; Caputi, Guido Marco; Santo, José Amalth do Espírito; de Oliveira, Juliana Aparecida Borges; Berwanger, Otavio; Cavalcanti, Alexandre Biasi; Jatene, Fabio B.

2017-01-01

Objective To report the early results of the BYPASS project - the Brazilian registrY of adult Patient undergoing cArdiovaScular Surgery - a national, observational, prospective, and longitudinal follow-up registry, aiming to chart a profile of patients undergoing cardiovascular surgery in Brazil, assessing the data harvested from the initial 1,722 patients. Methods Data collection involved institutions throughout the whole country, comprising 17 centers in 4 regions: Southeast (8), Northeast (5), South (3), and Center-West (1). The study population consists of patients over 18 years of age, and the types of operations recorded were: coronary artery bypass graft (CABG), mitral valve, aortic valve (either conventional or transcatheter), surgical correction of atrial fibrillation, cardiac transplantation, mechanical circulatory support and congenital heart diseases in adults. Results 83.1% of patients came from the public health system (SUS), 9.6% from the supplemental (private insurance) healthcare systems; and 7.3% from private (out-of -pocket) clinic. Male patients comprised 66%, 30% were diabetics, 46% had dyslipidemia, 28% previously sustained a myocardial infarction, and 9.4% underwent prior cardiovascular surgery. Patients underwent coronary artery bypass surgery were 54.1% and 31.5% to valve surgery, either isolated or combined. The overall postoperative mortality up to the 7th postoperative day was 4%; for CABG was 2.6%, and for valve operations, 4.4%. Conclusion This first report outlines the consecution of the Brazilian surgical cardiac database, intended to serve primarily as a tool for providing information for clinical improvement and patient safety and constitute a basis for production of research protocols. PMID:28492786

The use of autologous platelet gel (APG) for high-risk patients in cardiac surgery -- is it beneficial?

PubMed

Litmathe, Jens; Philipp, Christian; Kurt, Muhammed; Boeken, Udo; Gams, Emmeran; Feindt, Peter

2009-11-01

Wound healing in cardiac surgery has become a major problem due to the impaired risk profile of many patients. The aim of this study was to prove the influence of autologous platelet gel (APG) on wound healing in a special group of high-risk patients undergoing coronary surgery. We performed a prospective, double-blind study in 44 patients with a special risk constellation relating to wound complications (obesity, diabetes, smoker, New York Heart Association (NYHA) III-IV and peripheral vascular disease). The study group was treated with APG, prepared using the Magellan platelet separator, the control group underwent conventional wound treatment. The incidence of major and minor wound complications at the thoracotomy, as well as in the area of saphenous vein harvesting, was not pronounced in either of the groups. Blood loss and pain sensations did not differ significantly either. Stay in the intensive care unit (ICU) and the in-hospital mortality were also comparable. The duration of the entire operation and the time until removing the chest-tubes were prolonged in the study group. Despite promising results in other fields of surgery, APG shows no beneficial effect in high-risk patients undergoing cardiac surgery. Probably, it depends on different types of microcirculation in atherosclerotic patients, which are quite different from those of other surgical areas. This factor may offset the existing beneficial platelet effects which could be observed, for example, in maxillo-facial surgery.

Gross motor development is delayed following early cardiac surgery.

PubMed

Long, Suzanne H; Harris, Susan R; Eldridge, Beverley J; Galea, Mary P

2012-10-01

To describe the gross motor development of infants who had undergone cardiac surgery in the neonatal or early infant period. Gross motor performance was assessed when infants were 4, 8, 12, and 16 months of age with the Alberta Infant Motor Scale. This scale is a discriminative gross motor outcome measure that may be used to assess infants from birth to independent walking. Infants were videotaped during the assessment and were later evaluated by a senior paediatric physiotherapist who was blinded to each infant's medical history, including previous clinical assessments. Demographic, diagnostic, surgical, critical care, and medical variables were considered with respect to gross motor outcomes. A total of 50 infants who underwent elective or emergency cardiac surgery at less than or up to 8 weeks of age, between July 2006 and January 2008, were recruited to this study and were assessed at 4 months of age. Approximately, 92%, 84%, and 94% of study participants returned for assessment at 8, 12, and 16 months of age, respectively. Study participants had delayed gross motor development across all study time points; 62% of study participants did not have typical gross motor development during the first year of life. Hospital length of stay was associated with gross motor outcome across infancy. Active gross motor surveillance of all infants undergoing early cardiac surgery is recommended. Further studies of larger congenital heart disease samples are required, as are longitudinal studies that determine the significance of these findings at school age and beyond.

Hawthorn Herb Increases the Risk of Bleeding after Cardiac Surgery: An Evidence-Based Approach.

PubMed

Rababa'h, Abeer M; Altarabsheh, Salah E; Haddad, Osama; Deo, Salil V; Obeidat, Yagthan; Al-Azzam, Sayer

2016-08-22

Hawthorn extract consumption is becoming more widespread among the Jordanian population with cardiovascular disorders. We conducted this prospective observational longitudinal study to determine the impact of hawthorn extract on bleeding risk in patients who undergo cardiac surgery. A prospective observational study was performed on 116 patients who underwent cardiac surgery in the period between June 2014 and May 2015. Patients were divided into two groups: Group I (patients recently consumed hawthorn extract) and Group II (patients never consumed hawthorn extract). Endpoint measures included the rates of reopening to control bleeding, early mortality, duration of intensive care unit stay, total in-hospital stay period, and duration and amount of chest tube drainage. Hawthorn patients had a significantly higher rate of postoperative bleeding necessitating take back to the operating room compared to the control group (10% versus 1%; P = .03) respectively. The overall mortality rate for group I and II was 4% and 0% respectively; P = .17. Chest tubes were kept in for longer times in group I compared to group II (54 ± 14.6 versus 49 ± 14.7 hours respectively; P = .01). Group I stayed longer in the intensive care unit compared to group II (24 versus 22 hours respectively; P = .01). The total in-hospital stay period was comparable between the two groups. Hawthorn extract consumption does increase the potential for bleeding and the amount of chest tube output after cardiac surgery.

Pericardium closure after heart operations: a safety option?

PubMed

Dantas, Carlos Eduardo Pereira; Sá, Mauro Paes Leme de; Bastos, Eduardo Sergio; Magnanini, Monica M F

2010-01-01

Primary pericardium closure may reduce the risk of cardiac injury during chest re opening, especially the right ventricle, aorta and coronary bypass grafts. Nevertheless, concern about adverse hemodynamic effects prevents most heart surgeons of closuring the pericardium. We evaluated 48 patients undergoing open heart surgery consecutively which the pericardium was closed in 30 patients (group A) and 18 patients, as a control group (group B) in which the pericardium was left open. All patients underwent posteroanterior and lateral chest roentgenograms before surgery and one week postoperatively. Postoperative evaluation also included echocardiograms, ECG and postoperative enzyme analysis. There were no deaths or any complications in both groups (acute myocardial infarction, stroke, bleeding or cardiac tamponate). It was observed statistically differences between both groups especially in echocardiogram parameters and cardiothoracic ratio without clinical impact. Pericardium closure is a simple method to facilitate resternotomy during subsequent re operative procedures. However, cardiac surgeons should be aware of the transient deterioration in hemodynamics associated with it, even thought there was no clinical significance in this study.

Milrinone Use is Associated With Postoperative Atrial Fibrillation Following Cardiac Surgery

PubMed Central

Fleming, Gregory A.; Murray, Katherine T.; Yu, Chang; Byrne, John G.; Greelish, James P.; Petracek, Michael R.; Hoff, Steven J.; Ball, Stephen K.; Brown, Nancy J.; Pretorius, Mias

2009-01-01

Background Postoperative atrial fibrillation (AF), a frequent complication following cardiac surgery, causes morbidity and prolongs hospitalization. Inotropic drugs are commonly used perioperatively to support ventricular function. This study tested the hypothesis that the use of inotropic drugs is associated with postoperative AF. Methods and Results We evaluated perioperative risk factors in 232 patients who underwent elective cardiac surgery. All patients were in sinus rhythm at surgery. Sixty-seven (28.9%) patients developed AF a mean of 2.9±2.1 days after surgery. Patients who developed AF stayed in the hospital longer (P<0.001) and were more likely to die (P=0.02). Milrinone use was associated with an increased risk of postoperative AF (58.2% versus 26.1% in non-users, P<0.001). Older age (63.4±10.7 versus 56.7±12.3 years, P<0.001), hypertension (P=0.04), lower preoperative ejection fraction (P=0.03), mitral valve surgery (P=0.02), right ventricular dysfunction (P=0.03), and higher mean pulmonary artery pressure (PAP) (27.1±9.3 versus 21.8±7.5 mmHg, P=0.001) were also associated with postoperative AF. In multivariable logistic regression, age (P<0.001), ejection fraction (P=0.02), and milrinone use (odds ratio 4.86, 95% CI 2.31-10.25, P<0.001) independently predicted postoperative AF. When data only from patients with pulmonary artery catheters were analyzed and PAP was included in the model, age, milrinone use (odds ratio 4.45, 95% CI 2.01-9.84, P<0.001), and higher PAP (P=0.02) were associated with an increased risk of postoperative AF. Adding other potential confounders or stratifying analysis by mitral valve surgery did not change the association of milrinone use with postoperative AF. Conclusion Milrinone use is an independent risk factor for postoperative AF following elective cardiac surgery. PMID:18824641

Association between severity of untreated sleep apnoea and postoperative complications following major cardiac surgery: a prospective observational cohort study.

PubMed

Mason, Martina; Hernández Sánchez, Jules; Vuylsteke, Alain; Smith, Ian

2017-09-01

To examine whether untreated sleep apnoea is associated with prolonged Intensive Care Unit (ICU) stay and increased frequency of postoperative ICU complications, in patients undergoing major cardiac surgery. Adult patients, undergoing elective coronary artery bypass grafting with or without cardiac valve surgery, between March 2013 and July 2014, were considered. We excluded patients participating in other interventional studies, those who had a tracheostomy before surgery, required emergency surgery or were due to be admitted on the day of surgery. Patients underwent inpatient overnight oximetry on the night prior to their surgery to assess for the presence of sleep apnoea. Since oximetry alone cannot differentiate obstructive from central apnoea, the results are reported as sleep apnoea which was diagnosed in patients with an arterial oxygen desaturation index (ODI) ≥ 5/h. The primary outcome measure was length of stay (LoS) in ICU in days. The secondary outcome was a composite measure of postoperative complications in ICU. Multivariate models were developed to assess associations between ODI and the primary and secondary outcome measures, adjusting for preselected predictor variables, relative to primary and secondary outcomes. There was no significant association between ODI and ICU LoS, HR 1.0, 95% CI 0.99-1.02; p = 0.12. However we did find a significant association between ODI and postoperative complications in the ICU, OR = 1.1; 95% CI 1.02-1.17; p = 0.014. The probability of developing complications rose with higher ODI, reflecting sleep apnoea severity. Acknowledging the limitations of this prospective study, untreated sleep apnoea did not predict an increased length of stay in ICU but we do report an association with postoperative complications in patients undergoing major cardiac surgery. Copyright © 2017 Elsevier B.V. All rights reserved.

Risk Factors for Mortality in Reoperations for Pediatric and Congenital Heart Surgery in a Developing Country.

PubMed

Villa-Hincapie, Carlos A; Carreno-Jaimes, Marisol; Obando-Lopez, Carlos E; Camacho-Mackenzie, Jaime; Umaña-Mallarino, Juan P; Sandoval-Reyes, Nestor F

2017-07-01

The survival of patients with congenital heart disease has increased in the recent years, because of enhanced diagnostic capabilities, better surgical techniques, and improved perioperative care. Many patients will require reoperation as part of staged procedures or to treat grafts deterioration and residual or recurrent lesions. Reoperations favor the formation of cardiac adhesions and consequently increase surgery time; however, the impact on morbidity and operative mortality is certain. The objective of the study was to describe the risk factors for mortality in pediatric patients undergoing a reoperation for congenital heart disease. Historic cohort of patients who underwent reoperation after pediatric cardiac surgery from January 2009 to December 2015. Operations with previous surgical approach different to sternotomy were excluded from the analysis. In seven years, 3,086 surgeries were performed, 481 were reoperations, and 238 patients fulfilled the inclusion criteria. Mean number of prior surgeries was 1.4 ± 0.6. Median age at the time of reoperation was 6.4 years. The most common surgical procedures were staged palliation for functionally univentricular heart (17.6%). Median cross-clamp time was 66 minutes. Younger age at the moment of resternotomy, longer cross-clamp time, and Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery (STAT) Mortality Categories risk category greater than three were risk factors for mortality. The number of resternotomies was not associated with mortality. Mortality prior to hospital discharge was 4.6%, and mortality after discharge but prior to 30 days after surgery was 0.54%. Operative mortality was 5.1%. Resternotomy in pediatric cardiac surgery is a safe procedure in our center.

Brain natriuretic peptide levels predict perioperative events in cardiac patients undergoing noncardiac surgery: a prospective study.

PubMed

Leibowitz, David; Planer, David; Rott, David; Elitzur, Yair; Chajek-Shaul, Tova; Weiss, A Teddy

2008-01-01

Brain natriuretic peptide (BNP) levels correlate with prognosis in patients with cardiac disease and may be useful in the risk stratification of cardiac patients undergoing noncardiac surgery (NCS). The objective of this study was to examine whether BNP levels predict perioperative events in cardiac patients undergoing NCS. Patients undergoing NCS with at least 1 of the following criteria were included: a clinical history of congestive heart failure (CHF), ejection fraction <40%, or severe aortic stenosis. All patients underwent echocardiography and measurement of BNP performed using the ADVIA-Centaur BNP assay (Bayer HealthCare). Clinical endpoints were death, myocardial infarction or pulmonary congestion requiring intravenous diuretics at 30 days of follow-up. Forty-four patients were entered into the study; 15 patients (34%) developed cardiac postoperative complications. The mean BNP level was 1,366 +/- 1,420 pg/ml in patients with events and 167 +/- 194 pg/ml in patients without events, indicating a highly significant difference (p < 0.001). The ROC area under the curve was 0.91 (95% CI 0.83-0.99) with an optimal cutoff of >165 pg/ml (100% sensitivity, 70% specificity). BNP levels may predict perioperative complications in cardiac patients undergoing NCS, and the measurement of BNP should be considered to assess the preoperative cardiac risk. (c) 2007 S. Karger AG, Basel

Is Previous Cardiac Surgery a Risk Factor for Short and Mid-term Mortality Following Total Aortic Arch Replacement in Patients with Stanford Type A Aortic Dissection?

PubMed

Ge, Yi-Peng; Li, Cheng-Nan; Chen, Lei; Liu, Wei; Cheng, Li-Jian; Liu, Yong-Min; Zheng, Jun; Ma, Wei-Guo; Zhu, Jun-Ming; Sun, Li-Zhong

2015-11-01

The aim of this study was to evaluate if the previous cardiac surgery (PCS) is the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection. Between February 2009 and February 2012, a total of 384 patients who suffered Stanford type A aortic dissection involving aortic arch underwent total aortic arch replacement with frozen elephant trunk. Of these patients, 36 patients had PCS. Logistic regression was used to identify if the previous cardiac surgery was the risk factor for in-hospital mortality. Propensity score-matching (1:1 match) was used to yield patients from the primary surgery group who matched PCS group with respect to pre-operative clinical characteristics and post-operative complications. Survival analysis and differences between the two groups were performed by the Kaplan-Meier estimate and the log-rank test. The overall in-hospital mortality was 8%. Logistic multiple regression identified that cardiopulmonary bypass time≥ 300minutes (OR=12.05, p<0.001) and surgical period from symptom onset shorter than one week (OR=2.43, p=0.04) were final risk factors for in-hospital mortality and PCS was not the final risk factor. Of 36 patients with PCS, three patients died in the hospital and 33 patients were discharged from the hospital. Of these 33 patients, 32 patients matched primary surgery group successfully. During the follow-up period, two patients died in PCS group, one patient died in primary surgery group. The mean follow-up time was 35.38±14.12 months. The five-year survival was 96% for the primary surgery group. Previous cardiac surgery group five-year survival was 73%. Five-year survival was not significantly different between the two groups (p=0.84 log-rank test). PCS is not the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection. Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

Management and outcome of cardiac and endovascular cystic echinococcosis.

PubMed

Díaz-Menéndez, Marta; Pérez-Molina, José Antonio; Norman, Francesca Florence; Pérez-Ayala, Ana; Monge-Maillo, Begoña; Fuertes, Pilar Zamarrón; López-Vélez, Rogelio

2012-01-01

Cystic echinococcosis (CE) can affect the heart and the vena cava but few cases are reported. A retrospective case series of 11 patients with cardiac and/or endovascular CE, followed-up over a period of 15 years (1995-2009) is reported. Main clinical manifestations included thoracic pain or dyspnea, although 2 patients were asymptomatic. Cysts were located mostly in the right atrium and inferior vena cava. Nine patients were previously diagnosed with disseminated CE. Echocardiography was the diagnostic method of choice, although serology, electrocardiogram, chest X-ray, computed tomography/magnetic resonance imaging and histology aided with diagnosis and follow-up. Nine patients underwent cardiac surgery and nine received long-term antiparasitic treatment for a median duration of 25 months (range 4-93 months). One patient died intra-operatively due to cyst rupture and endovascular dissemination. Two patients died 10 and 14 years after diagnosis, due to pulmonary embolism (PE) and cardiac failure, respectively. One patient was lost to follow-up. Patients who had cardiac involvement exclusively did not have complications after surgery and were considered cured. There was only one recurrence requiring a second operation. Patients with vena cava involvement developed PEs and presented multiple complications. Cardiovascular CE is associated with a high risk of potentially lethal complications. Clinical manifestations and complications vary according to cyst location. Isolated cardiac CE may be cured after surgery, while endovascular extracardiac involvement is associated with severe chronic complications. CE should be included in the differential diagnosis of cardiovascular disease in patients from endemic areas. © 2012 Díaz-Menéndez et al.

Management and Outcome of Cardiac and Endovascular Cystic Echinococcosis

PubMed Central

Díaz-Menéndez, Marta; Pérez-Molina, José Antonio; Norman, Francesca Florence; Pérez-Ayala, Ana; Monge-Maillo, Begoña; Fuertes, Pilar Zamarrón; López-Vélez, Rogelio

2012-01-01

Background Cystic echinococcosis (CE) can affect the heart and the vena cava but few cases are reported. Methods A retrospective case series of 11 patients with cardiac and/or endovascular CE, followed-up over a period of 15 years (1995–2009) is reported. Results Main clinical manifestations included thoracic pain or dyspnea, although 2 patients were asymptomatic. Cysts were located mostly in the right atrium and inferior vena cava. Nine patients were previously diagnosed with disseminated CE. Echocardiography was the diagnostic method of choice, although serology, electrocardiogram, chest X-ray, computed tomography/magnetic resonance imaging and histology aided with diagnosis and follow-up. Nine patients underwent cardiac surgery and nine received long-term antiparasitic treatment for a median duration of 25 months (range 4–93 months). One patient died intra-operatively due to cyst rupture and endovascular dissemination. Two patients died 10 and 14 years after diagnosis, due to pulmonary embolism (PE) and cardiac failure, respectively. One patient was lost to follow-up. Patients who had cardiac involvement exclusively did not have complications after surgery and were considered cured. There was only one recurrence requiring a second operation. Patients with vena cava involvement developed PEs and presented multiple complications. Conclusions Cardiovascular CE is associated with a high risk of potentially lethal complications. Clinical manifestations and complications vary according to cyst location. Isolated cardiac CE may be cured after surgery, while endovascular extracardiac involvement is associated with severe chronic complications. CE should be included in the differential diagnosis of cardiovascular disease in patients from endemic areas. PMID:22235354

Postoperative acute kidney injury following intraoperative blood product transfusions during cardiac surgery.

PubMed

Kindzelski, Bogdan A; Corcoran, Philip; Siegenthaler, Michael P; Horvath, Keith A

2018-01-01

This study explored the nature of the association between intraoperative usage of red blood cell, fresh frozen plasma, cryoprecipitate or platelet transfusions and acute kidney injury. A total of 1175 patients who underwent cardiac surgery between 2008 and 2013 were retrospectively analyzed. We assessed the association between: (1) preoperative patient characteristics and acute kidney injury, (2) intraoperative blood product usage and acute kidney injury, (3) acute kidney injury and 30-day mortality or re-hospitalization. In our cohort of 1175 patients, 288 patients (24.5%) developed acute kidney injury. This included 162 (13.8%), 69 (5.9%) and 57 (4.9%) developing stage 1, stage 2 or stage 3 acute kidney injury, respectively. Increased red blood cell, fresh frozen plasma or platelet transfusions increased the odds of developing acute kidney injury. Specifically, every unit of red blood cells, fresh frozen plasma or platelets transfused was associated with an increase in the covariate-adjusted odds ratio of developing ⩾ stage 2 kidney injury of 1.18, 1.19 and 1.04, respectively. Intraoperative blood product transfusions were independently associated with an increased odds of developing acute kidney injury following cardiac surgery. Further randomized studies are needed to better define intraoperative transfusion criteria.

Continuous cytokine haemoadsorption incorporated into a venoarterial ECMO circuit for the management of postcardiotomy cardiogenic and septic shock - a case report.

PubMed

Nemeth, Endre; Szigeti, Szabolcs; Varga, Tamas; Daroczi, Laszlo; Barati, Zoltan; Merkely, Bela; Gal, Janos

2018-05-01

The acute surgical treatment of infective endocarditis (IE) carries a high risk of postoperative mortality. Most complications are linked to uncontrolled sepsis and inflammatory processes. Cytokine haemoadsorption is an extracorporeal technique which has benefits reported in haemodynamic stability and inflammatory response. A 46-year-old male patient underwent emergency cardiac surgery due to progressive IE. Postcardiotomy cardiogenic shock associated with cardiac surgery required the implantation of venoarterial (VA)-ECMO. Three days later, the patient developed secondary septic shock. The novel application of continuous CytoSorb TM treatment installed in the VA-ECMO circuit is demonstrated in this case during the management of simultaneous shocks. Advanced intensive care led to an improvement in the patient's condition, which facilitated successful weaning from mechanical ventilation. However, the patient died from a new onset fulminant septic shock two months after his initial cardiac surgery. VA-ECMO is suitable for installation of the CytoSorb TM cartridge. This modality could be an option for high-volume, continuous cytokine haemoadsorption when VA-ECMO is employed without renal replacement therapy. This specific application of CytoSorb TM was safe, feasible and contributed to the optimal management of simultaneous shocks.

Echocardiography: pericardial thickening and constrictive pericarditis.

PubMed

Schnittger, I; Bowden, R E; Abrams, J; Popp, R L

1978-09-01

A total of 167 patients with pericardial thickening noted on M node echocardiography were studied retrospectively. After the echocardiogram, 72 patients underwent cardiac surgery, cardiac catheterization or autopsy for various heart diseases; 96 patients had none of these procedures. In 49 patients the pericardium was directly visualized at surgery or autopsy; 76 percent of these had pericardial thickening or adhesions. In another 8 percent, pericardial adhesions were absent, but no comment had been made about the appearance of the pericardium itself. In the remaining 16 percent, no comment had been made about the pericardium or percardial space. Cardiac catheterization in 64 patients revealed 24 with hemodynamic findings of constrictive pericarditis or effusive constrictive disease. Seven echocardiographic patterns consistent with pericardial adhesions or pericardial thickening are described and related when possible to the subsequent findings at heart surgery or autopsy. The clinical diagnoses of 167 patients with pericardial thickening are presented. The hemodynamic diagnosis of constrictive pericardial disease was associated with the echocardiographic finding of pericardial thickening, but there were no consistent echocardiographic patterns of pericardial thickening diagnostic of constriction. However, certain other echocardiographic abnormalities of left ventricular posterior wall motion and interventricular septal motion and a high E-Fo slope were suggestive of constriction.

A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery.

PubMed

Magruder, J Trent; Crawford, Todd C; Harness, Herbert Lynn; Grimm, Joshua C; Suarez-Pierre, Alejandro; Wierschke, Chad; Biewer, Jim; Hogue, Charles; Whitman, Glenn R; Shah, Ashish S; Barodka, Viachaslau

2017-01-01

We sought to determine whether a pilot goal-directed perfusion initiative could reduce the incidence of acute kidney injury after cardiac surgery. On the basis of the available literature, we identified goals to achieve during cardiopulmonary bypass (including maintenance of oxygen delivery >300 mL O2/min/m 2 and reduction in vasopressor use) that were combined into a goal-directed perfusion initiative and implemented as a quality improvement measure in patients undergoing cardiac surgery at Johns Hopkins during 2015. Goal-directed perfusion initiative patients were matched to controls who underwent cardiac surgery between 2010 and 2015 using propensity scoring across 15 variables. The primary and secondary outcomes were the incidence of acute kidney injury and the mean increase in serum creatinine within the first 72 hours after cardiac surgery. We used the goal-directed perfusion initiative in 88 patients and matched these to 88 control patients who were similar across all variables, including mean age (61 years in controls vs 64 years in goal-directed perfusion initiative patients, P = .12) and preoperative glomerular filtration rate (90 vs 83 mL/min, P = .34). Controls received more phenylephrine on cardiopulmonary bypass (mean 2.1 vs 1.4 mg, P < .001) and had lower nadir oxygen delivery (mean 241 vs 301 mL O2/min/m 2 , P < .001). Acute kidney injury incidence was 23.9% in controls and 9.1% in goal-directed perfusion initiative patients (P = .008); incidences of acute kidney injury stage 1, 2, and 3 were 19.3%, 3.4%, and 1.1% in controls, and 5.7%, 3.4%, and 0% in goal-directed perfusion initiative patients, respectively. Control patients exhibited a larger median percent increase in creatinine from baseline (27% vs 10%, P < .001). The goal-directed perfusion initiative was associated with reduced acute kidney injury incidence after cardiac surgery in this pilot study. Copyright © 2016. Published by Elsevier Inc.

External validation of the Revised Cardiac Risk Index and update of its renal variable to predict 30-day risk of major cardiac complications after non-cardiac surgery: rationale and plan for analyses of the VISION study.

PubMed

Roshanov, Pavel S; Walsh, Michael; Devereaux, P J; MacNeil, S Danielle; Lam, Ngan N; Hildebrand, Ainslie M; Acedillo, Rey R; Mrkobrada, Marko; Chow, Clara K; Lee, Vincent W; Thabane, Lehana; Garg, Amit X

2017-01-09

The Revised Cardiac Risk Index (RCRI) is a popular classification system to estimate patients' risk of postoperative cardiac complications based on preoperative risk factors. Renal impairment, defined as serum creatinine >2.0 mg/dL (177 µmol/L), is a component of the RCRI. The estimated glomerular filtration rate has become accepted as a more accurate indicator of renal function. We will externally validate the RCRI in a modern cohort of patients undergoing non-cardiac surgery and update its renal component. The Vascular Events in Non-cardiac Surgery Patients Cohort Evaluation (VISION) study is an international prospective cohort study. In this prespecified secondary analysis of VISION, we will test the risk estimation performance of the RCRI in ∼34 000 participants who underwent elective non-cardiac surgery between 2007 and 2013 from 29 hospitals in 15 countries. Using data from the first 20 000 eligible participants (the derivation set), we will derive an optimal threshold for dichotomising preoperative renal function quantified using the Chronic Kidney Disease Epidemiology Collaboration (CKD-Epi) glomerular filtration rate estimating equation in a manner that preserves the original structure of the RCRI. We will also develop a continuous risk estimating equation integrating age and CKD-Epi with existing RCRI risk factors. In the remaining (approximately) 14 000 participants, we will compare the risk estimation for cardiac complications of the original RCRI to this modified version. Cardiac complications will include 30-day non-fatal myocardial infarction, non-fatal cardiac arrest and death due to cardiac causes. We have examined an early sample to estimate the number of events and the distribution of predictors and missing data, but have not seen the validation data at the time of writing. The research ethics board at each site approved the VISION protocol prior to recruitment. We will publish our results and make our models available online at http://www.perioperativerisk.com. ClinicalTrials.gov NCT00512109. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Malignant Hyperthermia: Report of Two Cases with a Neglected Complication in Cardiac Surgery

PubMed Central

Neshati, Mahdi; Azadeh, Manizheh; Neshati, Parinaz; Burnett, Tyrone; Saenz, Ryan; Karbasi, Bahman; Shahmohammadi, Ghader; Nourizadeh, Eskandar; Rostamzadeh, Mohsen

2017-01-01

Malignant hyperthermia (MH) can develop after contact with volatile anesthetics (halothane, enflurane, isoflurane, sevoflurane, and desflurane) as well as succinylcholine and cause hypermetabolism during anesthesia, which is associated with high mortality when untreated. Early diagnosis and treatment could be life-saving. During cardiac surgery, hypothermia and cardiopulmonary bypass make the diagnosis of MH extremely challenging compared with other settings such as general surgery. We herein report 2 cases of MH, graded as “very likely” or “almost certain” based on the MH clinical grading scale. A 14-month-old infant and a 53-year-old male underwent surgery for severe pulmonary valve stenosis and mitral valve replacement, respectively. Both of them were extubated on the operation day, but they deteriorated with the development of high-grade fever, hypotension, renal failure, and acidosis. The first case had muscle spasms. Unfortunately, the delayed symptoms of MH in the early postoperative course were not diagnosed in these 2 cases, which caused permanent neurologic damage in the first case and death in the second one. However, the infant was discharged from the hospital after 2 months. PMID:29576786

Malignant Hyperthermia: Report of Two Cases with a Neglected Complication in Cardiac Surgery.

PubMed

Neshati, Mahdi; Azadeh, Manizheh; Neshati, Parinaz; Burnett, Tyrone; Saenz, Ryan; Karbasi, Bahman; Shahmohammadi, Ghader; Nourizadeh, Eskandar; Rostamzadeh, Mohsen

2017-10-01

Malignant hyperthermia (MH) can develop after contact with volatile anesthetics (halothane, enflurane, isoflurane, sevoflurane, and desflurane) as well as succinylcholine and cause hypermetabolism during anesthesia, which is associated with high mortality when untreated. Early diagnosis and treatment could be life-saving. During cardiac surgery, hypothermia and cardiopulmonary bypass make the diagnosis of MH extremely challenging compared with other settings such as general surgery. We herein report 2 cases of MH, graded as "very likely" or "almost certain" based on the MH clinical grading scale. A 14-month-old infant and a 53-year-old male underwent surgery for severe pulmonary valve stenosis and mitral valve replacement, respectively. Both of them were extubated on the operation day, but they deteriorated with the development of high-grade fever, hypotension, renal failure, and acidosis. The first case had muscle spasms. Unfortunately, the delayed symptoms of MH in the early postoperative course were not diagnosed in these 2 cases, which caused permanent neurologic damage in the first case and death in the second one. However, the infant was discharged from the hospital after 2 months.

Continuous Intraoperative Cefazolin Infusion May Reduce Surgical Site Infections During Cardiac Surgical Procedures: A Propensity-Matched Analysis.

PubMed

Trent Magruder, J; Grimm, Joshua C; Dungan, Samuel P; Shah, Ashish S; Crow, Jessica R; Shoulders, Bethany R; Lester, Laeben; Barodka, Viachaslau

2015-12-01

The authors sought to determine whether an institutional transition from intermittent to continuous dosing of intraoperative antibiotics in cardiac surgery affected surgical site infection (SSI) outcomes. A retrospective chart review utilizing propensity matching. A single academic, tertiary care hospital. One thousand one hundred seventy-nine patients undergoing coronary artery bypass grafting (CABG) and/or cardiac valvular surgery between April 2013 and November 2014 who received perioperative cefazolin. By method of cefazolin administration, patients were divided into an "intermittent-dosing" (ID) group and a "continuous-infusion" (CI) group. Of the 1,179 patients who underwent cardiac surgery during the study period, 1:1 propensity score matching yielded 399 patients in each group. Rates of diabetes (33.6% ID v 33.8% CI, p = 0.94), coronary artery bypass (62.3% v 61.4%, p = 0.66), and bilateral internal mammary artery harvesting (6.0% v 8.3%, p = 0.22) were similar between groups. SSIs occurred in more ID patients than CI patients (2.3% v 0.5%, p = 0.03). This difference was driven by decreases in extremity and conduit harvest site SSIs (1.8% v 0.3%, p = 0.03), as there were no episodes of mediastinitis, and superficial sternal SSI rates did not differ (0.5% v 0.3%, p = 0.56). There also were significantly fewer episodes of pneumonia in the CI group (6.0% v 2.3%, p = 0.008). Intensive care unit and total lengths of stay did not differ. Thirty-day mortality was 2.8% in both groups (p = 1.00). As compared to ID regimens, CI cefazolin infusion may reduce post-cardiac surgery infectious complications. Further study in larger patient populations is needed. Copyright © 2015 Elsevier Inc. All rights reserved.

Patients' views of the consent process for adult cardiac surgery: questionnaire survey.

PubMed

Howlader, Mohammad H; Dhanji, Al-Rehan; Uppal, Rakesh; Magee, Patrick; Wood, Alan J; Anyanwu, Ani C

2004-12-01

Consent for surgical procedures has assumed increasing importance in surgical practice in recent days especially following the public inquiry into paediatric cardiac surgery deaths at Bristol in the UK. This study examines patient perceptions and recollections following surgical consent as currently practised in a UK cardiac unit. One hundred consecutive patients who underwent cardiac surgery in a London teaching hospital from January to February 2003 were studied. Patients completed questionnaires a day before their discharge from the hospital. The majority of patients (89/100) responded that the information given at consent had been adequate or more than adequate. The time spent on the consent process was thought to be adequate by 91 patients. Eleven patients felt the consent had been insensitive. Several patients (38/100) felt use of booklets in preference to verbal explanations would be less intimidating. For most patients (94/100) the operation and postoperative course met their expectations; although 12 patients experienced untold complications, only five felt that they should have been informed of the possibility of the complication. Although most patients were informed of the risk of death during consent, at time of discharge 43 had forgotten the figure that had been quoted. Regarding the influence of media and publicity, 19 patients said that media had influenced their expectations of the consent process, 59 would have liked to see hospital league tables while 26 would have liked to know the mortality figures for their surgeon prior to giving consent. Our study shows that patients undergoing cardiac surgery are largely satisfied with our improved consent procedures in the post-Bristol era. Use of booklets may be a useful adjunct to verbal consent as currently practised.

High-frequency oscillatory ventilation for cardiac surgery children with severe acute respiratory distress syndrome.

PubMed

Li, Shengli; Wang, Xu; Li, Shoujun; Yan, Jun

2013-08-01

Acute respiratory distress syndrome (ARDS) in children after open heart surgery, although uncommon, can be a significant source of morbidity. Because high-frequency oscillatory ventilation (HFOV) had been used successfully with pediatric patients who had no congenital heart defects, this therapy was used in our unit. This report aims to describe a single-center experience with HFOV in the management of ARDS after open heart surgery with respect to mortality. This retrospective clinical study was conducted in a pediatric intensive care unit. From October 2008 to August 2012, 64 of 10,843 patients with refractory ARDS who underwent corrective surgery at our institution were ventilated with HFOV. Patients with significant uncorrected residual lesions were not included. No interventions were performed. The patients were followed up until hospital discharge. The main outcome measure was survival to hospital discharge. Severe ARDS was defined as acute-onset pulmonary failure with bilateral pulmonary infiltrates and an oxygenation index (OI) higher than 13 despite maximal ventilator settings. The indication for HFOV was acute severe ARDS unresponsive to optimal conventional treatment. The variables recorded and subjected to multivariate analysis were patient demographics, underlying disease, clinical data, and ventilator parameters and their association with hospital mortality. Nearly 10,843 patients underwent surgery during the study period, and the ARDS incidence rate was 0.76 % (83/10,843), with 64 patients (77 %, 64/83) receiving HFOV. No significant changes in systemic or central venous pressure were associated with initiation and maintenance of HFOV. The complications during HFOV included pneumothorax for 22 patients. The overall in-hospital mortality rate was 39 % (25/64). Multiple regression analyses indicated that pulmonary hypertension and recurrent respiratory tract infections (RRTIs) before surgery were independent predictors of in-hospital mortality. The findings show that HFOV is an effective and safe method for ventilating severe ARDS patients after corrective cardiac surgery. Pulmonary hypertension and RRTIs before surgery were risk factors for in-hospital mortality.

Mitral and tricuspid valve surgery in homozygous sickle cell disease: perioperative considerations for a successful outcome.

PubMed

Sachithanandan, Anand; Nanjaiah, Prakash; Wright, Christine J; Rooney, Stephen J

2008-01-01

Homozygous sickle cell disease (SCD) presents a multitude of challenges in patients undergoing cardiac surgery with cardiopulmonary bypass. Special consideration must be made in such patients and routine practice modified to prevent hypoxia, hypothermia, acidaemia and low-flow states which may potentially trigger a fatal sickling crisis perioperatively. We discuss several perioperative management strategies including a preoperative exchange transfusion, high flow normothermic bypass and warm blood cardioplegia that was utilized in a woman with homozygous SCD who underwent a successful double valve procedure.

Inhibition of monoamine oxidase A increases recovery after experimental cardiac arrest.

PubMed

Vuohelainen, Vilma; Hämäläinen, Mari; Paavonen, Timo; Karlsson, Sari; Moilanen, Eeva; Mennander, Ari

2015-10-01

Perioperative myocardial infarction (MI) with ischaemia-reperfusion injury (IRI) is a devastating entity occurring in 1-2% of patients after cardiac surgery. The molecular pathway leading to myocardial cellular destruction after MI may include monoamine oxidases. We experimentally investigated whether moclobemide, a monoamine oxidase inhibitor, enhances myocardial recovery after cardiac arrest and MI. Fifty-six syngeneic Fischer rats underwent heterotopic cardiac transplantation to induce reversible IRI after cardiac arrest. Twenty-eight rats also underwent permanent ligation of the left anterior descending coronary artery to induce MI after cardiac arrest. Twenty-eight rats with or without MI were treated with subcutaneous moclobemide 10 mg/kg/day. Methods used to study myocardial recovery were microdialysis for intramyocardial metabolism, histology and quantitative reverse-transcription polymerase chain reaction for high-mobility group box-1 (HMGB1), haeme oxygenase-1 (HO-1), interleukin-6, hypoxia-inducible factor 1α and macrophages (CD68). Pyruvate increased in MI treated with moclobemide versus IRI with moclobemide (29.19 ± 7.64 vs 13.86 ± 8.49 µM, P = 0.028), reflecting metabolic activity after cardiac arrest and reperfusion. Myocardial inflammation increased in MI compared with IRI after 1 h (0.80 ± 0.56 vs 0, point score units [PSUs], P = 0.003), but decreased after 5 days in MI treated with moclobemide versus MI alone (0.80 ± 0.83 vs 2.00 ± 0.70, PSU, P = 0.033). Expressions of HMGB1, CD68 and HO-1 decreased in MI treated with moclobemide versus MI alone (1.33 ± 0.20 vs 1.75 ± 0.24, fold changes [FCs], P = 0.028; 5.15 ± 1.10 vs 9.59 ± 2.75, FC, P = 0.050; 10.41 ± 4.17 vs 21.28 ± 10.01, FC, P = 0.047), indicating myocardial recovery and increased cellularity of remote intramyocardial arteries. Moclobemide enhances myocardial recovery after cardiac arrest and MI; inhibition of remote myocardial changes may be achieved by targeting treatment against monoamine oxidase. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

The Blue Coma: The Role of Methylene Blue in Unexplained Coma After Cardiac Surgery.

PubMed

Martino, Enrico Antonio; Winterton, Dario; Nardelli, Pasquale; Pasin, Laura; Calabrò, Maria Grazia; Bove, Tiziana; Fanelli, Giovanna; Zangrillo, Alberto; Landoni, Giovanni

2016-04-01

Methylene blue commonly is used as a dye or an antidote, but also can be used off label as a vasopressor. Serotonin toxicity is a potentially lethal and often misdiagnosed condition that can result from drug interaction. Mild serotonin toxicity previously was reported in settings in which methylene blue was used as a dye. The authors report 3 cases of life-threatening serotonin toxicity in patients undergoing chronic selective serotonin reuptake inhibitor (SSRI) therapy who also underwent cardiac surgery and received methylene blue to treat vasoplegic syndrome. An observational study. A cardiothoracic intensive care unit (ICU) in a teaching hospital. Three patients who received methylene blue after cardiac surgery, later discovered to be undergoing chronic SSRI therapy. None. All 3 patients received high doses of fentanyl during general anesthesia. They all developed vasoplegic syndrome and consequently were given methylene blue in the ICU. All 3 patients developed serotonin toxicity, including coma, after this administration and diagnostic tests were negative for acute intracranial pathology. Coma lasted between 1 and 5 days. Two patients were discharged from the ICU shortly after awakening, whereas the third patient experienced a complicated postoperative course for concomitant refractory low-cardiac-output syndrome. Patients undergoing chronic SSRI therapy should not be administered methylene blue to treat vasoplegic syndrome. Copyright © 2016 Elsevier Inc. All rights reserved.

[Chronic surplus of Japanese cardiac surgeon--ideal nurse practitioner for cardiac surgery, cardiac surgeon's attitude toward the future].

PubMed

Ikegami, Hirohisa

2014-03-01

It is chronically surplus of doctors in the world of cardiac surgery. There are too many cardiac surgeons because cardiac surgery requires a large amount of manpower resources to provide adequate medical services. Many Japanese cardiac surgeons do not have enough opportunity to perform cardiac surgery operations, and many Japanese cardiac surgery residents do not have enough opportunity to learn cardiac surgery operations. There are physician assistants and nurse practitioners in the US. Because they provide a part of medical care to cardiac surgery patients, American cardiac surgeons can focus more energy on operative procedures. Introduction of cardiac surgery specialized nurse practitioner is essential to deliver a high quality medical service as well as to solve chronic problems that Japanese cardiac surgery has had for a long time.

Pectoral Fascial (PECS) I and II Blocks as Rescue Analgesia in a Patient Undergoing Minimally Invasive Cardiac Surgery.

PubMed

Yalamuri, Suraj; Klinger, Rebecca Y; Bullock, W Michael; Glower, Donald D; Bottiger, Brandi A; Gadsden, Jeffrey C

Patients undergoing minimally invasive cardiac surgery have the potential for significant pain from the thoracotomy site. We report the successful use of pectoral nerve block types I and II (Pecs I and II) as rescue analgesia in a patient undergoing minimally invasive mitral valve repair. In this case, a 78-year-old man, with no history of chronic pain, underwent mitral valve repair via right anterior thoracotomy for severe mitral regurgitation. After extubation, he complained of 10/10 pain at the incision site that was minimally responsive to intravenous opioids. He required supplemental oxygen because of poor pulmonary mechanics, with shallow breathing and splinting due to pain, and subsequent intensive care unit readmission. Ultrasound-guided Pecs I and II blocks were performed on the right side with 30 mL of 0.2% ropivacaine with 1:400,000 epinephrine. The blocks resulted in near-complete chest wall analgesia and improved pulmonary mechanics for approximately 24 hours. After the single-injection blocks regressed, a second set of blocks was performed with 266 mg of liposomal bupivacaine mixed with bupivacaine. This second set of blocks provided extended analgesia for an additional 48 hours. The patient was weaned rapidly from supplemental oxygen after the blocks because of improved analgesia. Pectoral nerve blocks have been described in the setting of breast surgery to provide chest wall analgesia. We report the first successful use of Pecs blocks to provide effective chest wall analgesia for a patient undergoing minimally invasive cardiac surgery with thoracotomy. We believe that these blocks may provide an important nonopioid option for the management of pain during recovery from minimally invasive cardiac surgery.

An Observational Cohort Feasibility Study to Identify Microvesicle and Micro-RNA Biomarkers of Acute Kidney Injury Following Pediatric Cardiac Surgery.

PubMed

Sullo, Nikol; Mariani, Silvia; JnTala, Maria; Kumar, Tracy; Woźniak, Marcin J; Smallwood, Dawn; Pais, Paolo; Westrope, Claire; Lotto, Attilio; Murphy, Gavin J

2018-06-15

Micro-RNA, small noncoding RNA fragments involved in gene regulation, and microvesicles, membrane-bound particles less than 1 μm known to regulate cellular processes including responses to injury, may serve as disease-specific biomarkers of acute kidney injury. We evaluated the feasibility of measuring these signals as well as other known acute kidney injury biomarkers in a mixed pediatric cardiac surgery population. Single center prospective cohort feasibility study. PICU. Twenty-four children (≤ 17 yr) undergoing cardiac surgery with cardiopulmonary bypass without preexisting inflammatory state, acute kidney injury, or extracorporeal life support. None. Acute kidney injury was defined according to modified Kidney Diseases Improving Global Outcomes criteria. Blood and urine samples were collected preoperatively and at 6-12 and 24 hours. Microvesicles derivation was assessed using flow cytometry and NanoSight analysis. Micro-RNAs were isolated from plasma and analyzed by microarray and quantitative real-time polymerase chain reaction. Data completeness for the primary outcomes was 100%. Patients with acute kidney injury (n = 14/24) were younger, underwent longer cardiopulmonary bypass, and required greater inotrope support. Acute kidney injury subjects had different fractional content of platelets and endothelial-derived microvesicles before surgery. Platelets and endothelial microvesicles levels were higher in acute kidney injury patients. A number of micro-RNA species were differentially expressed in acute kidney injury patients. Pathway analysis of candidate target genes in the kidney suggested that the most often affected pathways were phosphatase and tensin homolog and signal transducer and activator of transcription 3 signaling. Microvesicles and micro-RNAs expression patterns in pediatric cardiac surgery patients can be measured in children and potentially serve as tools for stratification of patients at risk of acute kidney injury.

The definition of chronic lung disease in patients undergoing cardiac surgery: a comparison between the Society of Thoracic Surgeons and the American Thoracic Society/European Respiratory Society Classifications.

PubMed

Henry, L; Holmes, S D; Lamberti, J; Halpin, L; Hunt, S; Ad, N

2012-12-01

Early and late outcomes following cardiac surgery may be adversely affected in patients with chronic lung disease (CLD) and the presence of CLD is definition dependent. The purpose of this study was to compare the Society of Thoracic Surgeons (STS) definitions for CLD to the modified American Thoracic Society (ATS)/European Respiratory Society (ERS) definitions in diagnosing and classifying CLD among a cohort of cardiac surgery patients. A prospectively-designed study whereby high risk patients for CLD presenting for non-emergent cardiac surgery and had a history of asthma, a 10 or more pack year history of smoking or a persistent cough were included. All patients underwent spirometry testing within two weeks of surgery. The presence and severity of CLD was coded two times: 1) STS definitions with spirometry; 2) ATS/ERS guidelines. The rate of misclassification was determined using concordance and discordance rates. Sensitivity analysis of the STS spirometry definitions was calculated against the ATS/ERS definitions and respective classifications. The discordant rate for the STS spirometry driven definitions versus the ATS/ERS definitions was 21%. Forty patients (21%) classified as no CLD by the STS spirometry definition were found to have CLD by the ATS/ERS definition. The STS classification had 68% sensitivity (84/124) when identifying any CLD and only 26% sensitivity (14/54) when identifying moderate CLD. The current STS spirometry driven definitions for CLD did not perform as well as the ATS/ERS definitions in diagnosing and classifying the degree of CLD. Consideration should be given to using the ATS/ERS definitions.

A Decline in Intraoperative Renal Near-Infrared Spectroscopy Is Associated With Adverse Outcomes in Children Following Cardiac Surgery.

PubMed

Gist, Katja M; Kaufman, Jonathan; da Cruz, Eduardo M; Friesen, Robert H; Crumback, Sheri L; Linders, Megan; Edelstein, Charles; Altmann, Christopher; Palmer, Claire; Jalal, Diana; Faubel, Sarah

2016-04-01

Renal near-infrared spectroscopy is known to be predictive of acute kidney injury in children following cardiac surgery using a series of complex equations and area under the curve. This study was performed to determine if a greater than or equal to 20% reduction in renal near-infrared spectroscopy for 20 consecutive minutes intraoperatively or within the first 24 postoperative hours is associated with 1) acute kidney injury, 2) increased acute kidney injury biomarkers, or 3) other adverse clinical outcomes in children following cardiac surgery. Prospective single center observational study. Pediatric cardiac ICU. Children less than or equal to age 4 years who underwent cardiac surgery with the use of cardiopulmonary bypass during the study period (June 2011-July 2012). None. A reduction in near-infrared spectroscopy was not associated with acute kidney injury. Nine of 12 patients (75%) with a reduction in renal near-infrared spectroscopy did not develop acute kidney injury. The remaining three patients had mild acute kidney injury (pediatric Risk, Injury, Failure, Loss, End stage-Risk). A reduction in renal near-infrared spectroscopy was associated with the following adverse clinical outcomes: 1) a longer duration of mechanical ventilation (p = 0.05), 2) longer intensive care length of stay (p = 0.05), and 3) longer hospital length of stay (p < 0.01). A decline in renal near-infrared spectroscopy in combination with an increase in serum interleukin-6 and serum interleukin-8 was associated with a longer intensive care length of stay, and the addition of urine interleukin-18 to this was associated with a longer hospital length of stay. In this cohort, the rate of acute kidney injury was much lower than anticipated thereby limiting the evaluation of a reduction in renal near-infrared spectroscopy as a predictor of acute kidney injury. A greater than or equal to 20% reduction in renal near-infrared spectroscopy was significantly associated with adverse outcomes in children following cardiac surgery. The addition of specific biomarkers to the model was predictive of worse outcomes in these patients. Thus, real-time evaluation of renal near-infrared spectroscopy using the specific levels of change of a 20% reduction for 20 minutes may be useful in predicting prolonged mechanical ventilation and other adverse outcomes in children undergoing cardiac surgery.

Acute pericarditis with cardiac tamponade induced by pacemaker implantation.

PubMed

Shingaki, Masami; Kobayashi, Yutaka; Suzuki, Haruo

2015-11-01

An 87-year-old woman was diagnosed with third-degree atrioventricular block and underwent pacemaker implantation. On postoperative day 12, she experienced cardiac tamponade that was suspected on computed tomography to be caused by lead perforation; therefore, we performed open-heart surgery. However, we could not identify a perforation site on the heart, and drained a 400-mL exudative pericardial effusion. Subsequently, we diagnosed the pericardial effusion as due to pericarditis induced by pacemaker implantation. It is sometimes difficult to distinguish pericarditis from pacemaker lead perforation, so both should be included in the differential diagnosis. © The Author(s) 2014.

Preoperative Electrocardiogram Score for Predicting New-Onset Postoperative Atrial Fibrillation in Patients Undergoing Cardiac Surgery.

PubMed

Gu, Jiwei; Andreasen, Jan J; Melgaard, Jacob; Lundbye-Christensen, Søren; Hansen, John; Schmidt, Erik B; Thorsteinsson, Kristinn; Graff, Claus

2017-02-01

To investigate if electrocardiogram (ECG) markers from routine preoperative ECGs can be used in combination with clinical data to predict new-onset postoperative atrial fibrillation (POAF) following cardiac surgery. Retrospective observational case-control study. Single-center university hospital. One hundred consecutive adult patients (50 POAF, 50 without POAF) who underwent coronary artery bypass grafting, valve surgery, or combinations. Retrospective review of medical records and registration of POAF. Clinical data and demographics were retrieved from the Western Denmark Heart Registry and patient records. Paper tracings of preoperative ECGs were collected from patient records, and ECG measurements were read by two independent readers blinded to outcome. A subset of four clinical variables (age, gender, body mass index, and type of surgery) were selected to form a multivariate clinical prediction model for POAF and five ECG variables (QRS duration, PR interval, P-wave duration, left atrial enlargement, and left ventricular hypertrophy) were used in a multivariate ECG model. Adding ECG variables to the clinical prediction model significantly improved the area under the receiver operating characteristic curve from 0.54 to 0.67 (with cross-validation). The best predictive model for POAF was a combined clinical and ECG model with the following four variables: age, PR-interval, QRS duration, and left atrial enlargement. ECG markers obtained from a routine preoperative ECG may be helpful in predicting new-onset POAF in patients undergoing cardiac surgery. Copyright © 2017 Elsevier Inc. All rights reserved.

Safety of minimally invasive mitral valve surgery without aortic cross-clamp.

PubMed

Umakanthan, Ramanan; Leacche, Marzia; Petracek, Michael R; Kumar, Sathappan; Solenkova, Nataliya V; Kaiser, Clayton A; Greelish, James P; Balaguer, Jorge M; Ahmad, Rashid M; Ball, Stephen K; Hoff, Steven J; Absi, Tarek S; Kim, Betty S; Byrne, John G

2008-05-01

We developed a technique for open heart surgery through a small (5 cm) right-anterolateral thoracotomy without aortic cross-clamp. One hundred and ninety-five consecutive patients (103 male and 92 female), age 69 +/- 8 years, underwent surgery between January 2006 and July 2007. Mean preoperative New York Heart Association function class was 2.2 +/- 0.7. Thirty-five patients (18%) had an ejection fraction 0.35 or less. Cardiopulmonary bypass was instituted through femoral (176 of 195, 90%), axillary (18 of 195, 9%), or direct aortic (1 of 195, 0.5%) cannulation. Under cold fibrillatory arrest (mean temperature 28.2 degrees C) without aortic cross-clamp, mitral valve repair (72 of 195, 37%), mitral valve replacement (117 of 195, 60%), or other (6 of 195, 3%) procedures were performed. Concomitant procedures included maze (45 of 195, 23%), patent foramen ovale closure (42 of 195, 22%) and tricuspid valve repair (16 of 195, 8%), or replacement (4 of 195, 2%). Thirty-day mortality was 3% (6 of 195). Duration of fibrillatory arrest, cardiopulmonary bypass, and "skin to skin" surgery were 88 +/- 32, 118 +/- 52, and 280 +/- 78 minutes, respectively. Ten patients (5%) underwent reexploration for bleeding and 44% did not receive any blood transfusions. Six patients (3%) sustained a postoperative stroke, eight (4%) developed low cardiac output syndrome, and two (1%) developed renal failure requiring hemodialysis. Mean length of hospital stay was 7 +/- 4.8 days. This simplified technique of minimally invasive open heart surgery is safe and easily reproducible. Fibrillatory arrest without aortic cross-clamping, with coronary perfusion against an intact aortic valve, does not increase the risk of stroke or low cardiac output. It may be particularly useful in higher risk patients in whom sternotomy with aortic clamping is less desirable.

Comparison of superior septal approach with left atriotomy in mitral valve surgery

PubMed Central

Aydin, Ebuzer; Arslan, Akin; Ozkokeli, Mehmet

2014-01-01

Objective In this study, we aimed to compare clinical outcomes of superior transseptal approach with the conventional left atriotomy in patients undergoing mitral valve surgery. Methods Between January 2010 and November 2012, a total of 91 consecutive adult patients (39 males, 52 females; mean age: 54.0±15.4 years; range, 16 to 82 years) who underwent mitral valve surgery in the Division of Cardiovascular Surgery at Koşuyolu Training Hospital were included. The patients were randomized to either superior transseptal approach (n=47) or conventional left atriotomy (n=44). Demographic characteristics of the patients, comorbidities, additional interventions, intraoperational data, pre- and postoperative electrophysiological study findings, and postoperative complications were recorded. Results Of all patients, 86.7% (n=79) were in New York Heart Association Class III, while 12 were in New York Heart Association Class IV. All patients underwent annuloplasty (42.9%) or valve replacement surgery (57.1%). There was no significant difference in pre- and postoperative electrocardiogram findings between the groups. Change from baseline in the cardiac rhythm was statistically significant in superior transseptal approach group alone (P<0.001). There was no statistically significant difference in mortality rate between the groups. Permanent pacemaker implantation was performed in 10.6% of the patients in superior transseptal approach group and 4.5% in the conventional left atriotomy group. No statistically significant difference in bleeding, total length of hospital and intensive care unit stay, the presence of low cardiac output syndrome was observed between the groups. Conclusion Our study results suggest that superior transseptal approach does not lead to serious or fatal adverse effects on sinus node function or atrial vulnerability, compared to conventional approach. PMID:25372911

Efficacy of intraoperative cell salvage in decreasing perioperative blood transfusion rates in first-time cardiac surgery patients: a retrospective study.

PubMed

Côté, Claudia L; Yip, Alexandra M; MacLeod, Jeffrey B; O'Reilly, Bill; Murray, Joshua; Ouzounian, Maral; Brown, Craig D; Forgie, Rand; Pelletier, Marc P; Hassan, Ansar

2016-09-01

Evidence regarding the safety and efficacy of intraoperative cell salvage (ICS) in transfusion reduction during cardiac surgery remains conflicting. We sought to evaluate the impact of routine ICS on outcomes following cardiac surgery. We conducted a retrospective analysis of patients who underwent nonemergent, first-time cardiac surgery 18 months before and 18 months after the implementation of routine ICS. Perioperative transfusion rates, postoperative bleeding, clinical and hematological outcomes, and overall cost were examined. We used multivariable logistic regression modelling to determine the risk-adjusted effect of ICS on likelihood of perioperative transfusion. A total of 389 patients formed the final study population (186 undergoing ICS and 203 controls). Patients undergoing ICS had significantly lower perioperative transfusion rates of packed red blood cells (pRBCs; 33.9% v. 45.3% p = 0.021), coagulation products (16.7% v. 32.5% p < 0.001) and any blood product (38.2% v. 52.7%, p = 0.004). Patients receiving ICS had decreased mediastinal drainage at 12 h (mean 320 [range 230-550] mL v. mean 400 [range 260-690] mL, p = 0.011) and increased postoperative hemoglobin (mean 104.7 ± 13.2 g/L v. 95.0 ± 11.9 g/L, p < 0.001). Following adjustment for other baseline and intraoperative covariates, ICS emerged as an independent predictor of lower perioperative transfusion rates of pRBCs (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.31-0.87), coagulation products (OR 0.41, 95% CI 0.24-0.71) and any blood product (OR 0.47, 95% CI 0.29-0.77). Additionally, ICS was associated with a cost benefit of $116 per patient. Intraoperative cell salvage could represent a clinically cost-effective way of reducing transfusion rates in patients undergoing cardiac surgery. Further research on systematic ICS is required before recommending it for routine use.

Cardiac Surgery Outcomes in Patients With Chronic Lymphocytic Leukemia.

PubMed

Zhu, Yuanjia; Toth, Andrew J; Lowry, Ashley M; Blackstone, Eugene H; Hill, Brian T; Mick, Stephanie L

2018-04-01

Surgical outcomes of patients with chronic lymphocytic leukemia (CLL) undergoing cardiac surgery are limited. Our objectives were to investigate hospital morbidity and mortality after open cardiac surgery in CLL versus non-CLL patients. From May 1995 to May 2015, 157 patients with CLL and 55,917 without and older than 47 years underwent elective cardiac surgery at Cleveland Clinic. By Rai criteria, 79 CLL patients (56%) were low risk (class 0), 13 (9.1%) intermediate risk (classes I and II), and 38 (27%) high risk (classes III and IV); 12 (8.5%) were in remission. Mean age of CLL patients was 72 ± 9.0 years, and 18% were women. CLL patients were propensity-score matched to 3 non-CLL patients to compare surgical outcomes. High-risk CLL patients received more blood products than matched non-CLL patients (33/38 [87%] versus 74/114 [65%], p = 0.01), but were less likely to receive cryoprecipitate (0% versus 15/114 [13%], p = .02). Intermediate-risk CLL patients received more platelet units, mean 12 versus 4.6 (p = 0.008). Occurrence of deep sternal wound infection (0% versus 5/471 [1.1%]), septicemia (5/157 [3.2%] versus 14/471 [3.0%]), and hospital mortality (4/157 [2.5%] versus 14/471 [3.0%]) were similar (p > 0.3), independent of prior chemotherapy treatment for CLL. Although CLL patients did not have higher hospital mortality than non-CLL patients, high-risk CLL patients were more likely to receive blood products. Risks associated with transfusion should be considered when evaluating CLL patients for elective cardiac surgery. Appropriate preoperative management, such as blood product transfusions, and alternative treatment options that decrease blood loss, should be considered for high-risk patients. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Early Efficacy Analysis of Biatrial Ablation versus Left and Simplified Right Atrial Ablation for Atrial Fibrillation Treatment in Patients with Rheumatic Heart Disease.

PubMed

Liu, Hong; Chen, Lin; Xiao, Yingbin; Ma, Ruiyan; Hao, Jia; Chen, Baicheng; Qin, Chuan; Cheng, Wei

2015-08-01

Atrial fibrillation (AF) is the most common sustained arrhythmia. About 60% of patients with rheumatic heart disease have persistent AF. A total of 197 patients underwent valve replacement concomitant bipolar radiofrequency ablation (BRFA). Patients were divided into the biatrial ablation group and the simplified right atrial ablation group. In biatrial ablation group, the patients underwent a complete left and right atrial ablation. In simplified right atrial ablation group, the patients underwent a complete left atrial ablation and a simplified right atrial ablation. The conversion of sinus rhythm (SR) was high in both groups during the follow-up period. In the simplified right atrial ablation group, SR conversion rate was 88.29% at discharge. At six months and 12 months after surgery, 87.39% of patients and 86.49% of patients were in SR free of antiarrhythmic drugs, respectively. While in the biatrial ablation group, SA conversion rate was 89.53% at discharge. Percentage of patients in SR free of antiarrhythmic drugs was 88.37% and 88.37% at six months and 12 months after surgery, respectively. Echocardiography showed left atrial diameter decreased significantly after the surgery in the two groups. The ejection fraction and fractional shortening were improved significantly, without significant differences between the two groups. The results suggest that the concomitant left atrial and simplified right atrial BRFA for AF in patients undergoing valve replacement can achieve similar early efficiency as biatrial ablation. Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

Relation of Milrinone Following Surgery for Congenital Heart Disease to Significant Postoperative Tachyarrhythmias

PubMed Central

Smith, Andrew H.; Owen, Jill; Borgman, Kristie Y.; Fish, Frank A.; Kannankeril, Prince J.

2011-01-01

Milrinone reduces the risk of low cardiac output syndrome for some pediatric patients following congenital heart surgery. Data from adults undergoing cardiac surgery suggest an association between milrinone and increased risk for postoperative arrhythmias. We tested the hypothesis that milrinone is an independent risk factor for tachyarrhythmias following congenital heart surgery. Subjects undergoing congenital heart surgery at our institution were consecutively enrolled for 38 months, through September 2010. Data was prospectively collected, including review of full-disclosure telemetry and the medical record. Over 38 months, 603 enrolled subjects underwent 724 operative procedures. The median age was 5.5 months (0.0–426), weight was 6.0 kg (0.7–108), and the cohort was 45% female. Overall arrhythmia incidence was 50%, most commonly monomorphic ventricular tachycardia (n=85, 12%), junctional ectopic tachycardia (n=69, 10%), accelerated junctional rhythm (n=58, 8%), and atrial tachyarrhythmias (including atrial fibrillation, atrial flutter, and ectopic or chaotic atrial tachycardia, n=58, 8%). Multivariate logistic regression analysis demonstrated that independent of age less than 1 month, use of cardiopulmonary bypass, duration of cardiopulmonary bypass, RACHS-1 score greater than 3, and the use of epinephrine or dopamine, milrinone use on admission to the cardiac intensive care unit remained independently associated with an increase in the odds of postoperative tachyarrhythmia resulting in an intervention (OR 2.8 [95%CI 1.3–6.0], p=0.007). In conclusion, milrinone use is an independent risk factor for clinically significant tachyarrhythmias in the early postoperative period following congenital heart surgery. PMID:21890079

Cardiopulmonary measurements in dogs undergoing gastropexy without gastrectomy for correction of gastric dilatation-volvulus.

PubMed

Wagner, A E; Dunlop, C I; Chapman, P L

1999-08-15

To measure cardiopulmonary variables, including cardiac index, in dogs with naturally acquired gastric dilatation-volvulus (GDV). Prospective clinical study. 6 dogs with GDV. In addition to typical medical and surgical management of GDV, the dorsal metatarsal and pulmonary arteries and right atrium of the dogs were catheterized to obtain cardiopulmonary measurements before and during anesthesia and surgery. All dogs underwent gastropexy but none required gastrectomy. Mean cardiac index and mean arterial blood pressure for this small population of dogs with GDV were not significantly different from those reported for clinically normal awake or anesthetized dogs. Dogs with naturally acquired GDV without gastric necrosis may not have the classic characteristics, including decreased cardiac index and hypotension, of hypovolemic circulatory shock.

[Prolonged therapeutic hypothermia after pericardial effusion drain surgery].

PubMed

Román Fernández, A; López Álvarez, A; Barreiro Canosa, J L; Varela García, O; Fossati Puertas, S; Pereira Tamayo, J Á

2014-01-01

Therapeutic hypothermia is an effective treatment for neurological protection after out-of-hospital cardiac arrest, and may also be beneficial for in-hospital cardiac arrest. Its use is limited in post-surgical patients due to the risk of specific complications, particularly bleeding. There are significant differences among previous publications regarding the time to reach the target temperature and the duration of therapy, so the optimal strategy is not yet established. We present the case of a patient who suffered a perioperative cardiac arrest related to a pericardial tamponade, and who underwent therapeutic hypothermia for 48h. Copyright © 2013 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.

Congenital absence of pulmonary valve leaflets.

PubMed Central

Buendia, A; Attie, F; Ovseyevitz, J; Zghaib, A; Zamora, C; Zavaleta, D; Vargas-Barron, J; Richheimer, R

1983-01-01

Congenital absence of pulmonary valve leaflets is an uncommon condition usually associated with ventricular septal defect and an obstructive pulmonary valve ring. Twenty-one patients with these malformations are described. Twenty had an associated ventricular septal defect with ventriculoarterial concordance, and one also had transposition of the great arteries, ventricular septal defect, and obstructive pulmonary valve ring. The clinical features, cardiac catheterisation findings, and angiocardiographic results are presented. Twelve patients underwent cardiac surgery. Three patients died, one in the early, and the other two in the late postoperative period. The results, according to the surgical technique employed and postoperative cardiac catheterisation findings, showed that patients in whom the bioprostheses were implanted in the pulmonary position had a better late follow-up. Images PMID:6860509

Phenol intoxication in a child.

PubMed

Unlü, R Erkin; Alagöz, M Sahin; Uysal, A Caĝri; Orbay, Hakan; Kilinç, Hidir; Tekin, Fatih; Sensöz, Omer; Erk, Gülcan

2004-11-01

Phenol preparations are used in dermatology and plastic surgery for the treatment of acne and during chemical face peeling. At this institution, phenol peeling is used in addition to mechanical dermabrasion for the elimination of subclinical premalignant lesions of patients having xeroderma pigmentosum. As the phenol peel is performed, most surgeons concentrate on skin results, ignoring systemic complications. Local histological changes and systemic toxicity have been seen during applications. Cardiac arrhythmias and even sudden death have been reported. The high incidence of cardiac arrhythmias after topical application of phenol preparations is demonstrated. The case of an 11-year-old boy with a diagnosis of xeroderma pigmentosum who underwent mechanical dermabrasion and chemical peeling with phenol and then developed severe cardiac arrhythmias is reported. A serious systemic toxic effect on cardiac rhythm from cutaneously applied phenol occurred in this case.

Pulmonary complications in pediatric cardiac surgery at a university hospital.

PubMed

Borges, Daniel Lago; Sousa, Lícia Raquel Teles; Silva, Raquel Teixeira; Gomes, Holga Cristina da Rocha; Ferreira, Fernando Mauro Muniz; Lima, Willy Leite; Borges, Lívia Christina do Prado Lui

2010-01-01

To identify the prevalence of pulmonary complications in children undergone cardiac surgery, as well as demographic and clinical characteristics of this population. The sample comprised 37 children of both genders, underwent cardiac surgery at the Hospital Universitário Presidente Dutra, São Luis (MA) during the year of 2007. There were not included patients who had lung disease in pre-operative period, patients with neurological disorders, intra-operative death besides lack of data in medical records. The data were obtained from general medical and nursing staff of their medical records. The population of the study was predominantly composed by female children, from the countryside and at school age. Pathologies considered low risk were the majority, especially the patent ductus arteriosus, interventricular communication and interatrial communication. It was observed that the largest share of children made use of cardiopulmonary bypass for more than 30 minutes, with a median of 80 minutes, suffered a median sternotomy, using only the mediastinal drain and made use of mechanical ventilation after surgery, with the median about 6.6 hours. Only three (8.1%) patients developed pulmonary complications, and of these, two died. Most of the sample was female, school aged and from the countryside. The low time of cardiopulmonary bypass and mechanical ventilation, and congenital heart disease with low risk, may have been factors that contributed to the low rate of pulmonary complications postoperative.

Inflammation, functional status, and weight loss during recovery from cardiac surgery in older adults: a pilot study.

PubMed

DiMaria-Ghalili, Rose Ann; Sullivan-Marx, Eileen M; Compher, Charlene

2014-07-01

To determine the nutritional, inflammatory, and functional aspects of unintentional weight loss after cardiac surgery that warrant further investigation. Twenty community-dwelling adults > 65 years old undergoing cardiac surgery (coronary artery bypass graft [CABG] or CABG + valve) were recruited for this prospective longitudinal (preoperative and 4-6 weeks postdischarge) pilot study. Anthropometrics (weight, standing height, and mid-arm and calf circumference), nutritional status (Mini-Nutritional Assessment™ [MNA]), appetite, physical performance (timed chair stand), muscle strength (hand grip) and functional status (basic and instrumental activities of daily living), and inflammatory markers (plasma leptin, ghrelin, interleukin [IL]-6, high-sensitivity[hs] C-reactive protein, and serum albumin and prealbumin) were measured. Participants who completed the study (n = 11 males, n = 3 females) had a mean age 70.21 ± 4.02 years. Of these, 12 lost 3.66 ± 1.44 kg over the study period. Weight, BMI, activities of daily living, and leptin decreased over time (p < .05). IL-6 increased over time (p < .05). Ghrelin, hs-CRP, and timed chair stand increased over time in those who underwent combined procedures (p < .05). Grip strength decreased in those who developed complications (p = .004). Complications, readmission status, and lowered grip strength were found in those with low preoperative MNA scores (p < .05). After cardiac surgery, postdischarge weight loss occurs during a continued inflammatory response accompanied by decreased physical functioning and may not be a positive outcome. The impacts of weight loss, functional impairment, and inflammation during recovery on disability and frailty warrant further study. © The Author(s) 2013.

Significant decreases in blood propofol concentrations during adrenalectomy for phaeochromocytoma.

PubMed

Watanabe, Tatsunori; Hiraoka, Haruhiko; Araki, Takuya; Nagano, Daisuke; Aomori, Tohru; Nakamura, Tomonori; Yamamoto, Koujirou; Baba, Hiroshi

2017-10-01

The kinetics of propofol are influenced by cardiac output. The aim of this study was to examine changes in blood propofol concentrations during phaeochromocytoma surgery using target-controlled infusion (TCI) anaesthesia with propofol. This is a prospective observational study. Ten patients with phaeochromocytoma who underwent unilateral adrenalectomy were included. Cardiac output was measured using an arterial pressure-based cardiac output analysis method. The target blood propofol concentrations were adjusted to maintain an approximate bispectral index (BIS) value of 40 before initiating surgery. The settings remained constant during surgery. Blood samples for propofol concentrations were collected from the radial artery at seven time points: two before tumour manipulation (T1, 2), two during tumour manipulation (T3, 4), and three after tumour vein ligation (T4-7). BIS values, the arterial pressure cardiac index (APCI) and haemodynamic parameters were measured at the same time points as the blood samples. The prop-ratio was calculated by dividing blood propofol concentrations by target concentrations of TCI. APCI increased during tumour manipulation and after tumour vein ligation. The prop-ratio was reduced significantly by approximately 40% and showed a significant negative correlation with APCI. BIS values increased significantly and showed a significant negative correlation with the prop-ratio. The increased APCI during tumour manipulation and after tumour vein ligation was associated with markedly reduced blood propofol concentrations. These results reveal that significant decreases in the anaesthetic effect may be observed in patients undergoing phaeochromocytoma surgery even if TCI anaesthesia is used with propofol. © 2017 The British Pharmacological Society.

Risk factors and outcome of increased red blood cell transfusion in cardiac surgical patients aged 65 years and older.

PubMed

Isil, Canan Tulay; Yazici, Pinar; Bakir, Ihsan

2015-02-01

The use of blood products is not uncommon during cardiac surgery in elderly patients. We conducted this study to investigate the risk factors and adverse outcomes of increased red blood cell (RBC) transfusion in the patients aged ≥ 65 years undergoing cardiac surgery. During 1 year period, 288 patients (197 male/91 female) aged ≥ 65 years who underwent coronary and/or valvular surgery were retrospectively reviewed. Patients were stratified into groups on the basis of the number of transfusions received (< 4 and ≥ 4 U) which was classified as increased transfusion. Univariate analysis and multivariate logistic regression were used to identify risk factors for increased transfusion. The mean unit of RBC transfusion was 4.5 ± 3.1 and 55.9% (n = 161) of patients received ≥ 4 U RBC. The overall postoperative complication rate was 36% and significantly higher in those with ≥ 4 U) RBC transfusion (p < 0.01). Risk factors including age, EuroSCORE, and low body surface were significantly higher in patient with ≥ 4 U RBC transfusion. Besides, preoperative anemia, postoperative drainage volume, and fresh frozen plasma (FFP) transfusion during hospital stay were found to be significantly associated with increased transfusion requirements. No difference was observed in mortality (p = 0.13). These results suggest that improvement in blood transfusion policy in elderly patients undergoing cardiac surgery requires elimination of preoperative anemia, careful attention to surgical hemostasis, and FFP use. Georg Thieme Verlag KG Stuttgart · New York.

Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery.

PubMed

Mehta, Rajendra H; Leimberger, Jeffrey D; van Diepen, Sean; Meza, James; Wang, Alice; Jankowich, Rachael; Harrison, Robert W; Hay, Douglas; Fremes, Stephen; Duncan, Andra; Soltesz, Edward G; Luber, John; Park, Soon; Argenziano, Michael; Murphy, Edward; Marcel, Randy; Kalavrouziotis, Dimitri; Nagpal, Dave; Bozinovski, John; Toller, Wolfgang; Heringlake, Matthias; Goodman, Shaun G; Levy, Jerrold H; Harrington, Robert A; Anstrom, Kevin J; Alexander, John H

2017-05-25

Levosimendan is an inotropic agent that has been shown in small studies to prevent or treat the low cardiac output syndrome after cardiac surgery. In a multicenter, randomized, placebo-controlled, phase 3 trial, we evaluated the efficacy and safety of levosimendan in patients with a left ventricular ejection fraction of 35% or less who were undergoing cardiac surgery with the use of cardiopulmonary bypass. Patients were randomly assigned to receive either intravenous levosimendan (at a dose of 0.2 μg per kilogram of body weight per minute for 1 hour, followed by a dose of 0.1 μg per kilogram per minute for 23 hours) or placebo, with the infusion started before surgery. The two primary end points were a four-component composite of death through day 30, renal-replacement therapy through day 30, perioperative myocardial infarction through day 5, or use of a mechanical cardiac assist device through day 5; and a two-component composite of death through day 30 or use of a mechanical cardiac assist device through day 5. A total of 882 patients underwent randomization, 849 of whom received levosimendan or placebo and were included in the modified intention-to-treat population. The four-component primary end point occurred in 105 of 428 patients (24.5%) assigned to receive levosimendan and in 103 of 421 (24.5%) assigned to receive placebo (adjusted odds ratio, 1.00; 99% confidence interval [CI], 0.66 to 1.54; P=0.98). The two-component primary end point occurred in 56 patients (13.1%) assigned to receive levosimendan and in 48 (11.4%) assigned to receive placebo (adjusted odds ratio, 1.18; 96% CI, 0.76 to 1.82; P=0.45). The rate of adverse events did not differ significantly between the two groups. Prophylactic levosimendan did not result in a rate of the short-term composite end point of death, renal-replacement therapy, perioperative myocardial infarction, or use of a mechanical cardiac assist device that was lower than the rate with placebo among patients with a reduced left ventricular ejection fraction who were undergoing cardiac surgery with the use of cardiopulmonary bypass. (Funded by Tenax Therapeutics; LEVO-CTS ClinicalTrials.gov number, NCT02025621 .).

Prevalence of Non-cardiac and Genetic abnormalities in Neonates Undergoing Cardiac Surgery: Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database

PubMed Central

Patel, Angira; Costello, John M.; Backer, Carl L.; Pasquali, Sara K.; Hill, Kevin D.; Wallace, Amelia S.; Jacobs, Jeffrey P.; Jacobs, Marshall L.

2016-01-01

Background Among congenital heart disease (CHD) patients, the coexistence of non-cardiac congenital anatomic abnormalities (NC), genetic abnormalities (GA), and syndromes (S) may influence therapeutic strategies and outcomes. The appreciated prevalence of these abnormalities has risen, as increased screening and improved diagnostic precision enable identification of these comorbidities in a larger fraction of neonates with CHD. We examined the contemporary prevalence and distribution of NC/GA/S across diagnostic groups among neonates undergoing cardiac surgery using a large, nationally representative clinical registry. Methods The Society of Thoracic Surgeons-Congenital Heart Surgery Database (STS-CHSD) was queried to identify neonates (≤ 30 days) who underwent index cardiac operations from 2010–2013. The fundamental cardiac diagnosis was used to identify 10 diagnostic groups. The prevalence of NC/GA/S was reported across each group. Results The cohort included 15,376 index neonatal operations from 112 centers. Overall 18.8% (2,894/15,376) of operations were performed on neonates with NC/GA/S. Patients with atrioventricular septal defect (212/357, 59.4%), interrupted aortic arch (248/567, 43.7%), truncus arteriosus (204/554, 36.8%), tetralogy of Fallot (417/1383, 30.2%) had the highest prevalence of NC/GA/S abnormalities, whereas those with transposition (111/2778, 4.0%) had the lowest prevalence. The most commonly identified NC/GA/S included: heterotaxy (597/15,376, 3.9%), DiGeorge/22q11 deletion (550/15,376, 3.6%), Down syndrome/trisomy 21 (318/15, 376, 2.1%), intestinal malrotation (220/15,376, 1.4%), and Turner syndrome/45XO (189/15,376, 1.2%). Conclusions The prevalence of NC/GA/S varies widely across CHD diagnostic groups. This information may be useful for patient counseling, recommendations for screening for anomalies and genetic disorders, and perioperative management. PMID:27319986

[Our experience with recombinant activated factor VII (NovoSeven) in the high risk cardiosurgical patients with bleeding complication].

PubMed

Miskolczi, Szabolcs; Vaszily, Miklós; Papp, Csaba; Péterffy, Arpád

2008-01-01

Haemorrhagic complications significantly increase mortality and cost of treatment in cardiac surgery. A few years ago recombinant activated factor VII has been introduced to decrease such complications. In our department recombinant activated factor VII has been used in 11 patients between 2004 and 2007. Nine of them underwent a combined (simultaneous CABG and valve replacement) high risk surgery with long aortic cross clamp time and long extracorporeal circulation time. One patient underwent a repeat coronary artery bypass operation and one was operated for aortic dissection. The average dose given was 6.5 mg (2.4-9.6 mg). The average amount of bleeding without NovoSeven given was 5440 ml, however it was only 987 ml when NovoSeven was used. Nine of the patients were completely recovered and discharged from hospital, but two of them died in the postoperative period for delayed use of the recombinant factor VII-a and for severe co-morbidities (bowel ischaemia, cirrhosis of the liver). NovoSeven given in the proper time and dose significantly reduces bleeding following cardiac surgery, even if it cannot be stopped surgically. Using recombinant factor VIIa can save life in case of severe non-surgical diffuse bleeding or in case of suture insufficiency caused by friable soft tissues following high risk combined surgery with extremely long aortic cross clamp time and extracorporeal circulation time. Significant delay in the use of NovoSeven should be avoided because the temporary reduction of bleeding usually does not change fatal outcome.

Aerobic exercise training rescues cardiac protein quality control and blunts endoplasmic reticulum stress in heart failure rats.

PubMed

Bozi, Luiz H M; Jannig, Paulo R; Rolim, Natale; Voltarelli, Vanessa A; Dourado, Paulo M M; Wisløff, Ulrik; Brum, Patricia C

2016-11-01

Cardiac endoplasmic reticulum (ER) stress through accumulation of misfolded proteins plays a pivotal role in cardiovascular diseases. In an attempt to reestablish ER homoeostasis, the unfolded protein response (UPR) is activated. However, if ER stress persists, sustained UPR activation leads to apoptosis. There is no available therapy for ER stress relief. Considering that aerobic exercise training (AET) attenuates oxidative stress, mitochondrial dysfunction and calcium imbalance, it may be a potential strategy to reestablish cardiac ER homoeostasis. We test the hypothesis that AET would attenuate impaired cardiac ER stress after myocardial infarction (MI). Wistar rats underwent to either MI or sham surgeries. Four weeks later, rats underwent to 8 weeks of moderate-intensity AET. Myocardial infarction rats displayed cardiac dysfunction and lung oedema, suggesting heart failure. Cardiac dysfunction in MI rats was paralleled by increased protein levels of UPR markers (GRP78, DERLIN-1 and CHOP), accumulation of misfolded and polyubiquitinated proteins, and reduced chymotrypsin-like proteasome activity. These results suggest an impaired cardiac protein quality control. Aerobic exercise training improved exercise capacity and cardiac function of MI animals. Interestingly, AET blunted MI-induced ER stress by reducing protein levels of UPR markers, and accumulation of both misfolded and polyubiquinated proteins, which was associated with restored proteasome activity. Taken together, our study provide evidence for AET attenuation of ER stress through the reestablishment of cardiac protein quality control, which contributes to better cardiac function in post-MI heart failure rats. These results reinforce the importance of AET as primary non-pharmacological therapy to cardiovascular disease. © 2016 The Authors. Journal of Cellular and Molecular Medicine published by John Wiley & Sons Ltd and Foundation for Cellular and Molecular Medicine.

Subxiphoid pericardial window to exclude occult cardiac injury after penetrating thoracoabdominal trauma.

PubMed

Hommes, M; Nicol, A J; van der Stok, J; Kodde, I; Navsaria, P H

2013-10-01

An occult cardiac injury may be present in patients with an acute abdomen after penetrating thoracoabdominal trauma. This study assessed the use of a subxiphoid pericardial window (SPW) as a diagnostic manoeuvre in this setting. This was a retrospective review of a trauma database (2001-2009). Patients presenting with a penetrating thoracoabdominal injury with an acute abdomen, and in whom there was concern about a potential cardiac injury from the site or tract of the injury, were included. Fifty patients with an indication for emergency laparotomy underwent a SPW for a possible cardiac injury. An occult haemopericardium was present at SPW in 14 patients (28 per cent) mandating, median sternotomy. Nine cardiac injuries (18 per cent) were identified including five tangential injuries and four perforations. The specific complication rate relating to the SPW was 2 per cent. The SPW is a useful technique at laparotomy to identify cardiac injuries in patients with penetrating thoracoabdominal injuries. © 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd.

FIASCO II failure to achieve a satisfactory cardiac outcome study: the elimination of system errors.

PubMed

Farid, Shakil; Page, Aravinda; Jenkins, David; Jones, Mark T; Freed, Darren; Nashef, Samer A M

2013-07-01

Death in low-risk cardiac surgical patients provides a simple and accessible method by which modifiable causes of death can be identified. In the first FIASCO study published in 2009, local potentially modifiable causes of preventable death in low-risk patients with a logistic EuroSCORE of 0-2 undergoing cardiac surgery were inadequate myocardial protection and lack of clarity in the chain of responsibility. As a result, myocardial protection was improved, and a formalized system introduced to ensure clarity of the chain of responsibility in the care of all cardiac surgical patients. The purpose of the current study was to re-audit outcomes in low-risk patients to see if improvements have been achieved. Patients with a logistic EuroSCORE of 0-2 who had cardiac surgery from January 2006 to August 2012 were included. Data were prospectively collected and retrospectively analysed. The case notes of patients who died in hospital were subject to internal and external review and classified according to preventability. Two thousand five hundred and forty-nine patients with a logistic EuroSCORE of 0-2 underwent cardiac surgery during the study period. Seven deaths occurred in truly low-risk patients, giving a mortality of 0.27%. Of the seven, three were considered preventable and four non-preventable. Mortality was marginally lower than in our previous study (0.37%), and no death occurred as a result of inadequate myocardial protection or communication failures. We postulate that the regular study of such events in all institutions may unmask systemic errors that can be remedied to prevent or reduce future occurrences. We encourage all units to use this methodology to detect any similarly modifiable factors in their practice.

Relation of milrinone after surgery for congenital heart disease to significant postoperative tachyarrhythmias.

PubMed

Smith, Andrew H; Owen, Jill; Borgman, Kristie Y; Fish, Frank A; Kannankeril, Prince J

2011-12-01

Milrinone reduces the risk of low cardiac output syndrome for some pediatric patients after congenital heart surgery. Data from adults undergoing cardiac surgery suggest an association between milrinone and an increased risk of postoperative arrhythmias. We tested the hypothesis that milrinone is an independent risk factor for tachyarrhythmias after congenital heart surgery. Subjects undergoing congenital heart surgery at our institution were consecutively enrolled for 38 months, through September 2010. The data were prospectively collected, including a review of full-disclosure telemetry and the medical records. Within 38 months, 603 enrolled subjects underwent 724 operative procedures. The median age was 5.5 months (range 0.0 to 426), the median weight was 6.0 kg (range 0.7 to 108), and the cohort was 45% female. The overall arrhythmia incidence was 50%, most commonly monomorphic ventricular tachycardia (n = 85, 12%), junctional ectopic tachycardia (n = 69, 10%), accelerated junctional rhythm (n = 58, 8%), and atrial tachyarrhythmias (including atrial fibrillation, atrial flutter, and ectopic or chaotic atrial tachycardia, n = 58, 8%). Multivariate logistic regression analysis demonstrated that independent of age <1 month, the use of cardiopulmonary bypass, the duration of cardiopulmonary bypass, Risk Adjusted classification for Congenital Heart Surgery, version 1, score >3, and the use of epinephrine or dopamine, milrinone use on admission to the cardiac intensive care unit remained independently associated with an increase in the odds of postoperative tachyarrhythmia resulting in an intervention (odds ratio 2.8, 95% confidence interval 1.3 to 6.0, p = 0.007). In conclusion, milrinone use is an independent risk factor for clinically significant tachyarrhythmias in the early postoperative period after congenital heart surgery. Copyright © 2011 Elsevier Inc. All rights reserved.

Accelerated recovery after cardiac operations.

PubMed

Kaplan, Mehmet; Kut, Mustafa Sinan; Yurtseven, Nurgul; Cimen, Serdar; Demirtas, Mahmut Murat

2002-01-01

The accelerated-recovery approach, involving early extubation, early mobility, decreased duration of intensive care unit stay, and decreased duration of hospitalization has recently become a controversial issue in cardiac surgery. We investigated timing of extubation, length of intensive care unit stay, and duration of hospitalization in 225 consecutive cardiac surgery patients. Of the 225 patients, 139 were male and 86 were female; average age was 49.73 +/- 16.95 years. Coronary artery bypass grafting was performed in 127 patients; 65 patients underwent aortic and/or mitral or pulmonary valvular operations; 5 patients underwent valvular plus coronary artery operations; and in 28 patients surgical interventions for congenital anomalies were carried out. The accelerated-recovery approach could be applied in 169 of the 225 cases (75.11%). Accelerated-recovery patients were extubated after an average of 3.97 +/- 1.59 hours, and the average duration of stay in the intensive care unit was 20.93 +/- 2.44 hours for these patients. Patients were discharged if they met all of the following criteria: hemodynamic stability, cooperativeness, ability to initiate walking exercises within wards, lack of pathology in laboratory investigations, and psychological readiness for discharge. Mean duration of hospitalization for accelerated-recovery patients was 4.24 +/- 0.75 days. Two patients (1.18%) who were extubated within the first 6 hours required reintubation. Four patients (2.36%) who were sent to the wards returned to intensive care unit due to various reasons and 6 (3.55%) of the discharged patients were rehospitalized. Approaches for decreasing duration of intubation, intensive care unit stay and hospitalization may be applied in elective and uncomplicated cardiac surgical interventions with short duration of aortic cross-clamping and cardiopulmonary bypass, without risking patients. Frequencies of reintubation, return to intensive care unit, and rehospitalization are quite low with this approach.

Renal ultrasound provides low utility in evaluating cardiac surgery associated acute kidney injury.

PubMed

Young, Allen; Crawford, Todd; Pierre, Alejandro Suarez; Trent Magruder, J; Fraser, Charles; Conte, John; Whitman, Glenn; Sciortino, Christopher

2017-09-02

Renal ultrasonography is part of the algorithm in assessing acute kidney injury (AKI). The purpose of this study was to assess the clinical utility of renal US in postoperative cardiac patients who develop AKI. We conducted a retrospective study of 90 postoperative cardiac surgery patients at a single institution from 1/19/2010 to 3/19/2016 who underwent renal US for AKI. We reviewed provider documentation to determine whether renal US changed management. We defined change as: administration of crystalloid or colloid, addition of inotropic or vasopressor, or procedural interventions on the renal system. Mean age of study patients was 68 ± 13 years. 48/90 patients (53.3%) had pre-existing chronic kidney disease of varying severity. 48 patients (53.3%) had normal renal US with incidental findings and 31 patients (34.4%) had US evidence of medical kidney disease. 10 patients (11.1%) had limited US results due to poor visualization and 1 patient (1.1%) had mild right-sided hydronephrosis. No patients were found to have obstructive uropathy or renal artery stenosis. Clinical management was altered in only 4/90 patients (4.4%), which included 3 patients that received a fluid bolus and 1 patient that received a fluid bolus and inotropes. No vascular or urologic procedures resulted from US findings. Although renal ultrasound is often utilized in the work-up of AKI, our study shows that renal US provides little benefit in managing postoperative cardiac patients. This diagnostic modality should be scrutinized rather than viewed as a universal measure in the cardiac surgery population.

Heparin-Induced Thrombocytopenia in Contemporary Cardiac Surgical Practice and Experience With a Protocol for Early Identification.

PubMed

Sun, Xiumei; Hill, Peter C; Taylor-PaneK, Sharon L; Corso, Paul J; Lindsay, Joseph

2016-01-15

This analysis was designed to (1) examine the impact of heparin-induced thrombocytopenia (HIT) on contemporary cardiac surgical practice and (2) describe the results of a protocol designed for early identification of the presence of the immune mechanisms involved. Consecutive patients who underwent cardiac surgery were screened postoperatively for thrombocytopenia. Patients with thrombocytopenia were tested for antiplatelet factor 4 (PF4)/heparin antibodies by ELISA and clinical evidence of thrombosis sought. Demographics, co-morbidities, operative details, and outcomes were abstracted from the departmental registry. Of 14,415 consecutive patients undergoing cardiac surgery, 1,849 patients (13%) had thrombocytopenia. Of them, 277 patients (15%) had PF4/heparin antibodies and 76 patients (4%) had both antibodies and clinical thrombosis. Antibodies were more frequent: (1) in women (p = 0.01), (2) in patients with an increased body mass index (p <0.01), and (3) in patients with clinical heart failure before surgery (p <0.01). Thirty-day mortality was greatest among the 76 patients with the triad of thrombocytopenia, antibodies, and clinical thrombosis (30%). Of the 1,849 patients with thrombocytopenia, the presence of PF4/heparin antibodies was an independent predictor of 30-day mortality (odds ratio 2.09, 95% CI 1.46 to 2.49; p <0.001). HIT remains an infrequent but very serious complication of heparin therapy in contemporary cardiac surgical practice. The possibility that the presence of HIT antibodies in patients with thrombocytopenia independently increases operative mortality deserves further study. Copyright © 2016 Elsevier Inc. All rights reserved.

Pre- and/or Intra-Operative Prescription of Diuretics, but Not Renin-Angiotensin-System Inhibitors, Is Significantly Associated with Acute Kidney Injury after Non-Cardiac Surgery: A Retrospective Cohort Study.

PubMed

Tagawa, Miho; Ogata, Ai; Hamano, Takayuki

2015-01-01

Pre- and/or intra-operative use of diuretics, angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin II receptor blockers (ARB) constitutes a potentially modifiable risk factor for postoperative acute kidney injury (AKI). It has been studied whether use of these drugs predicts AKI after cardiac surgery. The objective of this study was to examine whether administration of these agents was independently associated with AKI after non-cardiac surgery. This was a retrospective observational study. Inclusion criteria were adult patients (age ≥ 18) who underwent non-cardiac surgery under general anesthesia from 2007 to 2009 at Kyoto Katsura Hospital. Exclusion criteria were urological surgery, missing creatinine values, and preoperative dialysis. The exposures of interest were pre- and/or intra-operative use of diuretics or ACE-I/ARB. Outcome variables were postoperative AKI as defined by the AKI Network (increase in creatinine ≥ 0.3 mg/dL or 150% within 48 hours, or urine output < 0.5 ml/kg/hour for > 6 hours). Multivariable logistic regression analyses were conducted and adjusted for potential confounders. Propensity scores (PS) for receiving diuretics or ACE-I/ARB therapy were estimated and PS adjustment, PS matching, and inverse probability weighting were performed. There were 137 AKI cases (5.0%) among 2,725 subjects. After statistical adjustment for patient and surgical characteristics, odds (95% CI) of postoperative AKI were 2.07 (1.10-3.89) (p = 0.02) and 0.89 (0.56-1.42) (p = 0.63) in users of diuretics and ACE-I/ARB, respectively, compared with non-users. PS adjustment, PS matching, and inverse probability weighting yielded similar results. The effect size of diuretics was significantly greater in the patients with lower propensity for diuretic use (p for interaction < 0.1). Prescription of diuretics, but not ACE-I/ARB, was independently associated with postoperative AKI after non-cardiac surgery, especially in patients with low propensity for diuretic use. It might be reasonable to withhold preoperative diuretics in these patients.

Pre- and/or Intra-Operative Prescription of Diuretics, but Not Renin-Angiotensin-System Inhibitors, Is Significantly Associated with Acute Kidney Injury after Non-Cardiac Surgery: A Retrospective Cohort Study

PubMed Central

Tagawa, Miho; Ogata, Ai; Hamano, Takayuki

2015-01-01

Background and Objectives Pre- and/or intra-operative use of diuretics, angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin II receptor blockers (ARB) constitutes a potentially modifiable risk factor for postoperative acute kidney injury (AKI). It has been studied whether use of these drugs predicts AKI after cardiac surgery. The objective of this study was to examine whether administration of these agents was independently associated with AKI after non-cardiac surgery. Design, Setting, Participants, and Measurements This was a retrospective observational study. Inclusion criteria were adult patients (age ≥ 18) who underwent non-cardiac surgery under general anesthesia from 2007 to 2009 at Kyoto Katsura Hospital. Exclusion criteria were urological surgery, missing creatinine values, and preoperative dialysis. The exposures of interest were pre- and/or intra-operative use of diuretics or ACE-I/ARB. Outcome variables were postoperative AKI as defined by the AKI Network (increase in creatinine ≥ 0.3 mg/dL or 150% within 48 hours, or urine output < 0.5 ml/kg/hour for > 6 hours). Multivariable logistic regression analyses were conducted and adjusted for potential confounders. Propensity scores (PS) for receiving diuretics or ACE-I/ARB therapy were estimated and PS adjustment, PS matching, and inverse probability weighting were performed. Results There were 137 AKI cases (5.0%) among 2,725 subjects. After statistical adjustment for patient and surgical characteristics, odds (95% CI) of postoperative AKI were 2.07 (1.10-3.89) (p = 0.02) and 0.89 (0.56-1.42) (p = 0.63) in users of diuretics and ACE-I/ARB, respectively, compared with non-users. PS adjustment, PS matching, and inverse probability weighting yielded similar results. The effect size of diuretics was significantly greater in the patients with lower propensity for diuretic use (p for interaction < 0.1). Conclusions Prescription of diuretics, but not ACE-I/ARB, was independently associated with postoperative AKI after non-cardiac surgery, especially in patients with low propensity for diuretic use. It might be reasonable to withhold preoperative diuretics in these patients. PMID:26146836

How good patient blood management leads to excellent outcomes in Jehovah's witness patients undergoing cardiac surgery.

PubMed

Emmert, Maximilian Y; Salzberg, Sacha P; Theusinger, Oliver M; Felix, Christian; Plass, Andre; Hoerstrup, Simon P; Falk, Volkmar; Gruenenfelder, Juerg

2011-02-01

The refusal of blood products makes open-heart surgery in Jehovah's witnesses (JW) an ethical challenge. We demonstrate how patient blood management strategies lead to excellent surgical outcomes. From 2003 to 2008, 16 JW underwent cardiac surgery at our institution. Only senior surgeons performed coronary revascularization (n=6), valve (n=6), combined (n=1) and aortic surgery (n=3) of which two patients presented with acute type-A dissection. Off-pump surgery remained the method of choice for patients requiring a bypass procedure (n=5). Preoperative hematocrit (Hk) and hemoglobin (Hb) were 42.8±4.7% and 14.5±2 g/dl. In three patients with an Hb<12 g/dl, preoperative hematological stimulating treatment was implemented. All patients survived, no major complications occurred and no blood transfusion was administered. The Cell Saver® system (transfused volume: 474±101 ml) and synthetic plasma substitutes [Ringer's Lactate: 873±367 ml and hydroxyethyl starch (HES) 6%: 700±388 ml] were used routinely as well as hemostaticas, such as bone wax, and fibrin glue. The decrease of Hk and Hb appeared to be the lowest after off-pump surgery when compared to all other procedures requiring cardiopulmonary bypass (CPB) (25±9% vs. 33±6%; P=0.01 and 22±9% vs. 31±6%; P=0.04). Similarly, the decrease of platelets was significantly lower (20±12% vs. 43±14%; P=0.01). In the follow-up period (52±34 months), one patient died due to a non-cardiac reason, whereas all others were alive, in good clinical condition and did not have major adverse cardiac events (MACE) or recurrent symptoms requiring re-intervention. Patient blood management leads to excellent short- and long-term outcomes in JW. Combined efforts in regard to preoperative hematological parameter optimization, effective volume management and meticulous surgical techniques make this possible but raise the cautionary note why this is only possible in JW patients.

Hemodynamic deterioration after aortic valve replacement in a patient with mixed systemic amyloidosis.

PubMed

Seki, Tatsuya; Hattori, Atsuo; Yoshida, Toshihito

2017-08-01

We report a case of hemodynamic deterioration after aortic valve replacement in a patient with mixed systemic amyloidosis. A 77-year-old male with severe aortic valve stenosis and 19 years hemodialysis underwent aortic valve replacement. Postoperatively, the patient died of hemodynamic deterioration. Autopsy findings showed massive, whole-body edema and mixed systemic amyloidosis (dialysis-related and AA amyloidosis). Clinical and autopsy findings implied that hemodynamic deterioration was caused by increased vascular permeability. The amyloid deposit to the vessel causes inflammatory changes and increases vascular permeability. Mixed systemic amyloidosis occurs very rarely and could increases vascular permeability even more than each single type of amyloidosis. Systemic amyloidosis may be a risk factor for hemodynamic deterioration after cardiac surgery. Patients with longtime hemodialysis and a history associated with dialysis-related amyloidosis would have at least single systemic amyloidosis, which should be considered a contraindication to cardiac surgery with cardiopulmonary bypass.

Examining the "July effect" on patients undergoing pituitary surgery.

PubMed

Bashjawish, Bassel; Patel, Shreya; Kılıç, Suat; Hsueh, Wayne D; Liu, James K; Baredes, Soly; Eloy, Jean Anderson

2018-06-15

Our aim in this study was to assess the impact of the turnover of residents in July on patients undergoing pituitary surgery. This work was a retrospective cohort study of cases from the National Inpatient Sample (NIS). Patients who underwent pituitary surgery from 2005 to 2012 were selected in the NIS. Patients undergoing surgery in July and in non-July months were compared to determine differences in demographics, comorbidities, and complications. Of the 12,939 patients, 1098 (8.5%) underwent pituitary surgery in July. Patients receiving surgery in July had similar demographics and Agency for Healthcare Research and Quality comorbidity values compared with patients receiving surgery in other months. There were no significant differences in mortality, cerebral edema, cerebrospinal fluid leakage, iatrogenic pituitary complications, iatrogenic cerebrovascular accidents, urinary tract infections, pulmonary edema, pulmonary complications, or acute cardiac complications. There were no differences in the rate of postoperative fistulas, hematomas, perforations, or infections. The use of meningeal suturing, pedicled or free-flap reconstruction, and skin reconstruction was more frequent in July. Finally, hospitalization costs in July were similar to costs in other months. The turnover of new residents in July showed no change in complication rates for patients undergoing pituitary surgery. Patient care in July is similar to care during other months, demonstrating that hospitals are adequately supervising surgical residents during this transition. © 2018 ARS-AAOA, LLC.

Endovascular treatment of a postlaminectomy arteriovenous fistula. A case report.

PubMed

Ventura, M; Rivellini, C; Saracino, G; Mastromarino, A; Spartera, C; Zannetti, S

2002-08-01

We report a case of iliac arteriovenous fistula (AVF) following disk surgery. A 51-year-old woman underwent hemilaminectomy for a slipped disk. Two weeks after surgery the patient experienced dyspnea and oedema of the lower limbs. Presence of a systolic murmur on the cardiac floor and on the abdomen was detected and abdomen CT scan which evidenced a AVF between the right common iliac artery and vein. The lesion, confirmed by angiography, was successfully treated with the endovascular technique. The endovascular technique appears to be a valid alternative to the traditional surgical treatment of postlaminectomy AVF.

Albumin administration is associated with acute kidney injury in cardiac surgery: a propensity score analysis.

PubMed

Frenette, Anne Julie; Bouchard, Josée; Bernier, Pascaline; Charbonneau, Annie; Nguyen, Long Thanh; Rioux, Jean-Philippe; Troyanov, Stéphan; Williamson, David R

2014-11-14

The risk of acute kidney injury (AKI) with the use of albumin-containing fluids compared to starches in the surgical intensive care setting remains uncertain. We evaluated the adjusted risk of AKI associated with colloids following cardiac surgery. We performed a retrospective cohort study of patients undergoing on-pump cardiac surgery in a tertiary care center from 2008 to 2010. We assessed crystalloid and colloid administration until 36 hours after surgery. AKI was defined by the RIFLE (risk, injury, failure, loss and end-stage kidney disease) risk and Acute Kidney Injury Network (AKIN) stage 1 serum creatinine criterion within 96 hours after surgery. Our cohort included 984 patients with a baseline glomerular filtration rate of 72 ± 19 ml/min/1.73 m(2). Twenty-three percent had a reduced left ventricular ejection fraction (LVEF), thirty-one percent were diabetics and twenty-three percent underwent heart valve surgery. The incidence of AKI was 5.3% based on RIFLE risk and 12.0% based on the AKIN criterion. AKI was associated with a reduced LVEF, diuretic use, anemia, heart valve surgery, duration of extracorporeal circulation, hemodynamic instability and the use of albumin, pentastarch 10% and transfusions. There was an important dose-dependent AKI risk associated with the administration of albumin, which also paralleled a higher prevalence of concomitant risk factors for AKI. To address any indication bias, we derived a propensity score predicting the likelihood to receive albumin and matched 141 cases to 141 controls with a similar risk profile. In this analysis, albumin was associated with an increased AKI risk (RIFLE risk: 12% versus 5%, P = 0.03; AKIN stage 1: 28% versus 13%, P = 0.002). We repeated this methodology in patients without postoperative hemodynamic instability and still identified an association between the use of albumin and AKI. Albumin administration was associated with a dose-dependent risk of AKI and remained significant using a propensity score methodology. Future studies should address the safety of albumin-containing fluids on kidney function in patients undergoing cardiac surgery.

Referral to Cardiac Rehabilitation After Percutaneous Coronary Intervention, Coronary Artery Bypass Surgery, and Valve Surgery: Data From the Clinical Outcomes Assessment Program.

PubMed

Beatty, Alexis L; Bradley, Steven M; Maynard, Charles; McCabe, James M

2017-06-01

Despite guideline recommendations that patients undergoing percutaneous coronary intervention (PCI), coronary artery bypass surgery, or valve surgery be referred to cardiac rehabilitation, cardiac rehabilitation is underused. The objective of this study was to examine hospital-level variation in cardiac rehabilitation referral after PCI, coronary artery bypass surgery, and valve surgery. We analyzed data from the Clinical Outcomes Assessment Program, a registry of all nonfederal hospitals performing PCI and cardiac surgery in Washington State. We included eligible PCI, coronary artery bypass surgery, and valve surgery patients from 2010 to 2015. We analyzed PCI and cardiac surgery separately by performing multivariable hierarchical logistic regression for the outcome of cardiac rehabilitation referral at discharge, clustered by hospital. Patient-level covariates included age, sex, race/ethnicity, comorbidities, and procedure indication/status. Cardiac rehabilitation referral was reported in 48% (34 047/71 556) of PCI patients and 91% (21 831/23 972) of cardiac surgery patients. The hospital performing the procedure was a stronger predictor of referral than any individual patient characteristic for PCI (hospital referral range 3%-97%; median odds ratio, 5.94; 95% confidence interval, 4.10-9.49) and cardiac surgery (range 54%-100%; median odds ratio, 7.09; 95% confidence interval, 3.79-17.80). Hospitals having an outpatient cardiac rehabilitation program explained only 10% of PCI variation and 0% of cardiac surgery variation. Cardiac rehabilitation referral at discharge was less prevalent after PCI than cardiac surgery. The strongest predictor of cardiac rehabilitation referral was the hospital performing the procedure. Efforts to improve cardiac rehabilitation referral should focus on increasing referral after PCI, especially in low referral hospitals. © 2017 American Heart Association, Inc.

Influence of large hiatus hernia on cardiac volumes. A prospective observational cohort study by cardiovascular magnetic resonance.

PubMed

Milito, Pamela; Lombardi, Massimo; Asti, Emanuele; Bonitta, Gianluca; Fina, Dario; Bandera, Francesco; Bonavina, Luigi

2018-05-09

Large hiatus hernia (LHH) is often associated with post-prandial dyspnea, palpitations or chest discomfort, but its effect on cardiac volumes and performance is still debated. Before and 3-months after laparoscopic repair, 35 patients underwent cardiovascular magnetic resonance (CMR) in the fasting state and after a standardized meal. Preoperatively, LHH size increased significantly after meal (p < 0.010). Compared to the fasting state, a systematic trend of volume reduction of the cardiac chambers was observed. In addition, both the left ventricle stroke volume (p = 0.012) and the ejection fraction (p = 0.010) were significantly reduced. At 3-months after surgery there was a statistically significant increase in left atrial volume (p = 0.029), overall left ventricle volume (p < 0.05) and right ventricle end-systolic volume (p = 0.046). Both FEV 1 (Forced expiratory volume) (p = 0.02) and FVC (Forced Vital Capacity) (p = 0.01) values significantly improved after surgery. Cardiorespiratory symptoms significantly improved compared to pre-operative values (p < 0.01). The global heart function was significantly impaired by a standardized meal in the presence of a LHH. Restoration of the cardiac physiological status and improvement of clinical symptoms were noted after surgery. A multidisciplinary evaluation and CMR with a challenge meal may be added to routine pre-operative testing to select symptomatic patients for surgical hernia repair. Copyright © 2017 Elsevier B.V. All rights reserved.

Postoperative cerebrovascular accidents in general surgery.

PubMed

Larsen, S F; Zaric, D; Boysen, G

1988-11-01

In a prospective study of postoperative complications, strokes occurred in 6 out of 2463 patients (0.2%) who underwent non-cardiac, non-carotid artery surgery. The patients who experienced cerebrovascular accidents, including three cases of transient ischemic attack, were significantly older than the rest of the group (mean age 79 years versus 65 years) and had manifestations of atherosclerosis in at least one organ preoperatively. Significant predictors of risk for postoperative cerebrovascular accidents were previous cerebrovascular disease, heart disease, peripheral vascular disease, and hypertension. Cerebrovascular accidents occurred late in the postoperative period, 5-26 days after surgery, and were not directly related to surgery and anesthesia. They were more frequent after acute than after elective operations. Precipitating factors for some of the stroke incidents were rapid atrial fibrillation and postoperative dehydration.

Isolated Disruption of the Right Coronary Artery Following a Steam Pop during Cavotricuspid Linear Ablation with a Contact Force Catheter.

PubMed

Brunelli, Michele; Frommhold, Markus; Back, Dieter; Mierzwa, Marco; Lauer, Bernard; Geller, J Christoph

2016-07-01

A 70-year-old woman with persistent atrial fibrillation underwent pulmonary vein isolation and linear ablation with a contact sensor catheter. During cavotricuspid isthmus ablation, a steam pop resulted in cardiac tamponade, and the patient developed severe hypotension despite successful pericardial puncture and minimal residual pericardial effusion. Right coronary artery angiography revealed extravasal contrast medium accumulation posterior of the Crux Cordis. Emergent cardiac surgery confirmed isolated disruption of the artery in the absence of additional heart perforation. Although contact sensor catheters may reduce complications, steam pops can still occur and result in dramatic complications. © 2016 Wiley Periodicals, Inc.

Preoperative Statin Therapy in Cardiac Surgery Is More Effective in Patients Who Display Preoperative Activation of the Inflammatory System

PubMed Central

Martínez-Comendador, José; Alvarez, José Rubio; Sierra, Juan; Teijeira, Elvis; Adrio, Belén

2013-01-01

We sought to determine whether preoperative statin treatment is more effective in reducing, after cardiac surgery with cardiopulmonary bypass, systemic inflammatory response and myocardial damage markers in patients who have elevated preoperative interleukin-6 levels than in patients who have normal preoperative interleukin-6 levels. The study involved a prospective cohort of 164 patients who underwent coronary and valvular surgery with cardiopulmonary bypass. There were 2 study groups: group A (n = 60), patients with elevated preoperative interleukin-6 levels; and group B (n = 104), patients with normal preoperative interleukin-6 levels. Each group was subdivided according to whether patients were (group 1) or were not (group 2) treated preoperatively with statins. Accordingly, the subdivided study groups were A1 (n = 40), A2 (n = 20), B1 (n = 56), and B2 (n = 48). The plasma levels of proinflammatory interleukin-6 were measured 1, 6, 24, and >72 hours after surgery. The baseline, operative, and postoperative morbidity and mortality characteristics were similar in all groups. Group A1 had significantly lower levels of interleukin-6 and troponin I than did group A2 at all postoperative time points. Group B1 had significantly lower levels of interleukin-6 than did group B2 postoperatively. There were no significant differences in troponin I levels between groups B1 and B2. We conclude that, in patients with preoperative activation of the inflammatory system, preoperative treatment with statins is associated with lower postoperative interleukin-6 and troponin I levels after cardiac surgery with cardiopulmonary bypass. PMID:23466655

Preoperative statin therapy in cardiac surgery is more effective in patients who display preoperative activation of the inflammatory system.

PubMed

Martínez-Comendador, José; Alvarez, José Rubio; Sierra, Juan; Teijeira, Elvis; Adrio, Belén

2013-01-01

We sought to determine whether preoperative statin treatment is more effective in reducing, after cardiac surgery with cardiopulmonary bypass, systemic inflammatory response and myocardial damage markers in patients who have elevated preoperative interleukin-6 levels than in patients who have normal preoperative interleukin-6 levels. The study involved a prospective cohort of 164 patients who underwent coronary and valvular surgery with cardiopulmonary bypass. There were 2 study groups: group A (n = 60), patients with elevated preoperative interleukin-6 levels; and group B (n = 104), patients with normal preoperative interleukin-6 levels. Each group was subdivided according to whether patients were (group 1) or were not (group 2) treated preoperatively with statins. Accordingly, the subdivided study groups were A1 (n = 40), A2 (n = 20), B1 (n = 56), and B2 (n = 48). The plasma levels of proinflammatory interleukin-6 were measured 1, 6, 24, and >72 hours after surgery. The baseline, operative, and postoperative morbidity and mortality characteristics were similar in all groups. Group A1 had significantly lower levels of interleukin-6 and troponin I than did group A2 at all postoperative time points. Group B1 had significantly lower levels of interleukin-6 than did group B2 postoperatively. There were no significant differences in troponin I levels between groups B1 and B2. We conclude that, in patients with preoperative activation of the inflammatory system, preoperative treatment with statins is associated with lower postoperative interleukin-6 and troponin I levels after cardiac surgery with cardiopulmonary bypass.

Interleukin-1β gene variants are associated with QTc interval prolongation following cardiac surgery: a prospective observational study.

PubMed

Kertai, Miklos D; Ji, Yunqi; Li, Yi-Ju; Mathew, Joseph P; Daubert, James P; Podgoreanu, Mihai V

2016-04-01

We characterized cardiac surgery-induced dynamic changes of the corrected QT (QTc) interval and tested the hypothesis that genetic factors are associated with perioperative QTc prolongation independent of clinical and procedural factors. All study subjects were ascertained from a prospective study of patients who underwent elective cardiac surgery during August 1999 to April 2002. We defined a prolonged QTc interval as > 440 msec, measured from 24-hr pre- and postoperative 12-lead electrocardiograms. The association of 37 single nucleotide polymorphisms (SNPs) in 21 candidate genes -involved in modulating arrhythmia susceptibility pathways with postoperative QTc changes- was investigated in a two-stage design with a stage I cohort (n = 497) nested within a stage II cohort (n = 957). Empirical P values (Pemp) were obtained by permutation tests with 10,000 repeats. After adjusting for clinical and procedural risk factors, we selected four SNPs (P value range, 0.03-0.1) in stage I, which we then tested in the stage II cohort. Two functional SNPs in the pro-inflammatory cytokine interleukin-1β (IL1β), rs1143633 (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.53 to 0.95; Pemp = 0.02) and rs16944 (OR, 1.31; 95% CI, 1.01 to 1.70; Pemp = 0.04), remained independent predictors of postoperative QTc prolongation. The ability of a clinico-genetic model incorporating the two IL1B polymorphisms to classify patients at risk for developing prolonged postoperative QTc was superior to a clinical model alone, with a net reclassification improvement of 0.308 (P = 0.0003) and an integrated discrimination improvement of 0.02 (P = 0.000024). The results suggest a contribution of IL1β in modulating susceptibility to postoperative QTc prolongation after cardiac surgery.

Multifilament Cable Wire versus Conventional Wire for Sternal Closure in Patients Undergoing Major Cardiac Surgery.

PubMed

Oh, You Na; Ha, Keong Jun; Kim, Joon Bum; Jung, Sung-Ho; Choo, Suk Jung; Chung, Cheol Hyun; Lee, Jae Won

2015-08-01

Stainless steel wiring remains the most popular technique for primary sternal closure. Recently, a multifilament cable wiring system (Pioneer Surgical Technology Inc., Marquette, MI, USA) was introduced for sternal closure and has gained wide acceptance due to its superior resistance to tension. We aimed to compare conventional steel wiring to multifilament cable fixation for sternal closure in patients undergoing major cardiac surgery. Data were collected retrospectively on 1,354 patients who underwent sternal closure after major cardiac surgery, using either the multifilament cable wiring system or conventional steel wires between January 2009 and October 2010. The surgical outcomes of these two groups of patients were compared using propensity score matching based on 18 baseline patient characteristics. Propensity score matching yielded 392 pairs of patients in the two groups whose baseline profiles showed no significant differences. No significant differences between the two groups were observed in the rates of early mortality (2.0% vs. 1.3%, p=0.578), major wound complications requiring reconstruction (1.3% vs. 1.3%, p>0.99), minor wound complications (3.6% vs. 2.0%, p=0.279), or mediastinitis (0.8% vs. 1.0%, p=1.00). Patients in the multifilament cable group had fewer sternal bleeding events than those in the conventional wire group, but this tendency was not statistically significant (4.3% vs. 7.4%, p=0.068). The surgical outcomes of sternal closure using multifilament cable wires were comparable to those observed when conventional steel wires were used. Therefore, the multifilament cable wiring system may be considered a viable option for sternal closure in patients undergoing major cardiac surgery.

Left versus right atrial difference in dominant frequency, K(+) channel transcripts, and fibrosis in patients developing atrial fibrillation after cardiac surgery.

PubMed

Swartz, Michael F; Fink, Gregory W; Lutz, Charles J; Taffet, Steven M; Berenfeld, Omer; Vikstrom, Karen L; Kasprowicz, Kimberly; Bhatta, Luna; Puskas, Ferenc; Kalifa, Jérôme; Jalife, José

2009-10-01

The development of atrial fibrillation (AF) after cardiac surgery is associated with adverse outcomes; however, the mechanism(s) that trigger and maintain AF in these patients are unknown. The purpose of this study was to test our hypothesis that postoperative AF is maintained by high-frequency sources in the left atrium (LA) resulting from ion channel and structural features that differ from the right atrium (RA). Forty-four patients with no previous history of AF who underwent cardiac surgery consented to LA and RA biopsies. Histologic sections evaluated fatty infiltration, fibrosis, and iron deposition; quantitative reverse transcription-polymerase chain reaction (RT-PCR) assessed ion channel expression. In a subset of 27 patients, LA and RA unipolar recording leads were also placed. In patients who developed AF, the dominant frequency (DF) for each lead was calculated using fast Fourier transform. DFs during AF were LA 6.26 +/- 0.8 Hz, RA 4.56 +/- 0.7 Hz (P <.01). RT-PCR revealed LA-to-RA differences in mRNA abundance for Kir2.3 (1.8:1) and Kir3.4 (2.3:1). While LA fibrosis was greater in patients developing AF compared with those remaining in normal sinus rhythm (10.8% +/- 11% vs. 3.8% +/- 3.5%; P = .03), the amount of LA fibrosis inversely correlated with the LA DF. This is the first demonstration of LA-to-RA frequency differences during postoperative AF, which are associated with LA-to-RA differences in mRNA levels for potassium channel proteins and LA fibrosis. These results strongly suggest that sources of AF after cardiac surgery are located in the LA and are stabilized by LA fibrosis.

Anesthesia for a Rare Case of Uncorrected Pentalogy of Fallot Undergoing Craniotomy and Drainage of Brain Abscess.

PubMed

Marulasiddappa, Vinay; Raghavavendra, B S

2015-07-01

Children with uncorrected cyanotic congenital heart diseases can present for non cardiac surgeries. They pose several challenges to the Anaesthesiologist, especially when they are posted for emergency surgery, due to the complex haemodynamic changes secondary to the heart disease. Pentalogy of Fallot (POF) is a rare form of congenital heart disease characterized by the association of Tetralogy of Fallot (TOF) with an atrial septal defect (ASD). TOF is the leading cause of intracardiac right to left shunt and is the commonest type of cyanotic congenital heart disease to cause a brain abscess. Children with POF presenting with brain abscess pose several challenges to the anaesthesiologist due to the altered haemodynamics and warrant a meticulous anaesthetic plan. There are very few case reports of Anaesthesia management of a child with Pentalogy of Fallot (POF) presenting for non cardiac surgery. We report the anaesthetic management of a rare case of a 5-year-old child with uncorrected POF, who presented to our Superspeciality hospital with a brain abscess and underwent an emergency craniotomy with drainage of the brain abscess successfully.

Modified devascularization surgery for isolated gastric varices assessed by endoscopic ultrasonography.

PubMed

Hsieh, J-S; Wang, W-M; Perng, D-S; Huang, C-J; Wang, J-Y; Huang, T-J

2004-04-01

This study aimed to assess the role of endoscopic ultrasonography (EUS) in the surgical management of isolated gastric varices (IGV), and to report the authors' experience in the treatment of IGV with modified devascularization surgery. In this study, 26 cirrhotic patients with IGV were treated with devascularization surgery for variceal hemorrhage. Preoperatively, percutaneous transhepatic portography (PTP) and EUS were used to determine the mode of therapy for IGV. Fundectomy was performed for 14 patients with fundic IGV, whereas 12 patients with cardiac IGV underwent proximal gastrectomy. A significantly higher proportion of patients with cardiac varices showed grade 3 IGV on preoperative EUS than those who had fundic varices (p < 0.05). No major complications were observed during or after the operation, and only one patient died of prolonged shock and massive transfusion. Postoperatively, gastric varices had been eradicated completely in 25 of 26 patients, as determined by EUS study. During a mean follow-up period of 50 months, two patients had recurrent varices without bleeding, as demonstrated by EUS. The overall 5-year survival rate for the fundic IGV group was 67.9%, whereas that for the cardiac IGV group was 64.3% (p > 0.05). This study showed that devascularization surgery is highly effective for the prevention of recurrent bleeding from IGV and provides an alternative treatment method. Preoperatively, EUS is very helpful in detailed devascularization of patients with specific IGV, and may be used also for postoperative follow-up evaluation.

Cardiac surgery in patients with end-stage renal disease on dialysis.

PubMed

Bäck, Caroline; Hornum, Mads; Møller, Christian Joost Holdflod; Olsen, Peter Skov

2017-12-01

Over the past decade, the number of patients on dialysis and with cardiovascular diseases has steadily increased. This retrospective analysis compares the postoperative mortality after cardiac surgery between patients on hemodialysis and peritoneal dialysis. Between 1998 and 2015, 136 patients with end-stage renal disease initiating dialysis more than one month before surgery underwent cardiac surgery. Demographics, preoperative hemodynamic and biochemical data were collected from the patient records. Vital status and date of death was retrieved from a national register. Hemodialysis was undertaken in 73% and peritoneal dialysis in 22% of patients aged 59.7 ± 12.9 years, mean EuroSCORE 8.6% ± 3.5. Isolated coronary artery bypass graft was performed in 46%, isolated valve procedure in 29% and combined procedures in 24% with no significant statistical difference between groups. The 30-day mortality was 14% for hemodialysis patients and 3% for peritoneal dialysis patients (p = .056). One-year and 5-year mortality were, 30% and 59% in the hemodialysis group, 30% and 57% in the peritoneal dialysis group (p = .975, p = .852). Independent predictors of total mortality were age (p = .001), diabetes (p = .017) and active endocarditis (p = .012). No statistically significant difference in mortality was found between patients in hemo- or peritoneal dialysis. However, we observed that patients with end-stage renal disease on dialysis have two times higher mortality rate than estimated by EuroSCORE.

[Open cholecystectomy in cirrhotic patients. Experience at the Salvador Zubirán National Institute of Nutrition].

PubMed

Carmona, R; Suazo, J; Mercado, M A; Orozco, H

1996-01-01

To inform the morbidity and mortality observed in cirrhotic patients who underwent open cholecystectomy. We reviewed the clinical records of 31 cirrhotics that underwent open cholecystectomy and they were compared with a control group of the same age and sex. Despite administration of plasma or vitamin K or both, bleeding and transfusions during surgery were observed more frequently in cirrhotics. The morbidity was 13% in the controls and 42% in the cases. Renal failure, cardiac failure and upper gastrointestinal bleeding were present only in the cirrhotics. Mortality was 16% in this group (one Child A patient and four Child B-C patients). The variable related with major morbimortality was Child B or C classification. Open cholecystectomy was associated with high morbimortality. The valoration and preparation before surgery must be careful, and the indication from this procedure needs to be made with caution.

Reconstructive valve surgery within 10 days of stroke in endocarditis.

PubMed

Raman, Jai; Ballal, Apoorva; Hota, Bala; Mirza, Sara; Lai, David; Bleck, Thomas; Lateef, Omar

2016-07-01

The optimal timing of surgical treatment for infective endocarditis complicated by cerebrovascular events is controversial, largely due to the perceived risk of perioperative intracranial bleeding. Current guidelines suggest waiting 2 weeks between the diagnosis of stroke and surgery. The aim of this study was to investigate the clinical and neurological outcomes of early surgery following a stroke. This was a single-center retrospective analysis of 12 consecutive patients requiring surgery for infective endocarditis between 2011 and 2014 at Rush University Medical Center, with either ischemic (n = 6) and/or hemorrhagic (n = 6) cerebrovascular complications. All underwent computed tomographic angiography prior to early valve reconstructive surgery to identify potentially actionable neurological findings. Early valve surgery was performed for ongoing sepsis or persistent emboli. Neurologic risk and outcome were assessed pre- and postoperatively using the National Institutes of Health Stroke Scale and the Glasgow Outcome Scale, respectively. All 12 patients underwent surgical treatment within 10 days of the diagnosis of stroke. Mortality in the immediate postoperative period was 8%. Eleven of the 12 patients exhibited good neurological recovery in the immediate postoperative period, with a Glasgow Outcome Scale score ≥ 3. There was no correlation between duration of cardiopulmonary bypass and neurological outcomes. Early cardiac surgery in patients with infective endocarditis and stroke maybe lifesaving with a low neurological risk. Comprehensive neurovascular imaging may help in identifying patient-related risk factors. © The Author(s) 2016.

Secular trends in acute dialysis after elective major surgery — 1995 to 2009

PubMed Central

Siddiqui, Nausheen F.; Coca, Steven G.; Devereaux, Philip J.; Jain, Arsh K.; Li, Lihua; Luo, Jin; Parikh, Chirag R.; Paterson, Michael; Philbrook, Heather Thiessen; Wald, Ron; Walsh, Michael; Whitlock, Richard; Garg, Amit X.

2012-01-01

Background: Acute kidney injury is a serious complication of elective major surgery. Acute dialysis is used to support life in the most severe cases. We examined whether rates and outcomes of acute dialysis after elective major surgery have changed over time. Methods: We used data from Ontario’s universal health care databases to study all consecutive patients who had elective major surgery at 118 hospitals between 1995 and 2009. Our primary outcomes were acute dialysis within 14 days of surgery, death within 90 days of surgery and chronic dialysis for patients who did not recover kidney function. Results: A total of 552 672 patients underwent elective major surgery during the study period, 2231 of whom received acute dialysis. The incidence of acute dialysis increased steadily from 0.2% in 1995 (95% confidence interval [CI] 0.15–0.2) to 0.6% in 2009 (95% CI 0.6–0.7). This increase was primarily in cardiac and vascular surgeries. Among patients who received acute dialysis, 937 died within 90 days of surgery (42.0%, 95% CI 40.0–44.1), with no change in 90-day survival over time. Among the 1294 patients who received acute dialysis and survived beyond 90 days, 352 required chronic dialysis (27.2%, 95% CI 24.8–29.7), with no change over time. Interpretation: The use of acute dialysis after cardiac and vascular surgery has increased substantially since 1995. Studies focusing on interventions to better prevent and treat perioperative acute kidney injury are needed. PMID:22733671

Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept.

PubMed

Ender, Joerg; Borger, Michael Andrew; Scholz, Markus; Funkat, Anne-Kathrin; Anwar, Nadeem; Sommer, Marcus; Mohr, Friedrich Wilhelm; Fassl, Jens

2008-07-01

The authors compared the safety and efficacy of a newly developed fast-track concept at their center, including implementation of a direct admission postanesthetic care unit, to standard perioperative management. All fast-track patients treated within the first 6 months of implementation of our direct admission postanesthetic care unit were matched via propensity scores and compared with a historical control group of patients who underwent cardiac surgery prior to fast-track implementation. A total of 421 fast-track patients were matched successfully to 421 control patients. The two groups of patients had a similar age (64 +/- 13 vs. 64 +/- 12 yr for fast-track vs. control, P = 0.45) and European System for Cardiac Operative Risk Evaluation-predicted risk of mortality (4.8 +/- 6.1% vs. 4.6 +/- 5.1%, P = 0.97). Fast-track patients had significantly shorter times to extubation (75 min [45-110] vs. 900 min [600-1140]), as well as shorter lengths of stay in the postanesthetic or intensive care unit (4 h [3.0-5] vs. 20 h [16-25]), intermediate care unit (21 h [17-39] vs. 26 h [19-49]), and hospital (10 days [8-12] vs. 11 days [9-14]) (expressed as median and interquartile range, all P < 0.01). Fast-track patients also had a lower risk of postoperative low cardiac output syndrome (0.5% vs. 2.9%, P < 0.05) and mortality (0.5% vs. 3.3%, P < 0.01). The Leipzig fast-track protocol is a safe and effective method to manage cardiac surgery patients after a variety of operations.

Right ventricular systolic dysfunction and vena cava dilatation precede alteration of renal function in adult patients undergoing cardiac surgery: An observational study.

PubMed

Guinot, Pierre Grégoire; Abou-Arab, Osama; Longrois, Dan; Dupont, Herve

2015-08-01

Several authors have suggested that right ventricular dysfunction (RVd) may contribute to renal dysfunction in nonsurgical patients. We tested the hypothesis that RVd diagnosed immediately after cardiac surgery may be associated with subsequent development of renal dysfunction and tried to identify the possible mechanisms. A single-centre, prospective observational study. Amiens University Hospital, France. All adult patients undergoing cardiac surgery were considered eligible for participation. Patients who had undergone pulmonary or tricuspid valve surgery, repeat surgery or who underwent immediate postoperative renal replacement therapy were excluded. Data from 74 patients were analysed. Left ventricular and right ventricular function were assessed before surgery and on admission to ICU by transthoracic echocardiography (TTE): left ventricular and right ventricular ejection fractions (LVEF/RVEF), tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (Sr(t)) and right ventricular dilatation. RVd was defined as values in the lowest quartile of at least two echocardiographic variables. Renal dysfunction was defined as an increase in serum creatinine concentration (sCr) on postoperative day 1. All right ventricular TTE variables decreased (P < 0.05) after surgery: RVEF from 50% (49 to 60) to 40% (35 to 50); TAPSE from 22.3 mm (19.4 to 25.3) to 12.2 mm (8.8 to 14.8); and Sr(t) from 15.0 cm s(-1) (12.0 to 18.0) to 8.1 cm s(-1) (6.3 to 9.2). Fourteen (19%) patients had right ventricular dilatation and RVd was present in 23 (31%) patients. Forty patients had a positive variation in sCr. In multivariate analysis, patients with RVd had an odds ratio (OR) of 12.7 [95% confidence interval (95% CI) 2.6 to 63.4, P = 0.02] for development of renal dysfunction. Renal dysfunction was associated with increased central venous pressure but was not associated with cardiac index (CI). These results suggest that early postoperative RVd is associated with a subsequent increase of sCr and that the mechanism involved is congestion (vena cava dilatation/elevated CVP) rather than decreased CI.

The challenges of cardiothoracic surgery practice in Nigeria: a 12 years institutional experience.

PubMed

Falase, Bode; Sanusi, Michael; Animasahun, Adeola; Mgbajah, Ogadinma; Majekodunmi, Adetinuwe; Nzewi, Onyekwelu; Nwiloh, Jonathan; Oke, David

2016-10-01

Although the specialty of cardiothoracic surgery has been practiced in Nigeria for many years, open heart surgery (OHS) has only in the last decade become relatively more frequent, mainly through visiting foreign cardiac surgical teams. At this early phase of development it is faced with multiple challenges, especially financing and local skilled manpower for which solutions have to be identified in order to ensure sustainability and future growth. This study is aimed at highlighting these obstacles to growth of cardiothoracic surgery based on our own institutional experience at Lagos State University Teaching Hospital (LASUTH) and the current status of OHS activity in other cardiothoracic centers in Nigeria. Prospectively acquired data from our center from March 2004 to December 2015 was reviewed. A telephone survey was also conducted with all other institutions in Nigeria performing cardiac surgery. During the study period 1,520 patients underwent various procedures with a mean age of 37±22.4 years and 813 (53.5%) were males. There were 450 major procedures (29.6%), 889 minor procedures (58.5%) and 181 endoscopic procedures (11.9%). The top ten clinical diagnoses were empyema thoracis (17.5%), malignant pleural effusion (14.7%), chest trauma (12%), hemodialysis access (6.1%), bradyarrhythmia (5.3%), aerodigestive foreign bodies (4.1%), vascular injury (3.9%), pericardial disease (3.8%), lung cancer (3.6%) and congenital heart disease (3.4%). The range of procedures was chest tube insertion (41.6%), endoscopy (11.9%), lung procedures (7%), arterio-venous fistula (6.1%), pacemaker implantation (5.3%), vascular repair (4.4%), OHS (3.4%), esophageal procedures (2.6%), chest wall surgery (2%), video assisted thoracic surgery (2%), closed heart surgery (1.6%), diaphragmatic procedures (1.6%) and thymectomy (1%). Survey of 15 centers in Nigeria with cardiac surgery activity showed a total of 496 OHS cases between 1974 and 2016, with 330 cases (66.5%) done between 2012 and 2016. Infections, malignancy and trauma currently account for the bulk of cardiothoracic surgery practice in Nigeria, with surgical activity showing a predominance of minor procedures and comparatively minimal OHS activities. Identified challenges to increasing cardiothoracic surgical activity were limitations in manpower development, infrastructure, laboratory support, local availability of consumables, cost of surgery, funding mechanisms for surgery, multiple models for development of cardiac surgery, decentralization of efforts and lack of outcome data. Data collection and reporting of results must be started to enable development of more evidence-based practice.

Normalization of cardiac substrate utilization and left ventricular hypertrophy precede functional recovery in heart failure regression.

PubMed

Byrne, Nikole J; Levasseur, Jody; Sung, Miranda M; Masson, Grant; Boisvenue, Jamie; Young, Martin E; Dyck, Jason R B

2016-05-15

Impaired cardiac substrate metabolism plays an important role in heart failure (HF) pathogenesis. Since many of these metabolic changes occur at the transcriptional level of metabolic enzymes, it is possible that this loss of metabolic flexibility is permanent and thus contributes to worsening cardiac function and/or prevents the full regression of HF upon treatment. However, despite the importance of cardiac energetics in HF, it remains unclear whether these metabolic changes can be normalized. In the current study, we investigated whether a reversal of an elevated aortic afterload in mice with severe HF would result in the recovery of cardiac function, substrate metabolism, and transcriptional reprogramming as well as determined the temporal relationship of these changes. Male C57Bl/6 mice were subjected to either Sham or transverse aortic constriction (TAC) surgery to induce HF. After HF development, mice with severe HF (% ejection fraction < 30) underwent a second surgery to remove the aortic constriction (debanding, DB). Three weeks following DB, there was a near complete recovery of systolic and diastolic function, and gene expression of several markers for hypertrophy/HF were returned to values observed in healthy controls. Interestingly, pressure-overload-induced left ventricular hypertrophy (LVH) and cardiac substrate metabolism were restored at 1-week post-DB, which preceded functional recovery. The regression of severe HF is associated with early and dramatic improvements in cardiac energy metabolism and LVH normalization that precede restored cardiac function, suggesting that metabolic and structural improvements may be critical determinants for functional recovery. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

Melatonin protects against the pathological cardiac hypertrophy induced by transverse aortic constriction through activating PGC-1β: In vivo and in vitro studies.

PubMed

Zhai, Mengen; Liu, Zhenhua; Zhang, Bin; Jing, Lin; Li, Buying; Li, Kaifeng; Chen, Xiuju; Zhang, Meng; Yu, Bo; Ren, Kai; Yang, Yang; Yi, Wei; Yang, Jian; Liu, Jincheng; Yi, Dinghua; Liang, Hongliang; Jin, Zhenxiao; Reiter, Russel J; Duan, Weixun; Yu, Shiqiang

2017-10-01

Melatonin, a circadian molecule secreted by the pineal gland, confers a protective role against cardiac hypertrophy induced by hyperthyroidism, chronic hypoxia, and isoproterenol. However, its role against pressure overload-induced cardiac hypertrophy and the underlying mechanisms remains elusive. In this study, we investigated the pharmacological effects of melatonin on pathological cardiac hypertrophy induced by transverse aortic constriction (TAC). Male C57BL/6 mice underwent TAC or sham surgery at day 0 and were then treated with melatonin (20 mg/kg/day, via drinking water) for 4 or 8 weeks. The 8-week survival rate following TAC surgery was significantly increased by melatonin. Melatonin treatment for 8 weeks markedly ameliorated cardiac hypertrophy. Compared with the TAC group, melatonin treatment for both 4 and 8 weeks reduced pulmonary congestion, upregulated the expression level of α-myosin heavy chain, downregulated the expression level of β-myosin heavy chain and atrial natriuretic peptide, and attenuated the degree of cardiac fibrosis. In addition, melatonin treatment slowed the deterioration of cardiac contractile function caused by pressure overload. These effects of melatonin were accompanied by a significant upregulation in the expression of peroxisome proliferator-activated receptor-gamma co-activator-1 beta (PGC-1β) and the inhibition of oxidative stress. In vitro studies showed that melatonin also protects against angiotensin II-induced cardiomyocyte hypertrophy and oxidative stress, which were largely abolished by knocking down the expression of PGC-1β using small interfering RNA. In summary, our results demonstrate that melatonin protects against pathological cardiac hypertrophy induced by pressure overload through activating PGC-1β. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

TEG-Directed Transfusion in Complex Cardiac Surgery: Impact on Blood Product Usage.

PubMed

Fleming, Kevin; Redfern, Roberta E; March, Rebekah L; Bobulski, Nathan; Kuehne, Michael; Chen, John T; Moront, Michael

2017-12-01

Complex cardiac procedures often require blood transfusion because of surgical bleeding or coagulopathy. Thrombelastography (TEG) was introduced in our institution to direct transfusion management in cardiothoracic surgery. The goal of this study was to quantify the effect of TEG on transfusion rates peri- and postoperatively. All patients who underwent complex cardiac surgery, defined as open multiple valve repair/replacement, coronary artery bypass grafting with open valve repair/replacement, or aortic root/arch repair before and after implementation of TEG were identified and retrospectively analyzed. Minimally invasive cases were excluded. Patient characteristics and blood use were compared with t test and chi-square test. A generalized linear model including patient characteristics, preoperative and postoperative lab values, and autotransfusion volume was used to determine the impact of TEG on perioperative, postoperative, and total blood use. In total, 681 patients were identified, 370 in the pre-TEG period and 311 patients post-TEG. Patient demographics were not significantly different between periods. Mean units of red blood cells, plasma, and cryoprecipitate were significantly reduced after TEG was implemented (all, p < .0001); use of platelets was reduced but did not reach significance. Mean units of all blood products in the perioperative period and over the entire stay were reduced by approximately 40% (both, p < .0001). Total proportion of patients exposed to transfusion was significantly lower after introduction of TEG ( p < .01). Controlling for related factors on multivariate analysis, such as preoperative laboratory values and autotransfusion volume, use of TEG was associated with significant reduction in perioperative and overall blood product transfusion. TEG-directed management of blood product administration during complex cardiac surgeries significantly reduced the units of blood products received perioperatively but not blood usage more than 24 hours after surgery. Overall, fewer patients were exposed to allogenic blood. The use of TEG to guide blood product administration significantly impacted transfusion therapy and associated costs.

Predictive role of P-wave axis abnormalities in secondary cardiovascular prevention.

PubMed

Lazzeroni, Davide; Bini, Matteo; Camaiora, Umberto; Castiglioni, Paolo; Moderato, Luca; Ugolotti, Pietro Tito; Brambilla, Lorenzo; Brambilla, Valerio; Coruzzi, Paolo

2017-12-01

Background Abnormal P-wave axis has been correlated with an increased risk of all-cause and cardiovascular mortality in a general population. We aimed to evaluate the prognostic role of abnormal P-wave axis in patients undergoing myocardial revascularisation or cardiac valve surgery. Methods We considered data of 810 patients with available P-wave axis measure from a prospective monocentric registry of patients undergoing cardiovascular rehabilitation. A total of 436 patients (54%) underwent myocardial revascularisation, 253 (31%) valve surgery, 71 (9%) combined valve and coronary artery bypass graft surgery and 50 (6%) cardiac surgery for other cardiovascular disease. Mean follow-up was 47 ± 27 months. Results Over the whole group, P-wave axis was 43.8° ± 27.5° and an abnormal P-wave axis was found in 94 patients (12%). The risk of overall (hazard ratio (HR) 2.5, 95% confidence interval (CI) 1.6-4.0, P < 0.001) and cardiovascular mortality (HR 2.9, 95% CI 1.5-5.8, P = 0.002) was significantly higher in patients with abnormal P-wave axis even after adjustment for age, other electrocardiographic variables (PR, QRS, QTc intervals), left ventricular ejection fraction and left atrial volume index. After dividing the population according to the type of disease, patients with abnormal P-wave axis and ischaemic heart disease had 3.9-fold higher risk of cardiovascular mortality (HR 3.9, 95% CI 1.3-12.1, P = 0.017), while a 2.2-fold higher risk of cardiovascular mortality (HR 3.6, 95% CI 1.3-10.1, P = 0.015) was found in those with cardiac valve disease. Conclusion An abnormal P-wave axis represents an independent predictor of both overall and cardiovascular mortality in patients undergoing myocardial revascularisation or cardiac valve surgery.

Development of Models for Regional Cardiac Surgery Centers

PubMed Central

Park, Choon Seon; Park, Nam Hee; Sim, Sung Bo; Yun, Sang Cheol; Ahn, Hye Mi; Kim, Myunghwa; Choi, Ji Suk; Kim, Myo Jeong; Kim, Hyunsu; Chee, Hyun Keun; Oh, Sanggi; Kang, Shinkwang; Lee, Sok-Goo; Shin, Jun Ho; Kim, Keonyeop; Lee, Kun Sei

2016-01-01

Background This study aimed to develop the models for regional cardiac surgery centers, which take regional characteristics into consideration, as a policy measure that could alleviate the concentration of cardiac surgery in the metropolitan area and enhance the accessibility for patients who reside in the regions. Methods To develop the models and set standards for the necessary personnel and facilities for the initial management plan, we held workshops, debates, and conference meetings with various experts. Results After partitioning the plan into two parts (the operational autonomy and the functional comprehensiveness), three models were developed: the ‘independent regional cardiac surgery center’ model, the ‘satellite cardiac surgery center within hospitals’ model, and the ‘extended cardiac surgery department within hospitals’ model. Proposals on personnel and facility management for each of the models were also presented. A regional cardiac surgery center model that could be applied to each treatment area was proposed, which was developed based on the anticipated demand for cardiac surgery. The independent model or the satellite model was proposed for Chungcheong, Jeolla, North Gyeongsang, and South Gyeongsang area, where more than 500 cardiac surgeries are performed annually. The extended model was proposed as most effective for the Gangwon and Jeju area, where more than 200 cardiac surgeries are performed annually. Conclusion The operation of regional cardiac surgery centers with high caliber professionals and quality resources such as optimal equipment and facility size, should enhance regional healthcare accessibility and the quality of cardiac surgery in South Korea. PMID:28035295

Usefulness of Deep Hypothermic Circulatory Arrest and Regional Cerebral Perfusion in Children

PubMed Central

Guo, Zheng; Hu, Ren-Jie; Zhu, De-Ming; Zhu, Zhong-Qun; Zhang, Hai-Bo

2013-01-01

To compare the safety and usefulness of deep hypothermic circulatory arrest (DHCA) and regional cerebral perfusion (RCP) during pediatric open heart surgery. Between January 1, 2004 and September 30, 2012, 1250 children with congenital cardiac defect underwent corrective operation with the DHCA or RCP technique in the Shanghai Children's Medical Center. Of them, 947 cases underwent the operation with the aid of DHCA (DHCA group), and 303 cases with RCP (RCP group). The mean DHCA time was 30.64±15.81 (7–63) minutes and mean RCP time was 36.18±12.86 (10–82) minutes. The mortality rate was 7.18% (68/947) and 6.60% (20/30) in two groups, respectively. The postoperative incidences of temporary and permanent neurological dysfunction were 6.23% (59/947) in the DHCA group and 2.64% (8/303) in the RCP group (p<0.01). The incidence of other complications such as low cardiac output, renal dysfunction, and lung issues are similar in both groups. RCP is a reliable technique for cerebral protection and it facilitates time-consuming corrected procedures for complex congenital cardiac defect repair procedures. PMID:24066266

Age is not a good predictor of irreversibility of pulmonary hypertension in congenital cardiac malformations with left-to-right shunt.

PubMed

Hosseinpour, Amir-Reza; Perez, Marie-Hélène; Longchamp, David; Cotting, Jacques; Sekarski, Nicole; Hurni, Michel; Prêtre, René; Di Bernardo, Stefano

2018-03-01

Congenital cardiac malformations with high pulmonary blood flow and pressure due to left-to-right shunts are usually repaired in early infancy for both the benefits of early relief of heart failure and the fear that the concomitant pulmonary hypertension may become irreversible unless these defects are corrected at an early age. Age, however, has been a poor predictor of irreversibility of pulmonary hypertension in our experience, which is presented here. A retrospective observational study. We defined "late" as age ≥2 years. We examined clinical, echocardiographic, and hemodynamic data from all patients aged ≥2 years with such malformations referred to us from 2004 untill 2015. Department of Pediatric Cardiology and Cardiac Surgery, University Hospital of Vaud, Lausanne, Switzerland. There were 39 patients, aged 2-35 years (median: 5 years), without chromosomal abnormalities. All had malformations amenable to biventricular repair, and all had high systolic right ventricular pressures by echocardiography prior to referral. All patients underwent catheterization for assessment of pulmonary hypertension. If this was reversible, surgical correction was offered. (1) Operability based on reversibility of pulmonary hypertension. (2) When surgery was offered, mortality and evidence of persisting postoperative pulmonary hypertension were examined. Eighteen patients had no pulmonary hypertension, 5 of variable ages were inoperable due to irreversible pulmonary hypertension, and 16 had reversible pulmonary hypertension. Therefore, 34 patients underwent corrective surgery, with no immediate or late mortality. Pulmonary arterial and right ventricular pressures decreased noticeably in all operated patients. This is sustained to date; they are all asymptomatic with no echocardiographic evidence of pulmonary hypertension at a median follow-up of 7 years (range 2-13 years). Pulmonary hypertension may still be reversible in many surprisingly old patients with left-to-right shunt lesions, who may therefore still be operable. © 2017 Wiley Periodicals, Inc.

Papillary Fibroelastoma of the Aortic Valve: Analysis of 21 Cases, Including a Presentation with Cardiac Arrest

PubMed Central

Andrei, Adin-Cristian; Li, Zhi; McCarthy, Patrick M.; Malaisrie, S. Chris

2015-01-01

Cardiac papillary fibroelastoma is a rare, benign tumor, arising predominantly from cardiac valves. This tumor can cause a variety of symptoms due to thromboembolism. We describe our single-center surgical experience with papillary fibroelastoma of the aortic valve. From April 2004 through June 2013, 6,530 patients underwent cardiac surgery. Of those, 6,098 patients were included in the final analysis. Twenty-one patients (0.34%) underwent surgical resection of 30 papillary fibroelastomas of the aortic valve. Most patients (67%) were incidentally diagnosed to have cardiac papillary fibroelastoma. The usual symptom was cerebral infarction (in 5 of 7 symptomatic patients). A rare presentation of papillary fibroelastoma in one patient was cardiac arrest caused by left main coronary artery ostial obstruction. Tumor size was not related to patient age (Pearson correlation coefficient, 0.34; P=0.13). Neither the number of tumors (1.43 ± 0.72 vs 1.43 ± 0.62) nor tumor size (8.14 ± 2.42 vs 8.07 ± 3.31 mm) was significantly different between symptomatic and asymptomatic patients. All lesions were resected by means of the simple shave technique. There were no operative or 30-day deaths. Follow-up echocardiograms showed no tumor recurrence (mean follow-up duration, 17 ± 14 mo). We identified no significant relationship among tumor size, number of tumors, symptoms, or patient age. Because simple shave excision of the tumor can be safely achieved without evidence of tumor recurrence, we conclude that surgical resection can be reasonable in asymptomatic patients. PMID:25873822

Reoperations after tricuspid valve repair: re-repair versus replacement

PubMed Central

Hwang, Ho Young; Kim, Kyung-Hwan; Kim, Ki-Bong

2016-01-01

Background Data demonstrating results of reoperation after initial tricuspid valve repair are scarce. We evaluated outcomes of tricuspid reoperations after tricuspid valve repair and compared the results of tricuspid re-repair with those of tricuspid valve replacement (TVR). Methods From 1994 to 2012, 53 patients (56±15 years, male:female =14:39) underwent tricuspid reoperations due to recurrent tricuspid regurgitation (TR) after initial repair. Twenty-two patients underwent tricuspid re-repair (TAP group) and 31 patients underwent TVR (TVR group). Results Early mortality occurred in 6 patients (11%). Early mortality and incidence of postoperative complications were similar between the 2 groups. There were 14 cases of late mortality including 9 cardiac deaths. Five- and 10-year free from cardiac death rates were 82% and 67%, respectively, without any intergroup difference. Recurrent TR (> moderate) developed in 6 TAP group patients and structural valve deterioration occurred in 1 TVR group patient (P=0.002). Isolated tricuspid valve surgery (P=0.044) and presence of atrial fibrillation during the follow-up (P=0.051) were associated with recurrent TR after re-repair. However, the overall tricuspid valve-related event rates were similar between the 2 groups with 5- and 10-year rates of 61% and 41%, respectively. Conclusions Tricuspid valve reoperation after initial repair resulted in high rates of operative mortality and complications. Long-term event-free rate was similar regardless of the type of surgery. However, great care might be needed when performing re-repair in patients with atrial fibrillation and those who had isolated tricuspid valve disease due to high recurrence of TR after re-repair. PMID:26904221

The first Latin-American risk stratification system for cardiac surgery: can be used as a graphic pocket-card score.

PubMed

Carosella, Victorio C; Navia, Jose L; Al-Ruzzeh, Sharif; Grancelli, Hugo; Rodriguez, Walter; Cardenas, Cesar; Bilbao, Jorge; Nojek, Carlos

2009-08-01

This study aims to develop the first Latin-American risk model that can be used as a simple, pocket-card graphic score at bedside. The risk model was developed on 2903 patients who underwent cardiac surgery at the Spanish Hospital of Buenos Aires, Argentina, between June 1994 and December 1999. Internal validation was performed on 708 patients between January 2000 and June 2001 at the same center. External validation was performed on 1087 patients between February 2000 and January 2007 at three other centers in Argentina. In the development dataset the area under receiver operating characteristics (ROC) curve was 0.73 and the Hosmer-Lemeshow (HL) test was P=0.88. In the internal validation ROC curve was 0.77. In the external validation ROC curve was 0.81, but imperfect calibration was detected because the observed in-hospital mortality (3.96%) was significantly lower than the development dataset (8.20%) (P<0.0001). Recalibration was done in 2007, showing excellent level of agreement between the observed and predicted mortality rates on all patients (P=0.92). This is the first risk model for cardiac surgery developed in a population of Latin-America with both internal and external validation. A simple graphic pocket-card score allows an easy bedside application with acceptable statistic precision.

Impact of mitral valve intervention with left ventricular assist device implantation on postoperative outcomes and morphologic change.

PubMed

Hata, Hiroki; Fujita, Tomoyuki; Ishibashi-Ueda, Hatsue; Kuroda, Kensuke; Seguchi, Osamu; Matsumoto, Yorihiko; Yanase, Masanobu; Sato, Takuma; Nakajima, Seiko; Fukushima, Norihide; Kobayashi, Junjiro

2018-06-01

Although mitral regurgitation (MR) is prevalent in patients with end-stage heart failure, the impact of mitral valve (MV) surgery on outcomes after left ventricular assist device (LVAD) implantation and morphologic changes of MV remains unclear. We retrospectively reviewed 74 patients who underwent LVAD implantation as a bridge to transplant. Of these, 11 (15%) underwent MV repair concomitant with or prior to LVAD implantation, while 27 patients with preoperative significant (moderate or greater) MR did not undergo concomitant MV surgery. The mean interval between LVAD implantation and the last echocardiographic examination was 913 days. Irrespective of MV surgery, significant LV reverse remodeling including decreased LV and left atrial dimension and improved MR severity was observed in all patients except for patients with prior MV surgery. Histopathological examination of explanted hearts removed at heart transplantation (n = 69) or autopsy (n = 5) revealed that the MV annulus was still dilated (mean perimeter 11.7 cm) in the patients with preoperative significant MR and no concomitant MV surgery. Concomitant MV surgery at the time of LVAD implantation for significant MR might not be always necessary for bridge to transplant or destination therapy cases. However, it might be required in patients having potential for cardiac recovery or patients with severe pulmonary hypertension and depressed right ventricle.

Results of open heart surgery in Jehovah's Witness patients. Single centre experience.

PubMed

Juraszek, Andrzej; Kołsut, Piotr; Szymański, Jarosław; Kuriata, Jarosław; Kuśmierski, Krzysztof; Sitkowska-Rysiak, Ewa; Jasińska, Małgorzata; Kuśmierczyk, Mariusz

2017-09-01

Evaluation the results in patients from the religious community of Jehovah's Witness (JW) undergoing open heart surgery at our institution. Between September 2011 and March 2015, 21 patients with a religious background of the JW church underwent open heart surgery at our institution performed by the same surgical team. Mean age was 68.43 ±8.93 years. There were 13 (61.9%) female patients. Recombinant human erythropoietin was administered to every patient with a hemoglobin value < 12.0 g/dl. Nine patients undergoing isolated coronary artery revascularization were operated on without cardiopulmonary bypass. Seven patients underwent combined surgery and 5 patients underwent aortic valve replacement via ministernotomy. The mean follow-up time was 16.45 ±11.09 months (range: 1.67-44.3 months). Mean baseline hematocrit serum level was 40.15 ±3.34% (range: 34.5-46.1%). Perioperatively the hematocrit serum levels decreased to the mean level of 29.89 ±4.31% (range: 21.4-36.3%). The mean hematocrit value at discharge was 30.85 ±3.59% (range: 23.5-38.4%). One death was observed in the perioperative period. Five (24%) patients suffered from sternum wound infection requiring vacuum-assisted therapy. During the follow-up period 1 patient died due to a non-cardiac related cause. After careful preoperative preparation the results of open heart surgery in JW were very good, including combined procedures. The decrease of hematocrit serum levels significantly characterizing the postoperative period was highly acceptable in this series. Nevertheless, the number of sternum wound infections was a limiting factor for prompt postoperative recovery.

Echocardiographic versus histologic findings in Marfan syndrome.

PubMed

Gu, Xiaoyan; He, Yihua; Li, Zhian; Han, Jiancheng; Chen, Jian; Nixon, J V Ian

2015-02-01

This retrospective study attempted to establish the prevalence of multiple-valve involvement in Marfan syndrome and to compare echocardiographic with histopathologic findings in Marfan patients undergoing valvular or aortic surgery. We reviewed echocardiograms of 73 Marfan patients who underwent cardiovascular surgery from January 2004 through October 2009. Tissue histology was available for comparison in 29 patients. Among the 73 patients, 66 underwent aortic valve replacement or the Bentall procedure. Histologic findings were available in 29 patients, all of whom had myxomatous degeneration. Of 63 patients with moderate or severe aortic regurgitation as determined by echocardiography, 4 had thickened aortic valves. The echocardiographic findings in 18 patients with mitral involvement included mitral prolapse in 15. Of 11 patients with moderate or severe mitral regurgitation as determined by echocardiography, 4 underwent mitral valve repair and 7 mitral valve replacement. Histologic findings among mitral valve replacement patients showed thickened valve tissue and myxomatous degeneration. Tricuspid involvement was seen echocardiographically in 8 patients, all of whom had tricuspid prolapse. Two patients had severe tricuspid regurgitation, and both underwent repair. Both mitral and tricuspid involvement were seen echocardiographically in 7 patients. Among the 73 patients undergoing cardiac surgery for Marfan syndrome, 66 had moderate or severe aortic regurgitation, although their valves manifested few histologic changes. Eighteen patients had mitral involvement (moderate or severe mitral regurgitation, prolapse, or both), and 8 had tricuspid involvement. Mitral valves were most frequently found to have histologic changes, but the tricuspid valve was invariably involved.

A 20-year study on treating childhood infective endocarditis with valve replacement in a single cardiac center in China.

PubMed

Xiao, Jian; Yin, Liang; Lin, Yiyun; Zhang, Yufeng; Wu, Lihui; Wang, Zhinong

2016-07-01

Children with infective endocarditis (IE) have to undergo valve replacement instead of valve repair in China due to severe valve damage. The present study is to review our experience on surgical treatment of children with IE in reference to the incidence, pathologic status, diagnosis, surgical strategies and outcomes. We reviewed 35 patients with a mean age of 13.7±2.2 years who were underwent valve replacement surgery for IE during the period from January 1993 to December 2013. Preoperative transthoracic echocardiographic (TTE) evaluation and transesophageal echocardiography during operation were performed in all patients. All the children underwent chart review and retrospective risk-hazard analysis. Among the patients surveyed congenital cardiac lesions were present in 15 (42.8%), rheumatic heart valve disease in 2 (5.7%) and previous heart surgery in 2 (5.7%). The median stay of intensive care unit was 6 days. Intraoperative findings showed that the endocarditis involved mostly the mitral and aortic valves (88.5%). Triple or quadruple valve involvement was found in one patient each. Ten-year freedom from IE-related death and re-intervention was 94.2% and 91.6%, respectively. Children undergoing surgery for IE frequently have advanced disease with embolic complications. Although valve replacement is not the primary option for pediatric IE, the rate of 5-year survival and freedom from re-operation was optimal prognostically. Pediatric physicians should pay attention to the common clinical features of IE so that the native valve is preserved well.

Obscured hemorrhagic pancreatitis after orthotopic heart transplantation complicated with acute right heart failure and hepatic dysfunction: a case report.

PubMed

Lin, Ting-Wei; Tsai, Meng-Ta; Roan, Jun-Neng; Liu, Yi-Sheng; Tsai, Hong-Ming; Luo, Chwan-Yau

2016-12-01

Pancreatitis is a serious complication after cardiac surgery and can lead to significant morbidities and mortality. The incidence of pancreatitis is even higher in patients undergoing heart transplantation than in those undergoing other cardiac surgeries. Nevertheless, the clinical presentations of pancreatitis are frequently atypical in these patients. We report a heart recipient who was complicated with acute right heart failure initially after orthotopic heart transplantation and developed devastating unanticipated hemorrhagic pancreatitis 1 month after the transplantation. This crypto-symptomatic pancreatitis was not diagnosed until massive internal bleeding and hemorrhagic shock occurred, because the typical presentations of acute pancreatitis were masked by the intra-abdominal manifestations caused by right heart failure and congestive liver dysfunction. The patient underwent a successful transarterial embolization. The causes of pancreatitis after heart transplantation include low cardiac output, immunosuppressant use and cytomegalovirus infection. The typical symptoms of pancreatitis might be not apparent in patients after heart transplantation because of their immunosuppressive status. Furthermore, in patients complicated with right heart failure after transplantation, the manifestation of pancreatitis could be even more obscure. The prompt diagnosis is highly depended on the clinician's astuteness.

Strategies for blood conservation in pediatric cardiac surgery

PubMed Central

Singh, Sarvesh Pal

2016-01-01

Cardiac surgery accounts for the majority of blood transfusions in a hospital. Blood transfusion has been associated with complications and major adverse events after cardiac surgery. Compared to adults it is more difficult to avoid blood transfusion in children after cardiac surgery. This article takes into account the challenges and emphasizes on the various strategies that could be implemented, to conserve blood during pediatric cardiac surgery. PMID:27716703

Aortic valve bypass surgery in severe aortic valve stenosis: Insights from cardiac and brain magnetic resonance imaging.

PubMed

Mantini, Cesare; Caulo, Massimo; Marinelli, Daniele; Chiacchiaretta, Piero; Tartaro, Armando; Cotroneo, Antonio Raffaele; Di Giammarco, Gabriele

2018-04-13

To investigate and describe the distribution of aortic and cerebral blood flow (CBF) in patients with severe valvular aortic stenosis (AS) before and after aortic valve bypass (AVB) surgery. We enrolled 10 consecutive patients who underwent AVB surgery for severe AS. Cardiovascular magnetic resonance imaging (CMR) and brain magnetic resonance imaging were performed as baseline before surgery and twice after surgery. Quantitative flow measurements were obtained using 1.5-T magnetic resonance imaging (MRI) scanner phase-contrast images of the ascending aorta, descending thoracic aorta (3 cm proximally and distally from the conduit-to-aorta anastomosis), and ventricular outflow portion of the conduit. The evaluation of CBF was performed using 3.0-T MRI scanner arterial spin labeling (ASL) through sequences acquired at the gray matter, dorsal default-mode network, and sensorimotor levels. Conduit flow, expressed as the percentage of total antegrade flow through the conduit, was 63.5 ± 8% and 67.8 ± 7% on early and mid-term postoperative CMR, respectively (P < .05). Retrograde perfusion from the level of the conduit insertion in the descending thoracic aorta toward the aortic arch accounted for 6.9% of total cardiac output and 11% of total conduit flow. We did not observe any significant reduction in left ventricular stroke volume at postoperative evaluation compared with preoperative evaluation (P = .435). No differences were observed between preoperative and postoperative CBF at the gray matter, dorsal default-mode network, and sensorimotor levels (P = .394). After AVB surgery in patients with severe AS, cardiac output is split between the native left ventricular outflow tract and the apico-aortic bypass, with two-thirds of the total antegrade flow passing through the latter and one-third passing through the former. In our experience, CBF assessment confirms that the flow redistribution does not jeopardize cerebral blood supply. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

A Phase 1 Study of a Novel Bidirectional Perfusion Cannula in Patients Undergoing Femoral Cannulation for Cardiac Surgery.

PubMed

Marasco, Silvana F; Tutungi, Elli; Vallance, Shirley A; Udy, Andrew A; Negri, Justin C; Zimmet, Adam D; McGiffin, David C; Pellegrino, Vincent A; Moshinsky, Randall A

Leg ischemia is a serious complication of femoral artery cannulation. The primary aim of this study was to assess the safety and efficacy of a novel bidirectional femoral arterial cannula (Sorin Group USA, a wholly owned subsidiary of LivaNova PLC, Arvada, CO USA) that provides both antegrade and retrograde flow, in patients undergoing peripheral cannulation for cardiopulmonary bypass during cardiac surgery. Patients undergoing routine cardiac surgery requiring femoral artery cannulation for cardiopulmonary bypass were identified preoperatively. Informed written consent was obtained in all cases. Bidirectional cannula insertion used either a surgical cut-down and wire through needle approach or a percutaneous technique. Flow in the superficial femoral artery was assessed using Doppler ultrasound after commencement of cardiopulmonary bypass. Lower limb perfusion was assessed using reflectance near-infrared spectroscopy to measure regional oxygen saturations in the cannulated limb during cardiopulmonary bypass. Fifteen patients (median age = 61.3 years, range = 26-79 years, 10 males, 5 females) underwent femoral arterial cannulation using the novel bidirectional femoral cannula between August 2016 and May 2017. Fourteen cannulae were inserted directly into the femoral artery via a surgical cut-down and wire through needle technique. One bidirectional cannula was inserted using a percutaneous insertion technique. Indications included minimally invasive mitral and aortic valve surgery, thoracic aortic aneurysm repair, and redo cardiac surgery. The median duration of cardiopulmonary bypass was 129 minutes (range = 53-228 minutes). The cannula was inserted and positioned without difficulty in 14 of 15 patients. Incorrect sizing and arterial spasm prevented correct cannula positioning in one patient. Antegrade flow in the superficial femoral artery was observed on Doppler ultrasound in 12 of 12 patients in which this was performed. Continuous stable distal perfusion was demonstrated in the cannulated limb in 14 of 15 patients. No procedural complications occurred in the immediate or convalescent postoperative period. This study demonstrates that in patients undergoing femoral arterial cannulation for cardiopulmonary bypass during cardiac surgery, the use of a novel bidirectional cannula is safe and easy to insert and provides stable distal perfusion of the cannulated limb. Use of the device should largely obviate the need to insert a separate downstream perfusion cannula or use other techniques to protect against lower limb ischemia. Further research on a larger scale and in different patient populations is now warranted.

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience.

PubMed

Lio, Antonio; Nicolò, Francesca; Bovio, Emanuele; Serrao, Andrea; Zeitani, Jacob; Scafuri, Antonio; Chiariello, Luigi; Ruvolo, Giovanni

2016-12-01

We retrospectively evaluated early and intermediate outcomes of aortic arch surgery in patients with type A acute aortic dissection (AAD), investigating the effect of arch surgery extension on postoperative results. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent corrective surgery at our institution. Of the 92 patients chosen for this study, 59 underwent hemiarch replacement (hemiarch group), and 33 underwent total arch replacement (total arch group) in conjunction with ascending aorta replacement. The operative mortality rate was 22%. Total arch replacement was associated with a 33% risk of operative death, versus 15% for hemiarch ( P =0.044). Multivariable analysis found these independent predictors of operative death: age (odds ratio [OR]=1.13/yr; 95% confidence interval [CI], 1.04-1.23; P =0.002), body mass index >30 kg/m 2 (OR=9.9; 95% CI, 1.28-19; P =0.028), postoperative low cardiac output (OR=10.6; 95% CI, 1.18-25; P =0.035), and total arch replacement (OR=8.8; 95% CI, 1.39-15; P =0.021) The mean overall 5-year survival rate was 59.3% ± 5.5%, and mean 5-year freedom from distal reintervention was 95.4% ± 3.2% ( P =NS). In type A AAD, aortic arch surgery is still associated with high operative mortality rates; hemiarch replacement can be performed more safely than total arch replacement. Rates of distal aortic reoperation were not different between the 2 surgical strategies.

A Targeted Swallow Screen for the Detection of Postoperative Dysphagia.

PubMed

Gee, Erica; Lancaster, Elizabeth; Meltzer, Jospeh; Mendelsohn, Abie H; Benharash, Peyman

2015-10-01

Postoperative dysphagia leads to aspiration pneumonia, prolonged hospital stay, and is associated with increased mortality. A simple and sensitive screening test to identify patients requiring objective dysphagia evaluation is presently lacking. In this study, we evaluated the efficacy of a novel targeted swallow screen evaluation. This was a prospective trial involving all adult patients who underwent elective cardiac surgery with cardiopulmonary bypass at our institution over an 8-week period. Within 24 hours of extubation and before the initiation of oral intake, all postsurgical patients were evaluated using the targeted swallow screen. A fiberoptic endoscopic evaluation of swallowing was requested for failed screenings. During the study, 50 postcardiac surgery patients were screened. Fifteen (30%) failed the targeted swallow screen, and ten of the fifteen (66%) failed the subsequent fiberoptic endoscopic evaluation of swallowing exam and were confirmed to have dysphagia. The screening test had 100 per cent sensitivity for detecting dysphagia in our patient population, and a specificity of 87.5 per cent. The overall incidence of dysphagia was 20 per cent. We have shown that a targeted swallow evaluation can efficiently screen patients during the postcardiac surgery period. Furthermore, we have shown that the true incidence of dysphagia after cardiac surgery is significantly higher than previously recognized in literature.

Decrease of total antioxidant capacity during coronary artery bypass surgery.

PubMed

Kunt, Alper Sami; Selek, Sahbettin; Celik, Hakim; Demir, Deniz; Erel, Ozcan; Andac, Mehmet Halit

2006-09-01

Cardiac surgery induces an oxidative stress, which may lead to impairment of cardiac function. In this study, we aimed to measure the changes of oxidative and antioxidative status of patients undergoing coronary artery bypass surgery (CABG). We studied 79 patients who underwent CABG with and without cardiopulmonary bypass (CPB). Of the 79 patients, 39 had CPB and 40 did not. Blood samples were drawn before, during, and after the surgery. Antioxidant status was evaluated by measuring total antioxidant capacity (TAC), and oxidative status was evaluated by measuring total peroxide (TP) levels and oxidative stress index (OSI). TP and OSI levels increased, while TAC decreased progressively after the beginning of surgery, for all patients. There were negative correlations between TAC levels and aortic cross-clamping period and anastomosis time ( r = -0.553, p < 0.001 and r = -0.500, p < 0.001, respectively). In addition, there was a positive correlation between TAC and ejection fraction (r = 0.647, p < 0.001). During CABG, oxidant and OSI levels significantly increase and TAC significantly decreases. This situation is influenced by long CPB and anastomosis time, and also by low ventricular ejection fraction. We concluded that the patients who undergo CABG are exposed to potent oxidative stress that impairs their TAC. We speculate that supplementation with antioxidant vitamins such as vitamins C and E may be beneficial for patients undergoing CABG.

Preoperative Angiotensin Blocking Drug Therapy Is not Associated with Atrial Fibrillation after Cardiac Surgery

PubMed Central

Rader, Florian; Van Wagoner, David R.; Gillinov, A. Marc; Blackstone, Eugene H.

2010-01-01

Background Preoperative use of angiotensin blocking drug therapy (ABDT) with ACE-inhibitors or Angiotensin II receptor blockers (ARBs) and its link to occurrence of postoperative atrial fibrillation (POAF), a common marker of poor outcomes after cardiac surgery, remains controversial. Methods From 1997-2003 10,552 patients underwent coronary artery bypass grafting (CABG) with or without valve surgery. To adjust for differences of clinical characteristics between patients receiving ABDT within 24 hours prior to surgery compared to those who did not, propensity score analyses were conducted. Results ABDT was prescribed in 4,795 (45%) prior to surgery of which 1,725 (36%) developed POAF prior to discharge vs. 1908 (33%) of 5,757 patients who have not received ABDT (unadjusted odds ratio [OR] of 1.13 (95% Confidence Interval [CI] 1.05-1.25, p<0.01). In 6744 propensity score matched patients with well balanced co-morbidity profiles, ABDT was not associated with POAF (OR 1.05, CI 0.95-1.16, p=0.38). Stratified analysis within quintiles of propensity score and propensity-adjusted logistic multivariable regression confirmed these findings. Conclusions In this large observational study we found no evidence of an association between preoperative angiotensin blockade and the occurrence of postoperative atrial fibrillation. Adequately powered randomized studies are needed to clarify the best strategy of perioperative angiotensin blocking drug therapy in patients with and without guideline-based indications. PMID:20691840

The clinical significance of perivalvular pannus in prosthetic mitral valves: Can cardiac CT be helpful?

PubMed

Chang, Suyon; Suh, Young Joo; Han, Kyunghwa; Kim, Jin Young; Kim, Young Jin; Chang, Byung-Chul; Choi, Byoung Wook

2017-12-15

The clinical significance of pannus in the prosthetic mitral valve (MV) is not well documented. To investigate the clinical significance of pannus on cardiac computed tomography (CT) in patients with a prosthetic MV. A total of 130 patients with previous MV replacement who underwent cardiac CT were retrospectively included in this study. The presence of pannus, paravalvular leak (PVL) around the prosthetic MV and limitation of motion (LOM) of the MV were analyzed using CT. Between patients with MV pannus and those without pannus, CT, echocardiographic, and redo-surgery findings were compared. The diagnostic performance of CT and transesophageal echocardiography (TEE) for the detection of MV pannus was also compared, using surgical findings as a standard reference. MV pannus was observed on cardiac CT in 32.3% of the study population. Patients with MV pannus detected on CT more commonly had LOM (28.2% vs. 15.2%) and less frequently had PVL of the prosthetic MV (16.7% vs. 25%) than patients without MV pannus (P>0.05). Prosthetic valve obstruction (PVO) due prosthetic MV pannus requiring redo-surgery was present in only five patients (11.9%). Cardiac CT detected MV pannus with sensitivity of 65.2% and specificity of 80.9% and showed better diagnostic performance than TEE (P<0.05). Prosthetic MV pannus can frequently be seen on cardiac CT. However, its clinical significance should be assessed with careful consideration, because PVO due to MV pannus is relatively uncommon, and pannus can be seen in patients without any clinical problems. Copyright © 2017 Elsevier B.V. All rights reserved.

Role of hepatic resection for patients with carcinoid heart disease.

PubMed

Bernheim, Alain M; Connolly, Heidi M; Rubin, Joseph; Møller, Jacob E; Scott, Christopher G; Nagorney, David M; Pellikka, Patricia A

2008-02-01

To evaluate the effects of resection of hepatic carcinoid metastases on progression and prognosis of carcinoid heart disease. From our database of 265 consecutive patients diagnosed as having carcinoid heart disease from January 1, 1980, through December 31, 2005, we calculated survival from first diagnosis of cardiac involvement. Hepatic resection during follow-up was entered as a time-dependent covariable in a multivariable analysis. In patients with serial echocardiograms more than 1 year apart without intervening cardiac surgery, a previously validated cardiac severity score was calculated. A score increase that exceeded 25% was considered relevant progression. Hepatic resection was performed in 31 patients (12%) during follow-up. Five-year survival was significantly higher in these patients (86.5%; 95% confidence interval [CI], 73.5%-100.0%) than in patients without hepatic resection (29.0%; 95% CI, 23.3%-36.1%; univariable hazard ratio for hepatic resection, 0.25; 95% CI 0.12-0.53; P<.001). Hepatic resection remained strongly associated with improved prognosis in multivariable analysis (hazard ratio, 0.31; 95% CI, 0.14-0.66; P=.003). Among 77 patients (29%) with serial echocardiograms, 10 (13%) underwent hepatic resection during follow-up; resection was independently associated with decreased risk of cardiac progression (odds ratio, 0.29; 95% CI, 0.06-0.75; P=.03). Despite the limitations of this retrospective nonrandomized study, our data suggest that patients with carcinoid heart disease who undergo hepatic resection have decreased cardiac progression and improved prognosis. Eligible patients should be considered for hepatic surgery.

[Whipple's disease endocarditis: report of 5 cases and review of the literature].

PubMed

Aïouaz, H; Célard, M; Puget, M; Vandenesch, F; Mercusot, A; Fenollar, F; Delahaye, F; Obadia, J F; Tebib, J; Rousset, H

2005-10-01

Endocarditic lesions (infectious endocarditis) associated with Whipple's disease are exceptional. We report five cases from the cardiovascular and pneumologic hospital Louis Pradel in Lyon. We have collected all cases of Tropheryma whipplei endocarditis diagnosed between 1995 and 2004. Five men with a mean age of 53 years at time of diagnosis. The symptoms were essentially cardiovascular: murmur, embolism in 3 cases, and heart failure secondary to valvular insufficiency in 2 cases. The valvular involvement, double in 3 cases, was more often aortic. Vegetations were present in all patients and valvular destruction sometimes very important. A low grade fever was present in 4 cases, associated with weight loss in 2 cases. The only extra-cardiac symptoms were arthralgias or arthritis in all cases, considered in 3 patients as seronegative rheumatoid arthritis, B27+ spondylarthritis, and psoriasic arthritis. Their was no other clinical manifestations of Whipple's disease, particularly digestive, ocular, neurologic or adenopathy, and duodenal biopsies secondarily performed in 4 cases were non contributive. This differs from literature as an extra-cardiac location was identified in 11 out of 17 cases. The diagnosis was obtained by histology and PCR on the cardiac valves, as all the patients underwent surgery. The evolution was favourable with a prolonged antibiotic therapy. These report confirms the existence of endocarditic forms of the Whipple's disease, in which the single extra-cardiac manifestation is rheumatologic, and reminds us the usefulness of histology and PCR on the cardiac valves at the time of valvular surgery.

Clinical characteristics associated with pacing-induced cardiac dysfunction: a high incidence of undiagnosed cardiac sarcoidosis before permanent pacemaker implantation.

PubMed

Wakabayashi, Yasushi; Mitsuhashi, Takeshi; Akashi, Naoyuki; Hayashi, Takekuni; Umemoto, Tomio; Sugawara, Yoshitaka; Fujita, Hideo; Momomura, Shin-Ichi

2018-06-21

Previous studies suggested that right ventricular pacing was associated with pacing-induced cardiac dysfunction (PICD). The purpose of this study was to investigate the clinical characteristics including the incidence of undiagnosed cardiac sarcoidosis (CS) in patients with atrioventricular block (AVB) who manifest PICD. We retrospectively investigated consecutive patients with permanent pacemaker (PPM) undergoing a first-generator replacement surgery with a new PPM or an upgrade procedure to a cardiac resynchronization therapy (CRT) device between December 1, 2011 and June 30, 2017. Patients with AVB showing normal echocardiographic findings before PPM implantation were included and divided into 2 groups: patients with post-PPM left ventricular ejection fraction (LVEF) < 40% and/or undergoing an upgrade procedure to CRT (PICD group) and patients with post-PPM LVEF ≥ 40% who underwent replacement surgery with a new PPM (no-PICD group). There were 15 and 41 patients in the PICD and no-PICD groups, respectively. A wider-paced QRS duration just after the PPM implantation and/or lower pre-PPM LVEF was observed in the PICD group. Furthermore, 46.7% of the PICD patients (7/15) satisfied the diagnostic criteria for CS according to the guideline of the Japanese Circulation Society, although no patients fulfilled these criteria before PPM implantation. In conclusion, a high incidence of CS was observed in patients with AVB who had PICD. However, none of these patients was diagnosed with CS before PPM implantation.

Cold intermittent cardioplegia reduces the acidosis during prolonged cardiac surgery with cardiopulmonary bypass.

PubMed

Nollo, Giandomenico; Ferrari, Paolo; Graffigna, Angelo C

2011-01-01

The effect on acid-base balance efficacy of intermittent warm and cold blood cardioplegia (IWBC, ICBC) was assessed in 44 patients who underwent cardiac surgery with prolonged aortic cross clamping. With this purpose a customized multi sensor probe was inserted in the coronary sinus, and pH, PO(2), PCO(2) and temperature were continuously measured at 1 Hz sampling rate. The mean cross-clamping time was of 76 ± 26 min on 19 IWBC cases and of 80 ± 24 min on 14 ICBC cases. With IWBC perfusion, at the end of every ischemic period, the lowest pH and PO(2) progressively decreased and the maximal PCO(2) increased. During ICBC the minimum of pH and PO(2) and maximum of PCO2 at the end of different ischemic period during time were constant, also during long cross-clamping time. With IWBC, myocardial ischemia seemed not completely reversed by standardized reperfusions, as reflected by steady deterioration of PCO(2) and pH after each reperfusion.

Prospective Clinical Trial of Robotically Assisted Endoscopic Coronary Grafting With 1-Year Follow-Up

PubMed Central

Prasad, Sunil M.; Ducko, Christopher T.; Stephenson, Edward R.; Chambers, Charles E.; Damiano, Ralph J.

2001-01-01

Objective To follow up in prospective fashion patients with coronary artery anastomoses completed endoscopically with robotic assistance. The robotic system was evaluated for safety and its effectiveness in completing microsurgical coronary anastomoses. Summary Background Data Recently there has been an interest in using robotics and computers to enhance the surgeon’s ability to perform endoscopic cardiac surgery. This interest has stemmed from the rapid advancement of technology and the desire to make cardiac surgery less invasive. Using traditional endoscopic instruments, it has not been possible to perform coronary surgery. Methods Nineteen patients underwent robotically assisted endoscopic coronary artery bypass grafting of the left internal thoracic artery (LITA) to the left anterior descending artery (LAD). Two robotic instruments and one endoscopic camera were placed through three 5-mm ports. A robotic system was used to construct the LITA–LAD anastomosis. All other required grafts were completed by conventional techniques. Results Seventeen LITA–LAD grafts (89%) had adequate intraoperative flow. The mean LITA–LAD graft flow was 38.5 ± 5 mL/min. At 8 weeks, LITA–LAD grafts were assessed by angiography and showed 100% patency with thrombolysis in myocardial infarction (TIMI) I flow. At a mean follow-up of 17 ± 4.2 months, all patients were NYHA class I and there were no adverse cardiac events. Conclusions The results from the first prospective clinical trial of robotically assisted endoscopic coronary bypass surgery in the United States showed favorable short-term outcomes with no adverse events. Robotic assistance is an enabling technology allowing the performance of endoscopic coronary anastomoses. PMID:11371730

Prevalence of preoperative anemia, abnormal mean corpuscular volume and red cell distribution width among surgical patients in Singapore, and their influence on one year mortality

PubMed Central

Wee, Hide Elfrida; Ang, Ai Leen; Ranjakunalan, Niresh; Ong, Biauw Chi; Abdullah, Hairil Rizal

2017-01-01

Introduction Preoperative anemia and high red cell distribution width (RDW) are associated with higher perioperative mortality. Conditions with high RDW levels can be categorized by mean corpuscular volume (MCV). The relationship between RDW, anemia and MCV may explain causality between high RDW levels and outcomes. We aim to establish the prevalence of preoperative anemia and distribution of RDW and MCV among pre-surgical patients in Singapore. In addition, we aim to investigate the association between preoperative anemia, RDW and MCV levels with one-year mortality after surgery. Methods Retrospective review of 97,443 patients aged > = 18 years who underwent cardiac and non-cardiac surgeries under anesthesia between January 2012 and October 2016. Patient demographics, comorbidities, priority of surgery, surgical risk classification, perioperative transfusion, preoperative hemoglobin, RDW, MCV were collected. WHO anemia classification was used. High RDW was defined as >15.7%. Multivariate regression analyses were done to identify independent risk factors for mild or moderate/severe anemia and high RDW (>15.7). Multivariate cox regression analysis was done to determine the effect of preoperative anemia, abnormal RDW and MCV values on 1-year mortality. Results Our cohort comprised of 94.7% non-cardiac and 5.3% cardiac surgeries. 88.7% of patients achieved 1 year follow-up. Anemia prevalence was 27.8%—mild anemia 15.3%, moderate anemia 12.0% and severe anemia 0.5%. One-year mortality was 3.5%. Anemia increased with age in males, while in females, anemia was more prevalent between 18–49 years and > = 70 years. Most anemics were normocytic. Normocytosis and macrocytosis increased with age, while microcytosis decreased with age. Older age, male gender, higher ASA-PS score, anemia (mild- aHR 1.98; moderate/severe aHR 2.86), macrocytosis (aHR 1.47), high RDW (aHR 2.34), moderate-high risk surgery and emergency surgery were associated with higher hazard ratios of one-year mortality. Discussion Preoperative anemia is common. Anemia, macrocytosis and high RDW increases one year mortality. PMID:28777814

Recurrent left atrial myxoma in Carney complex

PubMed Central

Wang, Liaoyuan; Wang, Qing; Zhou, Yue; Xue, Qian; Sun, Xiao; Wang, Zhinong; Ji, Guangyu

2018-01-01

Abstract Rationale: Carney complex (CNC) accounts for up to two-thirds of familial cardiac myxoma, which is a rare autosomal dominant syndrome characterized by multiple mucocutaneous lesions and endocrine tumors. Mutation in the cAMP-dependent protein kinase A (PKA) regulatory (R) subunit 1 (PRKAR1A) gene has been identified as a cause of CNC. In this article, we report 3 first-degree relatives with cardiac myxoma who were diagnosed with CNC and underwent surgical resection. Presenting concerns: The recurrence of cardiac myxoma was detected in a 45-year-old male by echocardiography 5 years after the resection was carried out, without any additional symptoms. Family screening indicated that his brother and his brother's son also had a history of cardiac myxoma. Diagnosis: The echocardiography of the patient showed a 43 mm × 28 mm echo mass at the bottom of the atrial septum near anterior mitral leaflet. Sequencing of the patient's genomic DNA obtained from peripheral blood identified a p.E17X (c.491-492delTG) mutation in PRKAR1A, which encodes the type Iα regulatory subunit of protein kinase A. Interventions: The patient received redo cardiac myxoma resection and mitral valve repair under cardiopulmonary bypass. Echocardiographic surveillance was conducted after the surgery. Outcomes: The patient recovered quickly after the surgery and was discharged without any abnormality detected by echocardiography. Follow-up after 1 year showed no recurrence of the cardiac myxoma. Main lesson: We recommend echocardiographic surveillance of the affected individuals and their first-degree relatives at regular intervals, given the high risk of recurrence and the morbidity and mortality associated with cardiac tumors in any location. PMID:29561454

Anesthesia management of surgery for sigmoid perforation and acute peritonitis patient following heart transplantation: case report

PubMed Central

Yang, Xu-Li; Dai, Shu-Hong; Zhang, Juan; Zhang, Jing; Liu, Yan-Jun; Yang, Yan; Sun, Yu-E; Ma, Zheng-Liang; Gu, Xiao-Ping

2015-01-01

Here we described a case in which a patient underwent emergency laparotomy for acute peritonitis and sigmoid perforation under general anesthesia with a history of heart transplantation. A good knowledge in the physiology of the transplanted heart is critical for effective and safe general anesthesia. We chose etomidate that have a weaker impact on cardiovascular function plus propofol for induction, and propofol plus cisatracurium for maintenance with intermittently analgesics and vasoactive drugs to facilitate the anesthesia. In addition, fluid input, electrolyte and acid-base balance were well adjusted during the whole procedure. The patient was in good condition after the surgery. In this case report we are aiming to provide some guidance for those scheduled for non-cardiac surgery after heart transplant. PMID:26379997

Effusive-constrictive pericarditis as the manifestation of an unexpected diagnosis.

PubMed

Marta, Liliana; Alves, Miguel; Peres, Marisa; Ferreira, Ricardo; Ferreira, Hugo; Leal, Margarida; Nobre, Ângelo

2015-01-01

Constrictive pericarditis is a clinical condition characterized by the appearance of signs and symptoms of right heart failure due to loss of pericardial compliance. Cardiac surgery is now one of the most frequent causes in developed countries, while tuberculosis remains the most prevalent cause in developing countries. Malignancy is a rare cause but usually has a poor prognosis. The diagnosis of constrictive pericarditis remains a clinical challenge and requires a combination of noninvasive diagnostic methods (echocardiography, cardiac magnetic resonance and computed tomography); in some cases, cardiac catheterization is needed to confirm the diagnosis. The authors present the case of a 51-year-old man, hospitalized due to cardiac tamponade. Diagnostic investigation was suggestive of tuberculous etiology. Despite directed medical therapy, the patient developed effusive-constrictive physiology. He underwent pericardiectomy and anatomopathologic study suggested a neoplastic etiology. The patient died in the postoperative period from biventricular failure. Copyright © 2014 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

A Predictive Model for Assessing Surgery-Related Acute Kidney Injury Risk in Hypertensive Patients: A Retrospective Cohort Study

PubMed Central

Liu, Xing; Ye, Yongkai; Mi, Qi; Huang, Wei; He, Ting; Huang, Pin; Xu, Nana; Wu, Qiaoyu; Wang, Anli; Li, Ying; Yuan, Hong

2016-01-01

Background Acute kidney injury (AKI) is a serious post-surgery complication; however, few preoperative risk models for AKI have been developed for hypertensive patients undergoing general surgery. Thus, in this study involving a large Chinese cohort, we developed and validated a risk model for surgery-related AKI using preoperative risk factors. Methods and Findings This retrospective cohort study included 24,451 hypertensive patients aged ≥18 years who underwent general surgery between 2007 and 2015. The endpoints for AKI classification utilized by the KDIGO (Kidney Disease: Improving Global Outcomes) system were assessed. The most discriminative predictor was selected using Fisher scores and was subsequently used to construct a stepwise multivariate logistic regression model, whose performance was evaluated via comparisons with models used in other published works using the net reclassification index (NRI) and integrated discrimination improvement (IDI) index. Results Surgery-related AKI developed in 1994 hospitalized patients (8.2%). The predictors identified by our Xiang-ya Model were age, gender, eGFR, NLR, pulmonary infection, prothrombin time, thrombin time, hemoglobin, uric acid, serum potassium, serum albumin, total cholesterol, and aspartate amino transferase. The area under the receiver-operating characteristic curve (AUC) for the validation set and cross validation set were 0.87 (95% CI 0.86–0.89) and (0.89; 95% CI 0.88–0.90), respectively, and was therefore similar to the AUC for the training set (0.89; 95% CI 0.88–0.90). The optimal cutoff value was 0.09. Our model outperformed that developed by Kate et al., which exhibited an NRI of 31.38% (95% CI 25.7%-37.1%) and an IDI of 8% (95% CI 5.52%-10.50%) for patients who underwent cardiac surgery (n = 2101). Conclusions/Significance We developed an AKI risk model based on preoperative risk factors and biomarkers that demonstrated good performance when predicting events in a large cohort of hypertensive patients who underwent general surgery. PMID:27802302

Aortic valve replacement using continuous suture technique in patients with aortic valve disease.

PubMed

Choi, Jong Bum; Kim, Jong Hun; Park, Hyun Kyu; Kim, Kyung Hwa; Kim, Min Ho; Kuh, Ja Hong; Jo, Jung Ku

2013-08-01

The continuous suture (CS) technique has several advantages as a method for simple, fast, and secure aortic valve replacement (AVR). We used a simple CS technique without the use of a pledget for AVR and evaluated the surgical outcomes. Between October 2007 and 2012, 123 patients with aortic valve disease underwent AVR alone (n=28) or with other concomitant cardiac procedures (n=95), such as mitral, tricuspid, or aortic surgery. The patients were divided into two groups: the interrupted suture (IS) group (n=47), in which the conventional IS technique was used, and the CS group (n=76), in which the simple CS technique was used. There were two hospital deaths (1.6%), which were not related to the suture technique. There were no significant differences in cardiopulmonary bypass time or aortic cross-clamp time between the two groups for AVR alone or AVR with concomitant cardiac procedures. In the IS group, two patients had prosthetic endocarditis and one patient experienced significant perivalvular leak. These patients underwent reoperations. In the CS group, there were no complications related to the surgery. Postoperatively, the two groups had similar aortic valve gradients. The simple CS method is useful and secure for AVR in patients with aortic valve disease, and it may minimize surgical complications, as neither pledgets nor braided sutures are used.

Association of ethnicity and acute kidney injury after cardiac surgery in a South East Asian population.

PubMed

Chew, S T H; Mar, W M T; Ti, L K

2013-03-01

Postoperative acute kidney injury (AKI) is a frequent and serious complication after cardiac surgery. Clinical factors alone have failed to accurately predict the incidence of AKI after cardiac surgery. Ethnicity has been shown to be a predictor of AKI in the Western population. We tested the hypothesis that ethnicity is an independent predictor of AKI in patients undergoing cardiac surgery in a South East Asian population. A total of 1756 consecutive patients undergoing cardiac surgery were prospectively recruited. Among them, data of 1639 patients met the criteria for analysis. There were 1182 Chinese, 195 Indian, and 262 Malay patients. The main outcome was postoperative AKI, defined as a 25% or greater increase in preoperative to a maximum postoperative serum creatinine level within 3 days after surgery. Five hundred and seventy-nine patients (35.3%) developed AKI after cardiac surgery. Ethnicity was shown to be an independent predictor of AKI after cardiac surgery with Indians and Malays having a higher risk of developing AKI when compared with Chinese patients (odds ratio: Indian vs Chinese 1.44, Malay vs Chinese 1.51). Indians and Malays have a higher risk of developing AKI after cardiac surgery than Chinese in a South East Asian population. Ethnicity was shown to be an independent predictor of AKI after cardiac surgery.

No evidence for mosaic pathogenic copy number variations in cardiac tissue from patients with congenital heart malformations.

PubMed

Winberg, Johanna; Berggren, Håkan; Malm, Torsten; Johansson, Sune; Johansson Ramgren, Jens; Nilsson, Boris; Liedén, Agne; Nordenskjöld, Agneta; Gustavsson, Peter; Nordgren, Ann

2015-03-01

The aim of this study was to investigate if pathogenic copy number variations (CNVs) are present in mosaic form in patients with congenital heart malformations. We have collected cardiac tissue and blood samples from 23 patients with congenital heart malformations that underwent cardiac surgery and screened for mosaic gene dose alterations restricted to cardiac tissue using array comparative genomic hybridization (array CGH). We did not find evidence of CNVs in mosaic form after array CGH analysis. Pathogenic CNVs that were present in both cardiac tissue and blood were detected in 2/23 patients (9%), and in addition we found several constitutional CNVs of unclear clinical significance. This is the first study investigating mosaicism for CNVs in heart tissue compared to peripheral blood and the results do not indicate that pathogenic mosaic copy number changes are common in patients with heart malformations. Importantly, in line with previous studies, our results show that constitutional pathogenic CNVs are important factors contributing to congenital heart malformations. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

[Cardiac Anaesthesia: Anaesthesiological Management].

PubMed

Renner, Jochen; Bein, Berthold; Broch, Ole

2018-05-01

The anaesthesiological management of patients scheduled for cardiac surgery has been refined distinctively over the last decade due to different reasons. The continuing growth of the elderly patient population and the increasing number of combined cardiac surgery procedures in octogenarians on the one hand are one aspect. The rapid development of minimally invasive cardiac surgery and the enhancements in mechanical, artificial heart assist devices on the other hand can be seen as additional decisive factors. All of these innovations in the field of cardiac surgery implicate further enhancements regarding the anaesthesiological management. This review article addresses the following subareas of cardiac anaesthesia: significance of pharmacological myocardial protection, anaesthetic management during cardiopulmonary bypass, importance of "Enhanced Recovery After Cardiac Surgery"-protocols as well as innovations in the field of minimally invasive cardiac surgery like transcatheter aortic valve implantation. Georg Thieme Verlag KG Stuttgart · New York.

Department of Pediatric Cardiac Surgery in Gdansk in its new location – previous activity and perspectives for development

PubMed Central

Chojnicki, Maciej; Steffens, Mariusz; Jaworski, Radosław; Szofer-Sendrowska, Aneta; Paczkowski, Konrad; Kwaśniak, Ewelina; Romanowicz, Anna; Szymanowicz, Wiktor; Gierat-Haponiuk, Katarzyna

2017-01-01

The Department of Pediatric Cardiac Surgery in Gdansk is the only pediatric cardiac surgery center in northern Poland providing comprehensive treatment to children with congenital heart defects. The Department of Pediatric Cardiac Surgery in Gdansk currently offers a full spectrum of advanced procedures of modern cardiac surgery and interventional cardiology dedicated to patients from infancy to adolescence. January 19, 2016 marked the official opening of its new location. PMID:28515759

Benefits and limitations of multimodality imaging in the diagnosis of a primary cardiac lymphoma.

PubMed

Nijjar, Prabhjot Singh; Masri, Sofia Carolina; Tamene, Ashenafi; Kassahun, Helina; Liao, Kenneth; Valeti, Uma

2014-12-01

Primary cardiac tumors are far rarer than tumors metastatic to the heart. Angiosarcoma is the primary cardiac neoplasm most frequently detected; lymphomas constitute only 1% of primary cardiac tumors. We present the case of a 55-year-old woman with a recently diagnosed intracardiac mass who was referred to our institution for consideration of urgent orthotopic heart transplantation. Initial images suggested an angiosarcoma; however, a biopsy specimen of the mass was diagnostic for diffuse large B-cell lymphoma. The patient underwent chemotherapy rather than surgery, and she was asymptomatic 34 months later. We use our patient's case to discuss the benefits and limitations of multiple imaging methods in the evaluation of cardiac masses. Certain features revealed by computed tomography, cardiac magnetic resonance, and positron emission tomography can suggest a diagnosis of angiosarcoma rather than lymphoma. Cardiac magnetic resonance and positron emission tomography enable reliable distinction between benign and malignant tumors; however, the characteristics of different malignant tumors can overlap. Despite the great usefulness of multiple imaging methods for timely diagnosis, defining the extent of spread and the hemodynamic impact, and monitoring responses to treatment, we think that biopsy analysis is still warranted in order to obtain a correct histologic diagnosis in cases of suspected malignant cardiac tumors.

Extended use of cardiopulmonary bypass in a multidisciplinary hospital

PubMed Central

Shahabuddin, Syed; Habib, Nabeel

2015-01-01

Objective To share our experience highlighting the additional use of cardiopulmonary bypass (CPB) in cases other than the conventional ischemic, congenital and valvular heart diseases. Methodology All patients undergoing non-traditional cardiac surgery utilizing the cardiopulmonary bypass during a period from 1999 to 2009 reviewed. Their preoperative presentation, operative strategy and immediate postoperative status were assessed. Results A total of six such cases were identified including three female and three male patients. Two patients presented with road traffic accident having aortic transection along with other injuries. They underwent repair utilizing partial cardiopulmonary bypass. One patient presented with large PDA aneurysm and symptoms related to its pressure effect on respiratory system. He underwent repair under hypothermic circulatory arrest. These three patients were done via left thoracotomy. Three patients underwent deep hypothermic circulatory arrest, one for removal of thrombus from right atrium after complicated liver abscess, one patient required vascular graft interposition in left internal carotid artery for aneurysm extending into cranium and the third one underwent resection of vascular tumor of posterior cranial fossa. One patient required exploration for bleeding. One patient died after prolonged hospitalization. Rest of the patient had unremarkable postoperative course and were discharged home. Conclusion Our short experience highlights the extended use of cardiopulmonary bypass in a multidisciplinary hospital, facilitating to perform complex, technically challenging non cardiac procedures which otherwise may not be possible. PMID:26309443

Outcomes of PCI at hospitals with or without on-site cardiac surgery.

PubMed

Aversano, Thomas; Lemmon, Cynthia C; Liu, Li

2012-05-10

Performance of percutaneous coronary intervention (PCI) is usually restricted to hospitals with cardiac surgery on site. We conducted a noninferiority trial to compare the outcomes of PCI performed at hospitals without and those with on-site cardiac surgery. We randomly assigned participants to undergo PCI at a hospital with or without on-site cardiac surgery. Patients requiring primary PCI were excluded. The trial had two primary end points: 6-week mortality and 9-month incidence of major adverse cardiac events (the composite of death, Q-wave myocardial infarction, or target-vessel revascularization). Noninferiority margins for the risk difference were 0.4 percentage points for mortality at 6 weeks and 1.8 percentage points for major adverse cardiac events at 9 months. A total of 18,867 patients were randomly assigned in a 3:1 ratio to undergo PCI at a hospital without on-site cardiac surgery (14,149 patients) or with on-site cardiac surgery (4718 patients). The 6-week mortality rate was 0.9% at hospitals without on-site surgery versus 1.0% at those with on-site surgery (difference, -0.04 percentage points; 95% confidence interval [CI], -0.31 to 0.23; P=0.004 for noninferiority). The 9-month rates of major adverse cardiac events were 12.1% and 11.2% at hospitals without and those with on-site surgery, respectively (difference, 0.92 percentage points; 95% CI, 0.04 to 1.80; P=0.05 for noninferiority). The rate of target-vessel revascularization was higher in hospitals without on-site surgery (6.5% vs. 5.4%, P=0.01). We found that PCI performed at hospitals without on-site cardiac surgery was noninferior to PCI performed at hospitals with on-site cardiac surgery with respect to mortality at 6 weeks and major adverse cardiac events at 9 months. (Funded by the Cardiovascular Patient Outcomes Research Team [C-PORT] participating sites; ClinicalTrials.gov number, NCT00549796.).

Results of open heart surgery in Jehovah’s Witness patients. Single centre experience

PubMed Central

Kołsut, Piotr; Szymański, Jarosław; Kuriata, Jarosław; Kuśmierski, Krzysztof; Sitkowska-Rysiak, Ewa; Jasińska, Małgorzata; Kuśmierczyk, Mariusz

2017-01-01

Aim Evaluation the results in patients from the religious community of Jehovah’s Witness (JW) undergoing open heart surgery at our institution. Material and methods Between September 2011 and March 2015, 21 patients with a religious background of the JW church underwent open heart surgery at our institution performed by the same surgical team. Mean age was 68.43 ±8.93 years. There were 13 (61.9%) female patients. Recombinant human erythropoietin was administered to every patient with a hemoglobin value < 12.0 g/dl. Nine patients undergoing isolated coronary artery revascularization were operated on without cardiopulmonary bypass. Seven patients underwent combined surgery and 5 patients underwent aortic valve replacement via ministernotomy. The mean follow-up time was 16.45 ±11.09 months (range: 1.67–44.3 months). Results Mean baseline hematocrit serum level was 40.15 ±3.34% (range: 34.5–46.1%). Perioperatively the hematocrit serum levels decreased to the mean level of 29.89 ±4.31% (range: 21.4–36.3%). The mean hematocrit value at discharge was 30.85 ±3.59% (range: 23.5–38.4%). One death was observed in the perioperative period. Five (24%) patients suffered from sternum wound infection requiring vacuum-assisted therapy. During the follow-up period 1 patient died due to a non-cardiac related cause. Conclusions After careful preoperative preparation the results of open heart surgery in JW were very good, including combined procedures. The decrease of hematocrit serum levels significantly characterizing the postoperative period was highly acceptable in this series. Nevertheless, the number of sternum wound infections was a limiting factor for prompt postoperative recovery. PMID:29181043

Transradial percutaneous coronary intervention without on-site cardiac surgery for stable coronary disease and myocardial infarction: preliminary report and initial experience in 174 patients.

PubMed

Escárcega, Ricardo O; Pérez-Alva, Juan C; Jiménez-Hernández, Mario; Mendoza-Pinto, Claudia; Pérez, Ruben S; Porras, Renán S; García-Carrasco, Mario

2010-10-01

On-site cardiac surgery is not widely available in developing countries despite a high prevalence of coronary artery disease. To analyze the safety, feasibility and cost-effectiveness of transradial percutaneous coronary intervention without on-site cardiac surgery in a community hospital in a developing country. Of the 174 patients who underwent PCI for the first time in our center, we analyzed two groups: stable coronary disease and acute myocardial infarction. The primary endpoint was the rate of complications during the first 24 hours after PCI. We also analyzed the length of hospital stay and the rate of hospital readmission in the first week after PCI, and compared costs between the radial and femoral approaches. The study group comprised 131 patients with stable coronary disease and 43 with acute MI. Among the patients with stable coronary disease 8 (6.1%) had pulse loss, 12 (9.16%) had on-site hematoma, and 3 (2.29%) had bleeding at the site of the puncture. Among the patients with acute MI, 3 (6.98) had pulse loss and 5 (11.63%) had bleeding at the site of the puncture. There were no cases of atriovenous fistula or nerve damage. In the stable coronary disease group, 130 patients (99%) were discharged on the same day (2.4 +/- 2 hours). In the acute MI group, the length of stay was 6.6 +/- 2.5 days with at least 24 hours in the intensive care unit. There were no hospital readmissions in the first week after the procedure. The total cost, which includes equipment related to the specific approach and recovery room stay, was significantly lower with the radial approach compared to the femoral approach (US$ 500 saving per intervention). The transradial approach was safe and feasible in a community hospital in a developing country without on-site cardiac surgery backup. The radial artery approach is clearly more cost-effective than the femoral approach.

Interleukin-1β gene variants are associated with QTc interval prolongation following cardiac surgery: a prospective observational study

PubMed Central

Kertai, Miklos D.; Ji, Yunqi; Li, Yi-Ju; Mathew, Joseph P.; Daubert, James P.; Podgoreanu, Mihai V.

2016-01-01

Background We characterized cardiac surgery-induced dynamic changes of the corrected QT (QTc) interval and tested the hypothesis that genetic factors are associated with perioperative QTc prolongation independent of clinical and procedural factors. Methods All study subjects were ascertained from a prospective study of patients who underwent elective cardiac surgery during August 1999 to April 2002. We defined a prolonged QTc interval as >440 msec, measured from 24-hr pre- and postoperative 12-lead electrocardiograms. The association of 37 single nucleotide polymorphisms (SNPs) in 21 candidate genes – involved in modulating arrhythmia susceptibility pathways with postoperative QTc changes–was investigated in a two-stage design with a stage I cohort (n = 497) nested within a stage II cohort (n = 957). Empirical P values (Pemp) were obtained by permutation tests with 10,000 repeats. Results After adjusting for clinical and procedural risk factors, we selected four SNPs (P value range, 0.03-0.1) in stage I, which we then tested in the stage II cohort. Two functional SNPs in the pro-inflammatory cytokine interleukin-1β (IL1β), rs1143633 (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.53 to 0.95; Pemp = 0.02) and rs16944 (OR, 1.31; 95% CI, 1.01 to 1.70; Pemp = 0.04), remained independent predictors of postoperative QTc prolongation. The ability of a clinico-genetic model incorporating the two IL1B polymorphisms to classify patients at risk for developing prolonged postoperative QTc was superior to a clinical model alone, with a net reclassification improvement of 0.308 (P = 0.0003) and an integrated discrimination improvement of 0.02 (P = 0.000024). Conclusion The results suggest a contribution of IL1β in modulating susceptibility to postoperative QTc prolongation after cardiac surgery. PMID:26858093

Myocardial Oxidative Stress in Infants Undergoing Cardiac Surgery.

PubMed

Sznycer-Taub, Nathaniel; Mackie, Stewart; Peng, Yun-Wen; Donohue, Janet; Yu, Sunkyung; Aiyagari, Ranjit; Charpie, John

2016-04-01

Cardiac surgery for congenital heart disease often necessitates a period of myocardial ischemia during cardiopulmonary bypass and cardioplegic arrest, followed by reperfusion after aortic cross-clamp removal. In experimental models, myocardial ischemia-reperfusion is associated with significant oxidative stress and ventricular dysfunction. A prospective observational study was conducted in infants (<1 year) who underwent elective surgical repair of a ventricular septal defect (VSD) or tetralogy of Fallot (TOF). Blood samples were drawn following anesthetic induction (baseline) and directly from the coronary sinus at 1, 3, 5, and 10 min following aortic cross-clamp removal. Samples were analyzed for oxidant stress using assays for thiobarbituric acid-reactive substances, protein carbonyl, 8-isoprostane, and total antioxidant capacity. For each subject, raw assay data were normalized to individual baseline samples and expressed as fold-change from baseline. Results were compared using a one-sample t test with Bonferroni correction for multiple comparisons. Sixteen patients (ten with TOF and six with VSD) were enrolled in the study, and there were no major postoperative complications observed. For the entire cohort, there was an immediate, rapid increase in myocardial oxidative stress that was sustained for 10 min following aortic cross-clamp removal in all biomarker assays (all P < 0.01), except total antioxidant capacity. Infant cardiac surgery is associated with a rapid, robust, and time-dependent increase in myocardial oxidant stress as measured from the coronary sinus in vivo. Future studies with larger enrollment are necessary to assess any association between myocardial oxidative stress and early postoperative outcomes.

[Change in our approach in the surgical management of congenital heart defects in patients with Down syndrome, 1974-2016].

PubMed

Hartyánszky, István; Bogáts, Gábor

2016-10-01

Congenital heart defects are frequently present in patients with Down syndrome. The authors analyzed the impact of changing approach in surgical management of congenital heart defect on the life expectancy of patients with Down syndrome. Between 1974 and 1997 the data of 359 children with Down syndrome were collected. Among them 255 patients had no surgery and the mortality in this group was 25.9%, whereas the mortality in the group of 104 patients who underwent palliative surgery was 8.6%. Surgical management of congenital heart defects provides the same life expectancy for these patients as compared to Down patients without cardiac defects. Primary reconstruction is the preferable surgical procedure in infancy that provides good results. Nowadays the number of the operated grown-up congenital heart disease patients with Down syndrome is increasing. During the last three years 82 grown-up congenital heart disease patients, including 4 patients with Down syndrome (aged between 24 and 60 years) were reconstructed successfully. Due to the successful surgery in infancy the population of grown-up congenital heart disease patients with Down syndrome is increasing. The cardiac surgeons are ready to do everything for the optimal life expectancy of these patients. However, management of special problems (indication and necessity of reoperation, optimal age) in patients with Down syndrome poses a great challenge for cardiologists and cardiac surgeons. Orv. Hetil., 2016, 157(40), 1601-1603.

Cardiac perioperative complications in noncardiac surgery.

PubMed

Radovanović, Dragana; Kolak, Radmila; Stokić, Aleksandar; Radovanović, Zoran; Jovanović, Gordana

2008-01-01

Anesthesiologists are confronted with an increasing population of patients undergoing noncardiac surgery who are at risk for cardiac complications in the perioperative period. Perioperative cardiac complications are responsible for significant mortality and morbidity. The aim of the present study was to determine the incidence of perioperative (operative and postoperative) cardiac complications and correlations between the incidence of perioperative cardiac complications and type of surgical procedure, age, presence of concurrent deseases. A total of 100 patients with cardiac diseases undergoing noncardiac surgery were included in the prospective study (Group A 50 patients undergoing intraperitoneal surgery and Group B 50 patients undergoing breast and thyroid surgery). The patients were followed up during the perioperative period and after surgery until leaving hospital to assess the occurrence of cardiac events. Cardiac complications (systemic arterial hypertension, systemic arterial hypotension, abnormalities of cardiac conduction and cardiac rhythm, perioperative myocardial ischemia and acute myocardial infarction) occurred in 64% of the patients. One of the 100 patients (1%) had postoperative myocardial infarction which was fatal. Systemic arterial hypertension occured in 57% of patients intraoperatively and 33% postoperatively, abnormalities of cardiac rhythm in 31% of patients intraoperatively and 17% postoperatively, perioperative myocardial ischemia in 23% of patients intraoperatively and 11% of postoperatively. The most often cardiac complications were systemic arterial hypertension, abnormalities of cardiac rhythm and perioperative mvocardial ischemia. Factors independently associated with the incidence of cardiac complications included the type of surgical procedure, advanced age, duration of anaesthesia and surgery, abnormal preoperative electrocardiogram, abnormal preoperative chest radiography and diabetes.

Male-female differences and survival in patients undergoing isolated mitral valve surgery: a nationwide cohort study in the Netherlands.

PubMed

Mokhles, Mostafa M; Siregar, Sabrina; Versteegh, Michel I M; Noyez, Luc; van Putte, Bart; Vonk, Alexander B A; Roos-Hesselink, Jolien W; Bogers, Ad J J C; Takkenberg, Johanna J M

2016-09-01

The objective of this study was to compare male-female differences with respect to baseline characteristics and short-term outcome in a contemporary nationwide cohort of patients who underwent isolated mitral valve (MV) surgery. All patients [N = 3411; 58% males (N = 1977)] who underwent isolated MV surgery (replacement: N = 1048, 31%; reconstruction: N = 2364, 69%) in the Netherlands between January 2007 and December 2011 were included in this study. Differences in patient and procedural characteristics and in-hospital outcome were compared between male and female patients. Female patients were generally older (mean age, 64 vs 61 years, P < 0.001), presented more often with pulmonary hypertension (P = 0.03) and had higher logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) I (P < 0.001). Male patients presented more often with prior coronary artery bypass graft surgery (P < 0.001) and active endocarditis (P = 0.002). Female patients underwent MV replacement more often (P < 0.001) and, in case of replacement, received stented bioprostheses more often (P < 0.001). In-hospital mortality rates after MV replacement were 7% (n = 33) and 7% (n = 40) in male and female patients, respectively (OR 1.08, 95% CI 0.67-1.75; P = 0.75). In-hospital mortality rates after MV reconstruction were 1.4% (n = 21) and 1.3% (n = 11) in male and female patients, respectively (OR 0.88, 95% CI 0.42-1.84; P = 0.74). There are substantial male-female differences in patient presentation and procedural aspects in isolated MV surgery in the Netherlands. Female patients are older, have more severe disease at the time of surgery and undergo valve repair less often. Future studies are needed to identify potentially modifiable patient factors to improve the outcome of female patients with MV disease. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Perioperative angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor blockers for preventing mortality and morbidity in adults.

PubMed

Zou, Zui; Yuan, Hong B; Yang, Bo; Xu, Fengying; Chen, Xiao Y; Liu, Guan J; Shi, Xue Y

2016-01-27

Perioperative hypertension requires careful management. Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II type 1 receptor blockers (ARBs) have shown efficacy in treating hypertension associated with surgery. However, there is lack of consensus about whether they can prevent mortality and morbidity. To systematically assess the benefits and harms of administration of ACEIs or ARBs perioperatively for the prevention of mortality and morbidity in adults (aged 18 years and above) undergoing any type of surgery under general anaesthesia. We searched the current issue of the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 12), Ovid MEDLINE (1966 to 8 December 2014), EMBASE (1980 to 8 December 2014), and references of the retrieved randomized trials, meta-analyses, and systematic reviews. We included randomized controlled trials (RCTs) comparing perioperative administration of ACEIs or ARBs with placebo in adults (aged 18 years and above) undergoing any type of surgery under general anaesthesia. We excluded studies in which participants underwent procedures that required local anaesthesia only, or participants who had already been on ACEIs or ARBs. Two review authors independently performed study selection, assessed the risk of bias, and extracted data. We used standard methodological procedures expected by Cochrane. We included seven RCTs with a total of 571 participants in the review. Two of the seven trials involved 36 participants undergoing non-cardiac vascular surgery (infrarenal aortic surgery), and five involved 535 participants undergoing cardiac surgery, including valvular surgery, coronary artery bypass surgery, and cardiopulmonary bypass surgery. The intervention was started from 11 days to 25 minutes before surgery in six trials and during surgery in one trial. We considered all seven RCTs to carry a high risk of bias. The effects of ACEIs or ARBs on perioperative mortality and acute myocardial infarction were uncertain because the quality of the evidence was very low. The risk of death was 2.7% in the ACEIs or ARBs group and 1.6% in the placebo group (risk ratio (RR) 1.61; 95% confidence interval (CI) 0.44 to 5.85). The risk of acute myocardial infarction was 1.7% in the ACEIs or ARBs group and 3.0% in the placebo group (RR 0.55; 95% CI 0.14 to 2.26). ACEIs or ARBs may improve congestive heart failure (cardiac index) perioperatively (mean difference (MD) -0.60; 95% CI -0.70 to -0.50, very low-quality evidence). In terms of rate of complications, there was no difference in perioperative cerebrovascular complications (RR 0.48; 95% CI 0.18 to 1.28, very low-quality evidence) and hypotension (RR 1.95; 95% CI 0.86 to 4.41, very low-quality evidence). Cardiac surgery-related renal failure was not reported. ACEIs or ARBs were associated with shortened length of hospital stay (MD -0.54; 95% CI -0.93 to -0.16, P value = 0.005, very low-quality evidence). These findings should be interpreted cautiously due to likely confounding by the clinical backgrounds of the participants. ACEIs or ARBs may shorten the length of hospital stay, (MD -0.54; 95% CI -0.93 to -0.16, very low-quality evidence) Two studies reported adverse events, and there was no evidence of a difference between the ACEIs or ARBs and control groups. Overall, this review did not find evidence to support that perioperative ACEIs or ARBs can prevent mortality, morbidity, and complications (hypotension, perioperative cerebrovascular complications, and cardiac surgery-related renal failure). We found no evidence showing that the use of these drugs may reduce the rate of acute myocardial infarction. However, ACEIs or ARBs may increase cardiac output perioperatively. Due to the low and very low methodology quality, high risk of bias, and lack of power of the included studies, the true effect may be substantially different from the observed estimates. Perioperative (mainly elective cardiac surgery, according to included studies) initiation of ACEIs or ARBs therapy should be individualized.

Safety and efficiency of the new micro-multiplane transoesophageal probe in paediatric cardiology.

PubMed

Hascoët, Sébastien; Peyre, Marianne; Hadeed, Khaled; Alacoque, Xavier; Chausseray, Gérald; Fesseau, Rose; Amadieu, Romain; Léobon, Bertrand; Berthomieu, Lionel; Dulac, Yves; Acar, Philippe

2014-01-01

Transoesophageal echocardiography (TOE) is feasible in neonates using a miniaturized probe, but is not widely used because of low imaging quality. To assess handling and imaging quality of a new release of a micro-TOE probe in children. Thirty-eight consecutive children, enrolled during February and May 2013, underwent TOE with the Philips S8-3t probe. Insertion, handling and image quality were assessed. The 38 children (aged 7days to 12years; weight 3.1-27kg) underwent 75 TOE (30 [40.0%] before cardiac surgery, 31 [41.3%] after cardiac surgery, 4 [5.3%] during a percutaneous procedure, 10 [13.3%] in the intensive care unit). Insertion of the micro-TOE probe was 'very easy' in 37/38 patients (97.4%). Handling was better in the lightest children (P=0.001). Image quality was mainly 'good' or 'very good', with no significant changes between preoperative and postoperative examinations or over time. Total scores (insertion, handling, image quality) were significantly better in the lightest children (P=0.02). Preoperative TOE did not provide additional information over transthoracic echocardiography. Postoperative TOE was useful to assess surgical results, but no residual lesions required extracorporeal circulation return. Micro-TOE was useful during the postoperative care of neonatal surgery with open breastbone to assess the surgical result and ventricular function. It was also useful to guide extracorporeal membrane oxygenation (ECMO) indication and withdrawal; and was a useful guide for percutaneous procedures. Micro-multiplane TOE is safe and efficient for use in neonates and children. This minimally invasive tool increases the impact of TOE in paediatric cardiology. Copyright © 2014. Published by Elsevier Masson SAS.

Time to achieving therapeutic international normalized ratio increases hospital length of stay after heart valve replacement surgery.

PubMed

Arendt, Christopher J; Hong, Joon Hwa; Daly, Richard C; Scott, Christopher; Mehta, Ramila A; Bailey, Kent; Pathak, Jyotishman; Pereira, Naveen L

2017-05-01

Achieving a therapeutic international normalized ratio (INR) before hospital discharge is an important inpatient goal for patients undergoing mechanical cardiac valve replacement (MCVR). The use of clinical algorithms has reduced the time to achieve therapeutic INR (TTI) with warfarin therapy. Whether TTI prolongs length of stay (LOS) is unknown. Patients who underwent MCVR over a consecutive 42-month period were included. Clinical data were obtained from the Society of Thoracic Surgeons Adult Cardiac Surgery database and electronic medical records. Therapeutic INR was defined as per standard guidelines. Warfarin dose was prescribed using an inpatient pharmacy-managed algorithm and computer-based dosing tool. International normalized ratio trajectory, procedural needs, and drug interactions were included in warfarin dose determination. There were 708 patients who underwent MCVR, of which 159 were excluded for reasons that would preclude or interrupt warfarin use. Among the remainder of 549 patients, the average LOS was 6.4days and mean TTI was 3.5days. Landmark analysis showed that subjects in hospital on day 4 (n=542) who achieved therapeutic INR were more likely to be discharged by day 6 compared with those who did not achieve therapeutic INR (75% vs 59%, P<.001). Multivariable proportional hazards regression with TTI as a time-dependent effect showed a strong association with discharge (P=.0096, hazard ratio1.3) after adjustment for other significant clinical covariates. Time to achieve therapeutic INR is an independent predictor of LOS in patients requiring anticoagulation with warfarin after MCVR surgery. Alternative dosing and anticoagulation strategies will need to be adopted to reduce LOS in these patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Embolic capture with updated intra-aortic filter during coronary artery bypass grafting and transaortic transcatheter aortic valve implantation: first-in-human experience.

PubMed

Ye, Jian; Webb, John G

2014-12-01

We report our first-in-human clinical experience in the use of the new version of the EMBOL-X intra-aortic filter (Edwards Lifesciences Corporation, Irvine, Calif) to capture embolic material during transaortic transcatheter aortic valve implantation and cardiac surgery. Five patients were enrolled into the first-in-human clinical assessment of the new version of the EMBOL-X intra-aortic filter. Three patients underwent coronary artery bypass grafting, and 2 patients underwent transaortic transcatheter aortic valve implantation. During coronary artery bypass grafting, the filter was deployed before clamping of the aorta and removal of the aortic clamp. In contrast, the filter was deployed before aortic puncture for transaortic transcatheter aortic valve implantation and kept in the aorta throughout the entire procedure. The filter introducer sheath and filter were easily placed and removed without difficulty. There were no complications related to the use of the filter. Postoperative examination of the retrieved filters revealed the presence of multiple microemboli in the filters from all 5 cases. Histologic study revealed various kinds of tissue and thrombus. This first-in-human clinical experience has demonstrated the safety and feasibility of using the new version of the EMBOL-X intra-aortic filter during either cardiac surgery or transaortic transcatheter aortic valve implantation. We believe that the combination of the transaortic approach without aortic arch manipulation and the use of the EMBOL-X filter with a high capture rate is a promising strategy to reduce the incidence of embolic complications during transcatheter aortic valve implantation. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Preoperative statin treatment reduces systemic inflammatory response and myocardial damage in cardiac surgery.

PubMed

Martínez-Comendador, José Manuel; Alvarez, José Rubio; Mosquera, Ignacio; Sierra, Juan; Adrio, Belén; Carro, Javier G; Fernández, Angel; Bengochea, José

2009-12-01

To determine if preoperative statin treatment is associated with a reduction in systemic inflammatory response (SIR) and myocardial damage markers following cardiac surgery with cardiopulmonary bypass (CPB). We study a prospective cohort of 138 patients who underwent coronary and valvular surgery with CPB. We differentiate two study groups: patients with (group A, n=72) or without (group B, n=66) statins. Plasma levels of pro-inflammatory interleukins (tumour necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, IL-8 and IL-2R), creatine phosphokinase (CPK), CPK-MB and troponin I were measured before and 1, 6, 24 and >72 h after surgery. The baseline, operative and postoperative morbidity and mortality characteristics were similar for both the groups. Group A had significantly lower postoperative levels of IL-6 than group B at 6h (68.8+/-5 pg ml(-1) vs 108.9+/-108 pg ml(-1), p=0.01), 24h (71.7+/-7 pg ml(-1) vs 110.4+/-106 pg ml(-1), p=0.01) and before hospital discharge (21.6+/-12 pg ml(-1) vs 32.8+/-27 pg ml(-1), p=0.005), as well as significantly lower average IL-6 levels in the first 24h following surgery (71.8+/-5 pgml(-1) vs 112.8+/-82 pg ml(-1), p=0.002). The postoperative CPK-MB at 24h (19.7+/-23 ng ml(-1) vs 33.1+/-32 ng ml(-1), p=0.02) and troponin I levels at the end of the intervention (2.2+/-2.2 ng ml(-1) vs 3.3+/-3.1 ng ml(-1), p=0.03) and at 24h (4.1+/-3.5 ng ml(-1) vs 6.6+/-8 ng ml(-1), p=0.04) were also significantly lower in the group treated with statins prior to surgery. Preoperative treatment with statins is associated with a lower biochemical parameters of SIR and myocardial damage following cardiac surgery with CPB, regardless of it being coronary bypass grafting (CABG) or valvular surgery.

Nonemergency PCI at hospitals with or without on-site cardiac surgery.

PubMed

Jacobs, Alice K; Normand, Sharon-Lise T; Massaro, Joseph M; Cutlip, Donald E; Carrozza, Joseph P; Marks, Anthony D; Murphy, Nancy; Romm, Iyah K; Biondolillo, Madeleine; Mauri, Laura

2013-04-18

Emergency surgery has become a rare event after percutaneous coronary intervention (PCI). Whether having cardiac-surgery services available on-site is essential for ensuring the best possible outcomes during and after PCI remains uncertain. We enrolled patients with indications for nonemergency PCI who presented at hospitals in Massachusetts without on-site cardiac surgery and randomly assigned these patients, in a 3:1 ratio, to undergo PCI at that hospital or at a partner hospital that had cardiac surgery services available. A total of 10 hospitals without on-site cardiac surgery and 7 with on-site cardiac surgery participated. The coprimary end points were the rates of major adverse cardiac events--a composite of death, myocardial infarction, repeat revascularization, or stroke--at 30 days (safety end point) and at 12 months (effectiveness end point). The primary end points were analyzed according to the intention-to-treat principle and were tested with the use of multiplicative noninferiority margins of 1.5 (for safety) and 1.3 (for effectiveness). A total of 3691 patients were randomly assigned to undergo PCI at a hospital without on-site cardiac surgery (2774 patients) or at a hospital with on-site cardiac surgery (917 patients). The rates of major adverse cardiac events were 9.5% in hospitals without on-site cardiac surgery and 9.4% in hospitals with on-site cardiac surgery at 30 days (relative risk, 1.00; 95% one-sided upper confidence limit, 1.22; P<0.001 for noninferiority) and 17.3% and 17.8%, respectively, at 12 months (relative risk, 0.98; 95% one-sided upper confidence limit, 1.13; P<0.001 for noninferiority). The rates of death, myocardial infarction, repeat revascularization, and stroke (the components of the primary end point) did not differ significantly between the groups at either time point. Nonemergency PCI procedures performed at hospitals in Massachusetts without on-site surgical services were noninferior to procedures performed at hospitals with on-site surgical services with respect to the 30-day and 1-year rates of clinical events. (Funded by the participating hospitals without on-site cardiac surgery; MASS COM ClinicalTrials.gov number, NCT01116882.).

Brucellosis With Multi-Organ Involvement in a Patient With History of Composite Aortic Graft and Hepatitis B.

PubMed

Dehghan Manshadi, Seyed Ali; Rezahosseini, Omid; Abdi Liaei, Zahra

2016-11-01

The brucellosis with multi-organ involvement in a patient with a history of the composite aortic graft (Bentall procedure) and Hepatitis B infection is rare. A 35-year-old man presented to us with fever and loss of consciousness. Four years ago, he was IDU and underwent cardiac surgery because of endocarditis. Recently lumbar spondylodiscitis was diagnosed. The Wright (1/320) and Coombs Wright tests (1/640) were positive. After CNS imaging, lumbar puncture was done. The CSF pleocytosis was lymphocyte dominant. In cardiac echocardiography, large vegetation on prosthetic aortic valve leaflets was seen. The brain MRI was reported abnormal. Treatment of brucellosis started with Ceftriaxone, Doxycycline, Rifampin and Gentamycin. After 4 days, he became oriented, and fever was disappeared then we continued the treatment for 16 days. The patient discharged and followed by daily phone calls. As symptoms of abdominal pain and jaundice were presented on the fifth day, he re-admitted. The patient expired because of hepatorenal and cardiac insufficiency. Drug side effects, activation of Hepatitis B and embolism of cardiac vegetation to other organs were suspected causes of death. We do not suggest medical therapy without cardiac surgery in such cases. When combination therapy is necessary for brucellosis in an HBsAg-positive patient, hepatitis virus activity should be assess by HBV-DNA PCR and the dose of drugs with known hepatotoxic effects such as rifampin and co-trimoxazole should be adjust. Combination therapy with quinolones instead of hepatoxic drugs is one of our suggustions.

Enhanced recovery after elective coronary revascularization surgery with minimal versus conventional extracorporeal circulation: a prospective randomized study.

PubMed

Anastasiadis, Kyriakos; Asteriou, Christos; Antonitsis, Polychronis; Argiriadou, Helena; Grosomanidis, Vassilios; Kyparissa, Magdalena; Deliopoulos, Apostolos; Konstantinou, Dimitrios; Tossios, Paschalis

2013-10-01

A minimal extracorporeal circulation (MECC) circuit integrates the advances in cardiopulmonary bypass (CPB) technology into a single circuit and is associated with improved short-term outcome. The aim of this study was to prospectively evaluate MECC compared with conventional CPB in facilitating fast-track recovery after elective coronary revascularization procedures. Prospective randomized study. All patients scheduled for elective coronary artery surgery were evaluated, excluding those considered particularly high risk for fast-track failure. The fast-track protocol included careful preoperative patient selection, a fast-track anesthetic technique based on minimal administration of fentanyl, surgery at normothermia, early postoperative extubation in the cardiac recovery unit, and admission to the cardiothoracic ward within the first 24 hours postoperatively. One hundred twenty patients were assigned randomly into 2 groups (60 in each group). Group A included patients who were operated on using the MECC circuit, whereas patients in Group B underwent surgery on conventional CPB. Incidence of fast-track recovery was significantly higher in patients undergoing MECC (25% v 6.7%, p = 0.006). MECC also was recognized as a strong independent predictor of early recovery, with an odds ratio of 3.8 (p = 0.011). Duration of mechanical ventilation and cardiac recovery unit stay were significantly lower in patients undergoing MECC together with the need for blood transfusion, duration of inotropic support, need for an intra-aortic balloon pump, and development of postoperative atrial fibrillation and renal failure. MECC promotes successful early recovery after elective coronary revascularization procedures, even in a nondedicated cardiac intensive care unit setting. Copyright © 2013 Elsevier Inc. All rights reserved.

Variation in transfusion rates within a single institution: exploring the effect of differing practice patterns on the likelihood of blood product transfusion in patients undergoing cardiac surgery.

PubMed

Cote, Claudia; MacLeod, Jeffrey B; Yip, Alexandra M; Ouzounian, Maral; Brown, Craig D; Forgie, Rand; Pelletier, Marc P; Hassan, Ansar

2015-01-01

Rates of perioperative transfusion vary widely among patients undergoing cardiac surgery. Few studies have examined factors beyond the clinical characteristics of the patients that may be responsible for such variation. The purpose of this study was to determine whether differing practice patterns had an impact on variation in perioperative transfusion at a single center. Patients who underwent cardiac surgery at a single center between 2004 and 2011 were considered. Comparisons were made between patients who had received a perioperative transfusion and those who had not from the clinical factors at baseline, intraoperative variables, and differing practice patterns, as defined by the surgeon, anesthesiologist, perfusionist, and the year in which the procedure was performed. The risk-adjusted effect of these factors on perioperative transfusion rates was determined using multivariable regression modeling techniques. The study population comprised 4823 patients, of whom 1929 (40.0%) received a perioperative transfusion. Significant variation in perioperative transfusion rates was noted between surgeons (from 32.4% to 51.5%, P < .0001), anesthesiologists (from 34.4% to 51.9%, P < .0001) and across year (from 28.2% in 2004 to 48.8% in 2008, P < .0001). After adjustment for baseline and intraoperative variables, surgeon, anesthesiologist, and year of procedure were each found to be independent predictors of perioperative transfusion. Differing practice patterns contribute to significant variation in rates of perioperative transfusion within a single center. Strategies aimed at reducing overall transfusion rates must take into account such variability in practice patterns and account for nonclinical factors as well as known clinical predictors of blood transfusions. Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Predictors of survival in octogenarians after mitral valve surgery for degenerative disease: The Mitral Surgery in Octogenarians study.

PubMed

Chivasso, Pierpaolo; Bruno, Vito D; Farid, Shakil; Malvindi, Pietro Giorgio; Modi, Amit; Benedetto, Umberto; Ciulli, Franco; Abu-Omar, Yasir; Caputo, Massimo; Angelini, Gianni D; Livesey, Steve; Vohra, Hunaid A

2018-04-01

An increasing number of octogenarians are referred to undergo mitral valve surgery for degenerative disease, and percutaneous approaches are being increasingly used in this subgroup of patients. We sought to determine the survival and its predictors after Mitral Valve Surgery in Octogenarians (MiSO) in a multicenter UK study of high-volume specialized centers. Pooled data from 3 centers were collected retrospectively. To identify the predictors of short-term composite outcome of 30 days mortality, acute kidney injury, and cerebrovascular accident, a multivariable logistic regression model was developed. Multiple Cox regression analysis was performed for late mortality. Kaplan-Meier curves were generated for long-term survival in various subsets of patients. Receiver operating characteristic analysis was done to determine the predictive power of the logistic European System for Cardiac Operative Risk Evaluation. A total of 247 patients were included in the study. The median follow-up was 2.9 years (minimum 0, maximum 14 years). A total of 150 patients (60.7%) underwent mitral valve repair, and 97 patients (39.3%) underwent mitral valve replacement. Apart from redo cardiac surgery (mitral valve repair 6 [4%] vs mitral valve replacement 11 [11.3%], P = .04) and preoperative atrial fibrillation (mitral valve repair 79 [52.6%] vs mitral valve replacement 34 [35.1%], P < .01), there was no significant difference in terms of any other preoperative characteristics between the 2 groups. Patient operative risk, as estimated by logistic European System for Cardiac Operative Risk Evaluation, was lower in the mitral valve repair group (10.2 ± 11.8 vs 13.7 ± 15.2 in mitral valve replacement; P = .07). No difference was found between groups for duration of cardiopulmonary bypass and aortic crossclamp times. The 30-day mortality for the whole cohort was 13.8% (mitral valve repair 4.7% vs mitral valve replacement 18.6%; P < .01). No differences were found in terms of postoperative cerebrovascular accident (2% vs 3.1%; P = .9), acute kidney injury requiring dialysis (6.7% vs 13.4%; P = .12), and superficial or deep sternal wound infection (10% vs 16.5%, P = .17; 2% vs 3.1%, P = .67, respectively). The final multiple regression model for short-term composite outcome included previous cardiac surgery (odds ratio [OR], 4.47; 95% confidence interval [CI], 1.37-17.46; P = .02), intra-aortic balloon pump use (OR, 4.77; 95% CI, 1.67-15.79; P < .01), and mitral valve replacement (OR, 7.7; 95% CI, 4.04-14.9; P < .01). Overall survival for the entire cohort at 1, 5, and 10 years was 82.4%, 63.7%, and 45.5% (mitral valve repair vs mitral valve replacement: 89.9% vs 70.7% at 1 year, 69.6% vs 54% at 5 years, and 51.8% vs 35.5% at 10 years; P = .0005). Cox proportional hazard model results showed mitral valve replacement (hazard ratio, 1.88; 95% CI, 1.22-2.89; P < .01) and intra-aortic balloon pump use (hazard ratio, 2.54; 95% CI, 1.26-5.13; P < .01) to be independent predictor factors affecting long-term survival. Logistic European System for Cardiac Operative Risk Evaluation did not perform well in predicting early mortality (area under the curve, 0.57%). In octogenarians, mitral valve repair for degenerative disease is associated with good survival and remains the gold standard, whereas mitral valve replacement is still associated with significant mortality. Logistic European System for Cardiac Operative Risk Evaluation was unable to predict early mortality in our cohort of patients. Larger international multicenter registries are required to optimize the decision-making process in such a high-risk subgroup. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Does short preoperative statin therapy prevent infectious complications in adults undergoing cardiac or non-cardiac surgery? A meta-analysis of 5 randomized placebo-controlled trials.

PubMed

Li, Hua; Lin, Yuan-Long; Diao, Shu-Ling; Ma, Bao-Xin; Liu, Xian-Liang

2016-05-01

To evaluate the effect of preoperative statin therapy on the incidence of postoperative infection.  This systematic review of the literature was carried out in August 2015. Studies were retrieved via PubMed, Embase, and the Cochrane Library (1980 to 2015), and the reference files were limited to English-language articles. We used a standardized protocol, and a meta-analysis was performed for data abstraction.  Five studies comprising 1,362 patients qualified for the analysis. The incidence of postoperative infections in the statin group (1.1%) was not significantly lower than that in the placebo group (2.4%), with a risk ratio (RR) of 0.56 (95% confidence interval [CI] 0.24-1.33, p=0.19). Patients of 3 studies underwent cardiac surgery. The aggregated results of these studies failed to show significant differences in postoperative infection when a fixed effects model was used (RR: 0.39; 95% CI: 0.08-1.97, p=0.26].   We failed to find sufficient evidence to support the association between statin use and postoperative infectious complications. The absence of any evidence for a beneficial effect in available randomized trials reduces the likelihood of a causal effect as reported in observational studies.

Risk-taking attitudes and their association with process and outcomes of cardiac care: a cohort study

PubMed Central

King, Kathryn M; Norris, Colleen M; Knudtson, Merril L; Ghali, William A

2009-01-01

Background Prior research reveals that processes and outcomes of cardiac care differ across sociodemographic strata. One potential contributing factor to such differences is the personality traits of individuals within these strata. We examined the association between risk-taking attitudes and cardiac patients' clinical and demographic characteristics, the likelihood of undergoing invasive cardiac procedures and survival. Methods We studied a large inception cohort of patients who underwent cardiac catheterization between July 1998 and December 2001. Detailed clinical and demographic data were collected at time of cardiac catheterization and through a mailed survey one year post-catheterization. The survey included three general risk attitude items from the Jackson Personality Inventory. Patients' (n = 6294) attitudes toward risk were categorized as risk-prone versus non-risk-prone and were assessed for associations with baseline clinical and demographic characteristics, treatment received (i.e., medical therapy, coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI)), and survival (to December 2005). Results 2827 patients (45%) were categorized as risk-prone. Having risk-prone attitudes was associated with younger age (p < .001), male sex (p < .001), current smoking (p < .001) and higher household income (p < .001). Risk-prone patients were more likely to have CABG surgery in unadjusted (Odds Ratio [OR] = 1.21; 95% CI 1.08–1.36) and adjusted (OR = 1.18; 95% CI 1.02–1.36) models, but were no more likely to have PCI or any revascularization. Having risk-prone attitudes was associated with better survival in an unadjusted survival analysis (Hazard Ratio [HR] = 0.78 (95% CI 0.66–0.93), but not in a risk-adjusted analysis (HR = 0.92, 95% CI 0.77–1.10). Conclusion These exploratory findings suggest that patient attitudes toward risk taking may contribute to some of the documented differences in use of invasive cardiac procedures. An awareness of these associations could help healthcare providers as they counsel patients regarding cardiac care decisions. PMID:19660137

Recent Trends in Adherence to Secondary Prevention Guidelines for Patients Undergoing Coronary Revascularization in Washington State: An Analysis of the Clinical Outcomes Assessment Program (COAP) Registry.

PubMed

Riley, Robert F; Don, Creighton W; Aldea, Gabriel S; Mokadam, Nahush A; Probstfield, Jeffrey; Maynard, Charles; Goss, J Richard

2012-08-29

Previous studies indicated that patients undergoing coronary artery bypass graft (CABG) surgery are less likely to receive guideline-based secondary prevention therapy than are those undergoing percutaneous coronary intervention (PCI) after an acute myocardial infarction. We aimed to evaluate whether these differences have persisted after the implementation of public reporting of hospital metrics. The Clinical Outcomes Assessment Program (COAP) database was analyzed retrospectively to evaluate adherence to secondary prevention guidelines at discharge in patients who underwent coronary revascularization after an acute ST-elevation myocardial infarction in Washington State. From 2004 to 2007, 9260 patients received PCI and 692 underwent CABG for this indication. Measures evaluated included prescription of aspirin, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, or lipid-lowering medications; cardiac rehabilitation referral; and smoking-cessation counseling. Composite adherence was lower for CABG than for PCI patients during the period studied (79.6% versus 89.7%, P<0.01). Compared to patients who underwent CABG, patients who underwent PCI were more likely to receive each of the pharmacological therapies. There was no statistical difference in smoking-cessation counseling (91.7% versus 90.3%, P=0.63), and CABG patients were more likely to receive referral for cardiac rehabilitation (70.9% versus 48.3%, P<0.01). Adherence rates improved over time among both groups, with no significant difference in composite adherence in 2006 (85.6% versus 87.6%, P=0.36). Rates of guideline-based secondary prevention adherence in patients with ST-elevation myocardial infarction who underwent CABG surgery have been improving steadily in Washington State. The improvement possibly is associated with the implementation of public reporting of quality measures. © 2012 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley-Blackwell. This is an Open Access article under the terms of the Creative Commons Attribution Noncommercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Evaluation of sternochondroplasty efficacy in treatment of pectus deformities.

PubMed

Bagheri, Reza; Haghi, Seyed Ziaollah; Nouri Dalouee, Marzie; Ebrahimi, Kolsoumeh; Rajabnejad, Ata'ollah

2015-02-01

This study aimed to evaluate the efficacy of sternochondroplasty for repair of pectus deformities. Thirty-three patients underwent repair of pectus deformity with a sternochondroplasty technique between 1989 and 2009. Studied variables were age, sex, symptoms, pulmonary function tests before and after surgery, Haller index, complications, recurrence, and cosmetic results. The median age at operation was 13.27 years. Twenty patients (13 male and 7 female) had pectus excavatum, and 13 (11 male and 2 female) had pectus carinatum. Congenital anomalies associated with pectus excavatum included a skeletal anomaly in 6 (30%) patients and a cardiac anomaly in 4 (20%); only 1 patient with pectus carinatum had cardiac anomaly. Inspiratory vital capacity and forced expiratory volume in 1 s were significantly different before and after surgery in patients with pectus excavatum, but there was no significant difference in functional residual capacity. Pulmonary function tests showed no significant differences before and after surgery in patients with pectus carinatum. Complications after surgery were seroma in 2 cases and 1 case each of pneumothorax and atelectasis. Recurrence was observed in 2 cases of pectus excavatum. The cosmetic result was excellent in 93.9% of cases. Hospital mortality was zero. Sternochondroplasty is a desirable procedure for repairing pectus deformities. This procedure has minimal complications and the cosmetic and physiologic results are excellent. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Thoracoscopic resection of right auricular masses in dogs: 9 cases (2003-2011).

PubMed

Ployart, Stéphane; Libermann, Stéphane; Doran, Ivan; Bomassi, Eric; Monnet, Eric

2013-01-15

To determine the feasibility of thoracoscopic resection of masses located on the right auricle in dogs. Retrospective case series. Dogs (n = 9) with a mass on the right auricle. Hospital records from 2003 to 2011 were reviewed. Only dogs that underwent thoracoscopic resection of a mass on the right auricle were selected. Data collected included history, clinicopathologic findings, surgical technique, and outcome. All dogs with pericardial effusion were examined by means of echocardiography. Cardiac masses on the right auricle were identified in 5 dogs. Eight dogs had clinical signs of cardiac tamponade and right-sided heart failure. All dogs underwent thoracoscopic resection of a mass on the right atrium. Eight hemangiosarcomas and 1 pyogranulomatous lesion were resected. One dog with a mass located at the base of the right auricle died during surgery. No postoperative complications were noted. Right auricular masses were successfully removed in 8 dogs. Masses close to the base of the right atrial appendage may not be amenable to resection with thoracoscopy. Resection of small masses at the tip of the right auricular appendage can be performed thoracoscopically.

Junctional ectopic tachycardia after infant heart surgery: incidence and outcomes.

PubMed

Zampi, Jeffrey D; Hirsch, Jennifer C; Gurney, James G; Donohue, Janet E; Yu, Sunkyung; LaPage, Martin J; Hanauer, David A; Charpie, John R

2012-12-01

Junctional ectopic tachycardia (JET) is an arrhythmia observed almost exclusively after open heart surgery in children. Current literature on JET has not focused on patients at the highest risk of both developing and being negatively impacted by JET. The purpose of this study was to determine the overall incidence of JET in an infant patient cohort undergoing open cardiac surgery, to identify patient- and procedure-related factors associated with developing JET, and to assess the clinical impact of JET on patient outcomes. We performed a nested case-control study from the complete cohort of patients at our institution younger than 1 year of age who underwent open heart surgery between 2005 and 2010. JET patients were compared with an age matched control group undergoing open heart surgery without JET regarding potential risk factors and outcomes. The overall incidence of JET in infants after open cardiac surgery was 14.3 %. From multivariate analyses, complete repair of tetralogy of Fallot [adjusted odds ratio (AOR) 2.0, 95 % CI 1.12-3.57] and longer aortic cross clamp times (AOR 1.02, 95 % CI 1.01-1.03) increased the risk of developing JET. Patients with JET had longer length of intubation, intensive care unit stays, and total length of hospitalization, and were more likely to require extracorporeal membrane oxygenation support (13 vs. 4.3 %). JET is a common postoperative arrhythmia in infants after open heart operations. Both anatomic substrate and surgical procedure contribute to the overall risk of developing JET. Developing JET is associated with worse clinical outcomes.

Atriocaval Rupture After Right Atrial Isthmus Ablation for Atrial Flutter.

PubMed

Vloka, Caroline; Nelson, Daniel W; Wetherbee, Jule

2016-06-01

A patient with symptomatic typical atrial flutter (AFL) underwent right atrial isthmus ablation with an 8-mm catheter. Eight months later, his typical AFL recurred. Ten months later, he underwent a repeat right atrial isthmus ablation with an irrigated tip catheter and an 8-mm tip catheter. Six weeks after his second procedure, while performing intense sprint intervals on a treadmill, he developed an abrupt onset of chest pain, hypotension, and cardiac tamponade. He underwent emergency surgery to repair an atriocaval rupture and has done well since. Our report suggests that an association of multiple radiofrequency ablations with increased risk for delayed atriocaval rupture occurring 1 to 3 months after ablation. In conclusion, although patients generally were advised to limit exercise for 1 to 2 weeks after AFL ablation procedures in the past, it may be prudent to avoid intense exercise for at least 3 months after procedure. Copyright © 2016 Elsevier Inc. All rights reserved.

Perioperative renal outcome in cardiac surgical patients with preoperative renal dysfunction: aprotinin versus epsilon aminocaproic acid.

PubMed

Maslow, Andrew D; Chaudrey, Alyas; Bert, Arthur; Schwartz, Carl; Singh, Arun

2008-02-01

The administration of aprotinin to patients with pre-existing renal dysfunction who are undergoing cardiac surgery is controversial. Therefore, the authors present their experience with the use of aprotinin for patients with preoperative renal dysfunction who underwent elective cardiac surgery requiring cardiopulmonary bypass (CPB). Retrospective analysis. University hospital. Consecutive cardiac surgical patients with preoperative serum creatinine (SCr) > or =1.8 mg/dL undergoing nonemergent cardiac surgery requiring CPB. None. One hundred twenty-three patients either received epsilon aminocaproic acid (EACA, n = 82) or aprotinin (n = 41) as decided by the attending anesthesiologist and surgeon. Data were collected from the Society of Thoracic Surgeons database and from automated intraoperative anesthesia records. Renal function was assessed from measured serum creatinine (SCr) and calculated creatinine clearances (CrCls). Acute perioperative renal dysfunction was defined as a worsening of perioperative renal function by > or =25% and/or the need for hemodialysis (HD). Data were recorded as mean and standard deviation or percentage of population depending on whether the data were continuous or not. Data were compared by using an analysis of variance, chi-square analysis, Student paired and unpaired t tests, Fisher exact test, Wilcoxon rank sum test, and Mann-Whitney U test. A p value <0.05 was considered significant. Overall, 32% and 41% of patients had acute perioperative renal dysfunction measured by CrCl and SCr, respectively. Seven patients required HD (5.7%). Six of these 7 had complicated postoperative courses. Of all the variables measured, only the duration of the aortic crossclamp (AoXCl) and CPB were significantly associated with acute perioperative renal dysfunction. Acute perioperative renal dysfunction was associated with increased intensive care unit and hospital stays, postoperative blood transfusion, dialysis, and major infection. Aprotinin patients were significantly older (75.2 v 70.2 years, p < 0.05), had lower left ventricular ejection fraction (44.4% v 49.2%, p < 0.05), a greater preoperative history of congestive heart failure (63 v 44%, p < 0.05), a greater renal risk score (5.8 v 4.9, p < 0.05), and underwent more nonisolated coronary artery bypass graft surgeries (77% v 29%, p < 0.0001). CPB time (126.0 v 96.5 minutes, p < 0.001) and AoXCl duration (100.9 v 78.0 minutes, p < 0.005) were longer in the aprotinin group. Diabetes (60.5% v 41.5%, p < 0.05) and hypertension (90.1% v 73.2%, p < 0.05) were more prevalent in the EACA group. Baseline renal function and renal outcomes were not significantly different between the aprotinin and EACA groups. Six of the 7 patients who required HD received EACA (p = 0.1). The earliest SCr recorded > or =3 months after surgery was significantly lower in the aprotinin group compared with the EACA group (1.8 v 2.2 mg/dL, p < 0.05). Acute perioperative renal dysfunction was associated with worse patient outcome and longer CPB and AoXCl times. Demographic and surgical variables indicated that the sicker patients undergoing more complex surgeries were more likely to be treated with aprotinin. Although aprotinin patients had a higher renal risk score, the administration of aprotinin did not negatively impact renal outcome.

Effect of Head Insulation on the Total Time Required to Rewarm Postoperative Cardiac Surgery Patients.

DTIC Science & Technology

1992-05-01

two-hour period in the recovery room. Individuals were excluded from the study if they had cardiac surgery, craniotomies , surgeries precluding the use...years). Patients were excluded if they had: craniotomies , cardiac surgery, coagulation defects, 34 preoperative hyperthermia, or previous tympanoplasty...intraoperatively. 3. Postoperative mediastinal/chest tube drainage > 100 ml/hour for four hours. 4. Postoperative cardiac arrest during data collection period

Neuromuscular blockade in cardiac surgery: an update for clinicians.

PubMed

Hemmerling, Thomas M; Russo, Gianluca; Bracco, David

2008-01-01

There have been great advancements in cardiac surgery over the last two decades; the widespread use of off-pump aortocoronary bypass surgery, minimally invasive cardiac surgery, and robotic surgery have also changed the face of cardiac anaesthesia. The concept of "Fast-track anaesthesia" demands the use of nondepolarising neuromuscular blocking drugs with short duration of action, combining the ability to provide (if necessary) sufficiently profound neuromuscular blockade during surgery and immediate re-establishment of normal neuromuscular transmission at the end of surgery. Postoperative residual muscle paralysis is one of the major hurdles for immediate or early extubation after cardiac surgery. Nondepolarising neuromuscular blocking drugs for cardiac surgery should therefore be easy to titrate, of rapid onset and short duration of action with a pathway of elimination independent from hepatic or renal dysfunction, and should equally not affect haemodynamic stability. The difference between repetitive bolus application and continuous infusion is outlined in this review, with the pharmacodynamic and pharmacokinetic characteristics of vecuronium, pancuronium, rocuronium, and cisatracurium. Kinemyography and acceleromyography are the most important currently used neuromuscular monitoring methods. Whereas monitoring at the adductor pollicis muscle is appropriate at the end of surgery, monitoring of the corrugator supercilii muscle better reflects neuromuscular blockade at more central, profound muscles, such as the diaphragm, larynx, or thoraco-abdominal muscles. In conclusion, cisatracurium or rocuronium is recommended for neuromuscular blockade in modern cardiac surgery.

Older Age Confers a Higher Risk of 30-Day Morbidity and Mortality Following Laparoscopic Bariatric Surgery: an Analysis of the Metabolic and Bariatric Surgery Quality Improvement Program.

PubMed

Haskins, Ivy N; Ju, Tammy; Whitlock, Ashlyn E; Rivas, Lisbi; Amdur, Richard L; Lin, Paul P; Vaziri, Khashayar

2018-04-17

There is a paucity of literature describing the association of age with the risk of adverse events following bariatric surgery. The purpose of this study is to investigate the association of age with 30-day morbidity and mortality following laparoscopic bariatric surgery using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. All adult patients undergoing laparoscopic Roux-en-Y gastric bypass (RNGYB) or sleeve gastrectomy (SG) were identified within the MBSAQIP database. Patients were divided into five equal age quintiles. Binary outcomes of interest, including cardiac, pulmonary, wound, septic, clotting, and renal events, in addition to the incidence of related 30-day unplanned reintervention, related 30-day mortality, and a composite morbidity and mortality outcome were compared across the age quintiles and procedures. A total of 266,544 patients met inclusion criteria. Older age was associated with an increased risk of all morbidity outcomes except venous thromboembolism events, 30-day mortality, and the composite morbidity and mortality outcome. Patients who underwent Roux-en-Y gastric bypass had worse outcomes per quintile for almost every outcome of interest when compared to patients who underwent sleeve gastrectomy. Older patients and patients who undergo Roux-en-Y gastric bypass are at an increased risk of perioperative morbidity and mortality following laparoscopic bariatric surgery. Additional studies are needed to determine the association of age with long-term weight loss and cardiometabolic comorbidity resolution following bariatric surgery in order to determine if the increased perioperative risk is offset by improved long-term outcomes in older patients undergoing bariatric surgery.

Modular minimally invasive extracorporeal circulation systems; can they become the standard practice for performing cardiac surgery?

PubMed

Anastasiadis, K; Antonitsis, P; Argiriadou, H; Deliopoulos, A; Grosomanidis, V; Tossios, P

2015-04-01

Minimally invasive extracorporeal circulation (MiECC) has been developed in an attempt to integrate all advances in cardiopulmonary bypass technology in one closed circuit that shows improved biocompatibility and minimizes the systemic detrimental effects of CPB. Despite well-evidenced clinical advantages, penetration of MiECC technology into clinical practice is hampered by concerns raised by perfusionists and surgeons regarding air handling together with blood and volume management during CPB. We designed a modular MiECC circuit, bearing an accessory circuit for immediate transition to an open system that can be used in every adult cardiac surgical procedure, offering enhanced safety features. We challenged this modular circuit in a series of 50 consecutive patients. Our results showed that the modular AHEPA circuit design offers 100% technical success rate in a cohort of random, high-risk patients who underwent complex procedures, including reoperation and valve and aortic surgery, together with emergency cases. This pilot study applies to the real world and prompts for further evaluation of modular MiECC systems through multicentre trials. © The Author(s) 2015.

A hybrid surgical transcatheter strategy for treating severe para-right atrioventricular valvular regurgitation in a patient with left atrial isomerism.

PubMed

Kalantre, Atul; Vettukattil, Joseph; Haw, Marcus; Veldtman, Gruschen R

2007-12-01

Paravalvular leaks are a recognized complication of valve replacement surgery. We report a 47-year-old man with left atrial isomerism, interrupted left sided inferior caval vein with unilateral left sided superior caval vein, a common atrium, and anomalous pulmonary venous connection to the coronary sinus, who had recurrent severe para-right atrioventricular (AV) regurgitation with gross right heart failure following tricuspid valve (TCV) replacement. He underwent a hybrid surgery-transcatheter treatment strategy in the cardiac catheterization laboratory, which led to significant improvement in hemodynamics and symptoms. This to our knowledge is the first reported case of a minimally invasive approach to para-right sided AV valve regurgitation.

Candida endocarditis: systematic literature review from 1997 to 2014 and analysis of 29 cases from the Italian Study of Endocarditis.

PubMed

Giuliano, Simone; Guastalegname, Maurizio; Russo, Alessandro; Falcone, Marco; Ravasio, Veronica; Rizzi, Marco; Bassetti, Matteo; Viale, Pierluigi; Pasticci, Maria Bruna; Durante-Mangoni, Emanuele; Venditti, Mario

2017-09-01

Candida Endocarditis (CE) is a deadly disease. It is of paramount importance to assess risk factors for acquisition of both Candida native (NVE) and prosthetic (PVE) valve endocarditis and relate clinical features and treatment strategies with the outcome of the disease. Areas covered: We searched the literature using the Pubmed database. Cases of CE from the Italian Study on Endocarditis (SEI) were also included. Overall, 140 cases of CE were analyzed. Patients with a history of abdominal surgery and antibiotic exposure had higher probability of developing NVE than PVE. In the PVE group, time to onset of CE was significantly lower for biological prosthesis compared to mechanical prosthesis. In the whole population, greater age and longer time to diagnosis were associated with increased likelihood of death. Patients with effective anti-biofilm treatment, patients who underwent cardiac surgery and patients who were administered chronic suppressive antifungal treatment showed increased survival. For PVE, moderate active anti-biofilm and highly active anti-biofilm treatment were associated with lower mortality. Expert commentary: Both NVE and PVE could be considered biofilm-related diseases, pathogenetically characterized by Candida intestinal translocation and initial transient candidemia. Cardiac surgery, EAB treatment and chronic suppressive therapy might be crucial in increasing patient survival.

Tricuspid annuloplasty versus a conservative approach in patients with functional tricuspid regurgitation undergoing left-sided heart valve surgery: A study-level meta-analysis.

PubMed

Pagnesi, Matteo; Montalto, Claudio; Mangieri, Antonio; Agricola, Eustachio; Puri, Rishi; Chiarito, Mauro; Ancona, Marco B; Regazzoli, Damiano; Testa, Luca; De Bonis, Michele; Moat, Neil E; Rodés-Cabau, Josep; Colombo, Antonio; Latib, Azeem

2017-08-01

Tricuspid valve (TV) repair at the time of left-sided valve surgery is indicated in patients with either severe functional tricuspid regurgitation (TR) or mild-to-moderate TR with coexistent tricuspid annular dilation or right heart failure. We assessed the benefits of a concomitant TV repair strategy during left-sided surgical valve interventions, focusing on mortality and echocardiographic TR-related outcomes. A meta-analysis was performed of studies reporting outcomes of patients who underwent left-sided (mitral and/or aortic) valve surgery with or without concomitant TV repair. Primary endpoints were all-cause and cardiac-related mortality; secondary endpoints were the presence of more-than-moderate TR, TR progression, and TR severity grade. All endpoints were evaluated at the longest available follow-up. Fifteen studies were included for a total of 2840 patients. TV repair at the time of left-sided valve surgery was associated with a significantly lower risk of cardiac-related mortality (odds ratio [OR] 0.38; 95% confidence interval [CI]: 0.25-0.58; p<0.001), with a trend towards a lower risk of all-cause mortality (OR 0.57; 95% CI: 0.32-1.05; p=0.07) at a mean weighted follow-up of 6years. The presence of more-than-moderate TR (OR 0.19; 95% CI: 0.12-0.30; p<0.001), TR progression (OR 0.03; 95% CI: 0.01-0.05; p<0.001), and TR grade (standardized mean difference -1.11; 95% CI: -1.57 to -0.65; p<0.001) were significantly lower in the TV repair group at a mean weighted follow-up of 4.7years. A concomitant TV repair strategy during left-sided valve surgery is associated with a reduction in cardiac-related mortality and improved echocardiographic TR outcomes at follow-up. Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.

Distal Superficial Femoral Vein Cannulation for Peripherally Inserted Central Catheter Placement in Infants with Cardiac Disease.

PubMed

Richter, Robert P; Law, Mark A; Borasino, Santiago; Surd, Jessica A; Alten, Jeffrey A

2016-12-01

To describe a novel real-time ultrasound (US)-guided distal superficial femoral vein (DSFV) cannulation technique for insertion of peripherally inserted central catheters (PICC) in critically ill infants with congenital heart disease. Descriptive retrospective cohort study SETTING: Pediatric cardiac intensive care unit in a pediatric tertiary hospital PATIENTS: First 28 critically ill infants that received DSFV PICCs via this new technique. Thirty-seven US-guided DSFV PICCs were attempted on 31 infants from September 2012 to November 2014; 34 PICCs were placed in 28 patients (success rate 92%). Twenty-six of 28 patients underwent cardiac surgery. Median (IQR) age at time of PICC placement 39 days (13, 151); weight 3.4 kg (3.2, 5.3). 25/34 PICCs were placed in patients with STAT 4 or 5 category. Median PICC duration 16 days (11, 29); maximum duration 123 days. Ten infants (36%) had DSFV PICCs placed as the primary central venous access in perioperative period. Ten of 28 patients underwent cardiac catheterization while DSFV PICC was in place, four of which were performed through ipsilateral common femoral vein. Two patients had femoral arterial lines placed in the ipsilateral femoral artery while DSFV PICC was in place. There were no reported inadvertent arterial punctures. The PICC-associated infection rate was 4.6 per 1000 line days. Four of 34 DSFV PICCs (11.8%) were associated with deep venous thrombosis. DSFV is a novel venous access site for PICC placement with high success rate and sufficient longevity and flexibility for critically ill infants with cardiac disease. More experience and larger studies are needed to confirm its potential advantages. © 2016 Wiley Periodicals, Inc.

Comparison and usefulness of cardiac magnetic resonance versus computed tomography in infants six months of age or younger with aortic arch anomalies without deep sedation or anesthesia.

PubMed

Fogel, Mark A; Pawlowski, Thomas W; Harris, Matthew A; Whitehead, Kevin K; Keller, Marc S; Wilson, Justine; Tipton, Deanna; Harris, Christine

2011-07-01

The present project investigated whether cardiac magnetic resonance (CMR) of aortic arch anomalies can be performed successfully in infants <6 months of age without the use of cardiac anesthesia or deep sedation. We performed a retrospective review of infants ≤6 months old from 2005 to 2009 who underwent either CMR or computed tomography angiography to investigate aortic arch abnormalities. The CMR procedure used a "feed and swaddle" protocol without deep sedation or cardiac anesthesia. Of the 52 infants referred for CMR, 24 underwent the feed and swaddle protocol (aged 2.6 ± 1.4 months). One patient awoke during the study, and examination of the remaining 23 yielded a definitive diagnosis (success rate 96%). The scanning time was 6.2 ± 3.1 minutes, with the large airways evaluation accounting for 1/2 the time. Single-shot axial steady-state free precession, in which the definitive diagnosis was made, accounted for 0.59 ± 0.3 minutes. Fifteen infants were diagnosed with a vascular ring. Of the 8 infants who underwent surgery, the diagnostic accuracy was 100%. During the same period, 19 patients, who had undergone computed tomography angiography (aged 1.67 ± 1.20 months), were referred for aortic arch evaluation. Of these 19 patients, 6 (32%) underwent sedation or anesthesia. The imaging time was 0.08 ± 0.06 minutes, significantly different from the CMR times (p <0.01). However, the overall room times (31.3 ± 22.3 and 35.8 ± 3.86 minutes, respectively) were not different between the CMR and angiographic groups. The radiation dose was 1.41 ± 1.03 mSv. In conclusion, CMR evaluation of aortic arch anomalies in children <6 months old can be successfully completed quickly using a feed and swaddle approach with high diagnostic accuracy. This protocol avoids the risks of sedation, as well as the radiation associated with computed tomography angiography. Copyright © 2011 Elsevier Inc. All rights reserved.

The New York State cardiac registries: history, contributions, limitations, and lessons for future efforts to assess and publicly report healthcare outcomes.

PubMed

Hannan, Edward L; Cozzens, Kimberly; King, Spencer B; Walford, Gary; Shah, Nirav R

2012-06-19

In 1988, the New York State Health Commissioner was confronted with hospital-level data demonstrating very large, multiple-year, interhospital variations in short-term mortality and complications for cardiac surgery. The concern with the extent to which these differences were due to variations in patients' pre-surgical severity of illness versus hospitals' quality of care led to the development of clinical registries for cardiac surgery in 1989 and for percutaneous coronary interventions in 1992 in New York. In 1990, the Department of Health released hospitals' risk-adjusted cardiac surgery mortality rates for the first time, and shortly thereafter, similar data were released for hospitals and physicians for percutaneous coronary interventions, cardiac valve surgery, and pediatric cardiac surgery (only hospital data). This practice is still ongoing. The purpose of this communication is to relate the history of this initiative, including changes or purported changes that have occurred since the public release of cardiac data. These changes include decreases in risk-adjusted mortality, cessation of cardiac surgery in New York by low-volume and high-mortality surgeons, out-of-state referral or avoidance of cardiac surgery/angioplasty for high-risk patients, alteration of contracting choices by insurance companies, and modifications in market share of cardiac hospitals. Evidence related to these impacts is reviewed and critiqued. This communication also includes a summary of numerous studies that used New York's cardiac registries to examine a variety of policy issues regarding the choice and use of cardiac procedures, the comparative effectiveness of competing treatment options, and the examination of the relationship among processes, structures, and outcomes of cardiac care. Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Perioperative management of a patient with Dandy Walker malformation with tetralogy of Fallot undergoing total correction and fresh homologous pericardial pulmonary valve conduit implantation: Report of a rare case

PubMed Central

Datt, Vishnu; Tempe, D. K.; Lalwani, Parin; Aggarwal, Saket; Kumar, Pradeep; Diwakar, Anitha; Tomar, A. S.

2015-01-01

Perioperative management of a patient with Dandy–Walker malformation (DWM) with tetralogy of Fallot (TOF), patent ductus arteriosus, and pulmonary artery stenosis is a great challenge to the anesthesiologist. Anesthetic management in such patients can trigger tet spells that might rapidly increase intracranial pressure (ICP), conning and even death. The increase in ICP can precipitate tet spells and further brain hypoxia. To avoid an increase in ICP during TOF corrective surgery ventriculo-peritoneal (VP) shunt should be performed before cardiac surgery. We present the first case report of a 11-month-old male baby afflicted with DWM and TOF who underwent successful TOF total corrective surgery and fresh autologous pericardial pulmonary valve conduit implantation under cardiopulmonary bypass after 1 week of VP shunt insertion. PMID:26139758

Perioperative management of a patient with Dandy Walker malformation with tetralogy of Fallot undergoing total correction and fresh homologous pericardial pulmonary valve conduit implantation: Report of a rare case.

PubMed

Datt, Vishnu; Tempe, D K; Lalwani, Parin; Aggarwal, Saket; Kumar, Pradeep; Diwakar, Anitha; Tomar, A S

2015-01-01

Perioperative management of a patient with Dandy-Walker malformation (DWM) with tetralogy of Fallot (TOF), patent ductus arteriosus, and pulmonary artery stenosis is a great challenge to the anesthesiologist. Anesthetic management in such patients can trigger tet spells that might rapidly increase intracranial pressure (ICP), conning and even death. The increase in ICP can precipitate tet spells and further brain hypoxia. To avoid an increase in ICP during TOF corrective surgery ventriculo-peritoneal (VP) shunt should be performed before cardiac surgery. We present the first case report of a 11-month-old male baby afflicted with DWM and TOF who underwent successful TOF total corrective surgery and fresh autologous pericardial pulmonary valve conduit implantation under cardiopulmonary bypass after 1 week of VP shunt insertion.

Red man syndrome caused by vancomycin powder.

PubMed

Nagahama, Yasunori; VanBeek, Marta J; Greenlee, Jeremy D W

2018-04-01

Red man syndrome (RMS) is a well-known hypersensitivity reaction caused by intravenous administration of vancomycin, with symptoms ranging from flushing, erythematous rash, pruritus, mild to profound hypotension, and even cardiac arrest. RMS has not previously been described from local application of vancomycin powder in a surgical wound, a technique increasingly utilized for infection prophylaxis in many surgical disciplines including neurosurgery. We describe the first reported case of RMS as a result of local intra-wound application of vancomycin powder for infection prophylaxis. A 73-year-old male with a history of Parkinson's disease underwent 2-stage deep brain stimulation implantation surgeries. Vancomycin powder was applied locally in the surgical wounds for infection prophylaxis during both of the surgeries. The patient developed a well-demarcated, geometric erythematous pruritic rash following the second surgery that was clinically diagnosed as RMS and resolved without sequelae. Copyright © 2018 Elsevier Ltd. All rights reserved.

[Intra-operative Acute Aortic Dissection during Aortic Root Reimplantation and Mitral Valve Reconstruction Surgery in a Patient with Marfan Syndrome;Report of a Case].

PubMed

Teramoto, Chikao; Kawaguchi, Osamu; Araki, Yoshimori; Yoshikawa, Masaharu; Uchida, Wataru; Takemura, Gennta; Makino, Naoki

2016-08-01

In patients with Marfan syndrome, cardiovascular complication due to aortic dissection represents the primary cause of death. Iatrogenic acute aortic dissection during cardiac surgery is a rare, but serious adverse event. A 51-year-old woman with Marfan syndrome underwent elective aortic surgery and mitral valve reconstruction surgery for the enlarged aortic root and severe mitral regurgitation. We replaced the aortic root and ascending aorta based on reimplantation technique. During subsequent mitral valve reconstruction, we found the heart pushed up from behind. Trans-esophageal echocardiography revealed a dissecting flap in the thoracic descending aorta. There was just weak signal of blood flow in the pseudolumen. We did not add any additional procedures such as an arch replacement. Cardio-pulmonary bypass was successfully discontinued. After protamine sulfate administration and blood transfusion, blood flow in the pseudolumen disappeared. The patient was successfully discharged from the hospital on 33th postoperative day without significant morbidities.

[Acute kidney injury after pediatric cardiac surgery: risk factors and outcomes. Proposal for a predictive model].

PubMed

Cardoso, Bárbara; Laranjo, Sérgio; Gomes, Inês; Freitas, Isabel; Trigo, Conceição; Fragata, Isabel; Fragata, José; Pinto, Fátima

2016-02-01

To characterize the epidemiology and risk factors for acute kidney injury (AKI) after pediatric cardiac surgery in our center, to determine its association with poor short-term outcomes, and to develop a logistic regression model that will predict the risk of AKI for the study population. This single-center, retrospective study included consecutive pediatric patients with congenital heart disease who underwent cardiac surgery between January 2010 and December 2012. Exclusion criteria were a history of renal disease, dialysis or renal transplantation. Of the 325 patients included, median age three years (1 day-18 years), AKI occurred in 40 (12.3%) on the first postoperative day. Overall mortality was 13 (4%), nine of whom were in the AKI group. AKI was significantly associated with length of intensive care unit stay, length of mechanical ventilation and in-hospital death (p<0.01). Patients' age and postoperative serum creatinine, blood urea nitrogen and lactate levels were included in the logistic regression model as predictor variables. The model accurately predicted AKI in this population, with a maximum combined sensitivity of 82.1% and specificity of 75.4%. AKI is common and is associated with poor short-term outcomes in this setting. Younger age and higher postoperative serum creatinine, blood urea nitrogen and lactate levels were powerful predictors of renal injury in this population. The proposed model could be a useful tool for risk stratification of these patients. Copyright © 2015 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

Triple valve surgery: a 25-year experience.

PubMed

Yilmaz, Mustafa; Ozkan, Murat; Böke, Erkmen

2004-09-01

Surgical treatment of rheumatic valvular disease still constitutes a significant number of cardiac operations in developing countries. Despite improvements in myocardial protection and cardiopulmonary bypass techniques, triple valve operations (aortic, mitral and tricuspid valves) are still challenging because of longer duration of cardiopulmonary bypass and higher degree of myocardial decompensation. This study was instituted in order to assess results of triple valve surgery. Between 1977 and 2002, 34 patients underwent triple valve surgery in our clinic by the same surgeon (EB). Eleven patients underwent triple valve replacement (32.4%) and 23 underwent tricuspid valve annuloplasty with aortic and mitral valve replacements (67.6%). There was no significant difference between the two groups of patients who underwent triple valve replacement and aortic and mitral valve replacement with tricuspid valve annuloplasty. There were 4 hospital deaths (11.8%) occurring within 30 days. The duration of follow-up for 30 survivors ranged from 6 to 202 months (mean 97 months). The actuarial survival rates were 85%, 72%, and 48% at 5, 10, and 15 years respectively. Actuarial freedom from reoperation rates at 5, 10, and 15 years was 86.3%, 71.9%, and 51.2%, respectively. Freedom from cerebral thromboembolism and anticoagulation-related hemorrhage rates, expressed in actuarial terms was 75.9% and 62.9% at 5 and 10 years. Major cerebral complications occurred in 10 of the 30 patients. We prefer replacing, if repairing is not possible, the tricuspid valve, with a bileaflet mechanical prosthesis in a patient with valve replacement of the left heart who will be anticoagulated in order to avoid unfavorable properties of bioprosthesis like degeneration and of old generation mechanical prosthesis like thrombosis and poor hemodynamic function. In recent years, results of triple valve surgery either with tricuspid valve conservation or valve replacement in suitable cases have become encouraging with improvements in surgical techniques and myocardial preservation methods.

Circulating and Urinary miR-210 and miR-16 Increase during Cardiac Surgery Using Cardiopulmonary Bypass - A Pilot Study.

PubMed

Mazzone, Annette L; Baker, Robert A; McNicholas, Kym; Woodman, Richard J; Michael, Michael Z; Gleadle, Jonathan M

2018-03-01

A pilot study to measure and compare blood and urine microRNAs miR-210 and miR-16 in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) and off-pump coronary artery bypass grafting surgery. Frequent serial blood and urine samples were taken from patients undergoing cardiac surgery with CPB (n = 10) and undergoing off-pump cardiac surgery (n = 5) before, during, and after surgery. Circulating miR-210 and miR-16 levels were determined by relative quantification real-time polymerase chain reaction. Levels of plasma-free haemoglobin (fHb), troponin-T, creatine kinase, and creatinine were measured. Perioperative serum miR-210 and miR-16 were elevated significantly compared to preoperative levels in patients undergoing cardiac surgery with CPB (CPB vs. Pre Op and Rewarm vs. Pre Op; p < .05 for both). There were increases of greater than 200% in miR-210 levels during rewarming and immediately postoperatively and a 3,000% increase in miR-16 levels immediately postoperatively in urine normalized to urinary creatinine concentration. Serum levels of miR-16 were relatively constant during off-pump surgery. miR-210 levels increased significantly in off-pump patients perioperatively ( p < .05 Octopus on vs. Pre Op); however, the release was less marked when compared to cardiac surgery with CPB. A significant association was observed between both miR-16 and miR-210 and plasma fHb when CPB was used ( r = -.549, p < .0001 and r = -.463, p < .0001 respectively). Serum and urine concentrations of hypoxically regulated miR-210 and hemolysis-associated miR-16 increased in cardiac surgery using CPB compared to off-pump surgery. These molecules may have utility in indicating severity of cardiac, red cell, and renal injury during cardiac surgery.

Aortic valve replacement in a patient with severe nickel allergy.

PubMed

Lusini, Mario; Barbato, Raffaele; Spadaccio, Cristiano; Chello, Massimo

2011-11-01

Nickel allergy can raise clinical problems in patients undergoing cardiac surgery who require sternal closure with stainless steel wire. We describe the case of a 51-year-old woman with severe nickel allergy who underwent aortic valve replacement with a nickel-free ON-X prosthesis and sternal closure by Fiberwire # 2 suture without complications. Considering its biocompatibility and its mechanical characteristics including optimal strength and knot resistance, this suture might be a viable alternative in patients in which the use of stainless steel wire is contraindicated. © 2011 Wiley Periodicals, Inc.

Xenograft transplantation in congenital cardiac surgery at Baskent University: midterm results.

PubMed

Ozkan, S; Akay, T H; Gultekin, B; Sezgin, A; Tokel, K; Aslamaci, S

2007-05-01

Xenograft valved conduits have been used in several cardiac pathologies. In this study we have presented our midterm results of pediatric patients pathologies who were operated with xenograft conduits. Between January 1999 and January 2005, 134 patients underwent open heart surgery with xenograft conduits. The conduits were used to establish the continuity of the right ventricle to the pulmonary artery or aorta, the left ventricle to the pulmonary artery, or aorta due to various types of complex cardiac anomalies. Patients were evaluated by transthoracic echocardiography (ECHO) at 6-month follow-ups. Cardiac catheterization was performed when ECHO demonstrated significant conduit failure. Hospital mortality was observed in 28 patients (20.1%), and 13 patients died upon follow-up (9.7%). Mean follow-up was 24.6 +/- 4 months (range, 13 to 85 months). Among 93 survivors 20 patients (21.5%) were reoperated due to conduit failure. The main reasons for conduit failure were stenosis (n=13), valvular regurgitation (n=2), or both conditions in 5 cases. Mean pulmonary gradient before conduit re-replacement was 47.7 +/- 30.1 mmHg. The 1-, 3-, and 6-year actuarial survival rates were 95 +/- 2%, 91 +/- 3%, and 86 +/- 5%. The 1-, 3-, and 6-year actuarial freedom rates from reoperation were 95 +/- 1%, 90 +/- 3%, and 86 +/- 4%. An increased gradient between the pulmonary artery and the right ventricle and prolonged cardiopulmonary bypass times were observed to be significant risk factors for reoperation. There was no mortality among reoperated patients. Xenograft conduits should be closely followed for calcification and stenosis. Conduit stenosis is the major risk factor for reoperation. In these patients, reoperation for conduit replacement can be performed safely before deterioration of cardiac performance.

Grundvoraussetzungen herzchirurgischer Einheiten zur Behandlung von Patienten mit angeborenen Herzfehlern.

PubMed

2016-01-01

This document defines fundamental structures of congenital cardiac surgery departments in Germany. It has been developed by the executive boards of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) and the German Society of Pediatric Cardiology (GSPC) in collaboration with the working group for Congenital and Pediatric Heart Surgery of the GSTCVS.This updated consensus paper is based on a previous publication of the European Association for Cardiothoracic Surgery (EACTS) and is a refinement and adaptation of its initial version published by the GSTCVS in 2005. In Germany, pediatric cardiology and cardiac surgery facilities caring for patients with congenital cardiac defects are subject to certain regulations. For example, in 2010 the Federal Joint Committee implemented the resolution on Quality Assurance Measures in the Provision of Cardiac Surgical Care for Children and Adolescents (directive congenital cardiac surgery) which regulates structural and process quality compulsorily. To date, fundamental and considerable differences of the respective departments persist.Congenital cardiac surgery departments have to provide the whole spectrum of the cardiac surgical therapy from the neonate to the adult with congenital cardiac defects (with the exception of heart transplantation) continuously and with the appropriate experience. Furthermore, the departments have to prove their constant scientific activity and ensure that they facilitate education and training for the specialty certification in cardiac surgery. The responsible surgeons of all congenital cardiac surgery departments commit to participate in the currently voluntary national quality assurance for congenital cardiac defects of the GSTCVS and the GSPC and perform an individual surgical outcome assessment and risk stratification. This is supplemented by the willingness for external certification specific to the individual and the facilitation of peer review procedures for quality assurance purposes. Additional measures, such as collaboration in clinical research and ongoing interdisciplinary education and training, are preferable. Georg Thieme Verlag KG Stuttgart · New York.

Revised ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Implications for preoperative clinical evaluation.

PubMed

Guarracino, F; Baldassarri, R; Priebe, H J

2015-02-01

Each year, an increasing number of elderly patients with cardiovascular disease undergoing non-cardiac surgery require careful perioperative management to minimize the perioperative risk. Perioperative cardiovascular complications are the strongest predictors of morbidity and mortality after major non-cardiac surgery. A Joint Task Force of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA) has recently published revised Guidelines on the perioperative cardiovascular management of patients scheduled to undergo non-cardiac surgery, which represent the official position of the ESC and ESA on various aspects of perioperative cardiac care. According to the Guidelines effective perioperative cardiac management includes preoperative risk stratification based on preoperative assessment of functional capacity, type of surgery, cardiac risk factors, and cardiovascular function. The ESC/ESA Guidelines discourage indiscriminate routine preoperative cardiac testing, because it is time- and cost-consuming, resource-limiting, and does not improve perioperative outcome. They rather emphasize the importance of individualized preoperative cardiac evaluation and the cooperation between anesthesiologists and cardiologists. We summarize the relevant changes of the 2014 Guidelines as compared to the previous ones, with particular emphasis on preoperative cardiac testing.

Nutritional status of pediatric patients with congenital heart disease: pre- and post cardiac surgery.

PubMed

Ratanachu-Ek, Suntaree; Pongdara, Aujjimavadee

2011-08-01

Malnutrition is common in infants and children with congenital heart disease (CHD). Cardiac surgery has improved patient survival and nutritional status. To evaluate the impact of cardiac surgery on nutritional status of pediatric patients with CHD. A prospective cohort study was conducted in pediatric patients with CHD, admitted for cardiac surgery at Queen Sirikit National Institute of Child Health (QSNICH), Bangkok, from August 1st, 2002 to 2003. Demographic data, cardiac and related problems were obtained before operation. Anthropometry was performed at the presentation and post cardiac surgery. Nutritional status was assessed by Z-score of weight for age (ZWA), weight for height (ZWH) and height for age (ZHA). Malnutrition was defined as Z-score <- 2 and compared pre- and post-operation using Chi-square. Paired t-test was used to compare mean Z-score and p-value < 0.05 was statistically significant. All of 161 pediatric patients with CHD undergoing cardiac surgery were 41% males and 59% females. Patients' age ranged from 1 month to 15 years. The related problems included low birth weight (28%) and feeding problem (58%). The most common CHD was ventricular septal defect (29%). The nutritional status of the patients before surgery was defined as normal 57%, malnutrition 40% and over-nutrition 3%. Malnutrition included underweight 28%, wasting 22% and stunting 16%. Post cardiac surgery, the means of ZWA, ZWH and ZHA were significantly increased and the prevalence of underweight and wasting were decreased to 17% and 6% respectively, with statistically significant from the baseline (p < 0.05). Malnutrition was found in 40% of pediatric patients with CHD and cardiac surgery has a significant positive effect on weight gain and nutritional status.

Determinants of the relationship between cost and survival time after elective adult cardiac surgery.

PubMed

Ho, K M

2014-05-01

Cardiac surgery is increasingly performed on elderly patients with multiple comorbid conditions, but the determinants of the relationship between cost and survival time after cardiac surgery for patients with a serious cardiac condition remain uncertain. Using the long-term outcome data of a cohort study on adult cardiac surgical patients, the relationship between cost and survival time after cardiac surgery from a hospital service perspective was determined. The total cost for each patient was estimated by the costs of the surgical procedures, intra-aortic balloon pump utilisation, operating theatre utilisation, blood products, intensive care unit stay and cumulative hospital stay up to a median follow-up time of 30 months. Of the 2131 patients considered in this study, a total cost >A$100,000 per life-year after cardiac surgery was observed only in 171 patients (8.0%, 95% confidence interval 6.9 to 9.3%). Age, Charlson Comorbidity Index and EuroSCORE were all related to the cost per life-year after cardiac surgery, but EuroSCORE (odds ratio 1.26 per score increment, 95% confidence interval 1.18 to 1.35, P=0.001) was, by far, the most important determinant and explained 32% of the variability in cost per life-year after cardiac surgery. Patients with a high EuroSCORE were associated with a substantially longer length of intensive care unit stay and cumulative hospital stay, as well as a shorter survival time after cardiac surgery compared to patients with a lower EuroSCORE. Of all the subgroups of patients examined, only patients with a EuroSCORE >5 were consistently associated with a cost >A$100,000 per life-year (cost per life-year $183,148, 95% confidence interval 125, 394 to 240, 902).

Carbon dioxide field flooding reduces neurologic impairment after open heart surgery.

PubMed

Martens, Sven; Neumann, Katrin; Sodemann, Christian; Deschka, Heinz; Wimmer-Greinecker, Gerhard; Moritz, Anton

2008-02-01

Air emboli released from incompletely deaired cardiac chambers may cause neurocognitive decline after open heart surgery. Carbon dioxide (CO2) field flooding is reported to reduce residual intracavital air during cardiac surgery. A protective effect of carbon dioxide insufflation on postoperative brain function remains unproven in clinical trials. Eighty patients undergoing heart valve operations by median sternotomy were randomly assigned to either CO2 insufflation (group I, n = 39) or unprotected controls (group II, n = 41). Preoperative evaluation included neurocognitive test batteries consisting of six different tests, and objective measurements of brain function by means of P300 wave auditory-evoked potentials (peak latencies, ms). Neurocognitive testing and P300 measurements were repeated on postoperative day 5. Neurocognitive deficit (ND) was defined as a 20% decrement in two or more tests. Preoperatively, P300 peak latencies did not differ between groups (374 +/- 75 vs 366 +/- 72 ms, not significant [n.s.]). Five days after surgery, P300 peak latencies were significantly shorter with CO2 protection as compared with the unprotected control group (group I: 390 +/- 68 ms, group II: 429 +/- 75 ms, p = 0.02). Clinical outcome was comparable as for mortality (group I: 1 patient; group II: 2 patients) and cerebrovascular events or confusional syndromes (group I: 5 patients; group II: 4 patients) or other clinical variables as intubation time or hospital stay. Neurocognitive test batteries did not reveal differences between groups. Shorter P300 peak latencies after surgery indicate less brain damage in patients who underwent heart valve operations with CO2 flooding of the thoracic cavity. Even if these findings were not supported by clinical results or neurocognitive test batteries in our cohort, carbon dioxide field flooding has proven efficiency and should be advocated for all patients undergoing open heart surgery.

Advantages of autologous blood transfusion in off-pump coronary artery bypass.

PubMed

Ela, Yuksel; Emmiler, Mustafa; Kocogullari, Cevdet Ugur; Terzi, Yuksel; Sivaci, Remziye Gul; Cekirdekci, Ahmet

2009-10-01

In this randomized controlled study, we investigated the effects of autologous Hemobag blood transfusion (AHBT) and allogenic blood transfusion (ABT) in off-pump coronary artery bypass (OPCAB) surgery. Sixty patients who underwent surgery between February 2008 and August 2008 were randomized into 2 groups. The AHBT group (n = 30) consisted of patients who received autologous Hemobag blood transfusion, and the ABT group (n = 30) consisted of patients who received allogenic blood transfusion. All patients underwent OPCAB via sternotomy. The time to extubation, chest tube drainage volume, postoperative white blood cell counts, amount of blood transfusion, sedimentation rate, C-reactive protein concentration, postoperative temperature, and the presence of atelectasis were recorded in the intensive care unit. Intraoperative bleeding and fluid resuscitation were similar in the 2 groups (P > .05); however, there were significant decreases in postoperative blood loss, extubation period, postoperative white cell counts, sedimentation rate, incidence of atelectasis, C-reactive protein, and fever in the AHBT group compared with the ABT group (P < .05). The rate of atrial fibrillation in the AHBT group tended to be lower than in the ABT group. Autologous blood transfusion in OPCAB may be beneficial in certain cardiac surgery patients; however, these beneficial effects require further study to be proved.

Minimally Invasive Mitral Valve Procedures: The Current State

PubMed Central

Ritwick, Bhuyan; Chaudhuri, Krishanu; Crouch, Gareth; Edwards, James R. M.; Worthington, Michael; Stuklis, Robert G.

2013-01-01

Since its early days, cardiac surgery has typically involved large incisions with complete access to the heart and the great vessels. After the popularization of the minimally invasive techniques in general surgery, cardiac surgeons began to experiment with minimal access techniques in the early 1990s. Although the goals of minimally invasive cardiac surgery (MICS) are fairly well established as decreased pain, shorter hospital stay, accelerated recuperation, improved cosmesis, and cost effectiveness, a strict definition of minimally invasive cardiac surgery has been more elusive. Minimally invasive cardiac surgery started with mitral valve procedures and then gradually expanded towards other valve procedures, coronary artery bypass grafting, and various types of simple congenital heart procedures. In this paper, the authors attempt to focus on the evolution, techniques, results, and the future perspective of minimally invasive mitral valve surgery (MIMVS). PMID:24382998

Carperitide and atrial fibrillation after coronary bypass grafting: the Nihon University working group study of low-dose HANP infusion therapy during cardiac surgery trial for postoperative atrial fibrillation.

PubMed

Sezai, Akira; Iida, Mitsuru; Yoshitake, Isamu; Wakui, Shinji; Osaka, Shunji; Kimura, Haruka; Yaoita, Hiroko; Hata, Hiroaki; Shiono, Motomi; Nakai, Toshiko; Takayama, Tadateru; Kunimoto, Satoshi; Kasamaki, Yuji; Hirayama, Atsushi

2015-06-01

Occurrence of atrial fibrillation after cardiac surgery is associated with long-term mortality. We investigated whether infusion of human atrial natriuretic peptide (carperitide) could prevent postoperative atrial fibrillation. A total of 668 patients who underwent isolated coronary artery bypass grafting were randomized to receive infusion of carperitide or physiological saline from the initiation of cardiopulmonary bypass. Patients were monitored continuously for 1 week after surgery to detect atrial fibrillation. The risk factors were investigated by Cox proportional hazard model. Postoperative atrial fibrillation occurred in 41 of 335 patients (12.2%) from the carperitide group versus 110 of 333 patients (32.7%) from the placebo group (P<0.0001). Postoperative levels of angiotensin-II, aldosterone, creatine kinase MB isoenzyme, human heart fatty acid-binding protein, and brain natriuretic peptide were all significantly lower in the carperitide group. The risk factors for postoperative atrial fibrillation by the Cox proportional hazard model were an age ≥70 years, emergency surgery, preoperative aldosterone level >150 ng/mL, preoperative nonuse of angiotensin receptor antagonists, preoperative use of calcium antagonists, postoperative nonuse of β-blockers, postoperative nonuse of aldosterone blockers, and nonuse of carperitide. -Perioperative carperitide infusion reduced the occurrence of postoperative atrial fibrillation. Accordingly, carperitide could be a useful option for preventing postoperative atrial fibrillation. -URL: http://www.umin.ac.jp. Unique Identifier: UMIN000003958. © 2015 American Heart Association, Inc.

The History of Heart Surgery at The Johns Hopkins Hospital.

PubMed

Patel, Nishant D; Alejo, Diane E; Cameron, Duke E

2015-01-01

Johns Hopkins has made many lasting contributions to cardiac surgery, including the discovery of heparin and the Blalock-Taussig Shunt, which represents the dawn of modern cardiac surgery. Equally important, Johns Hopkins has trained some of the world's leaders in academic cardiac surgery, and is committed to training the future leaders in our specialty. Copyright © 2015. Published by Elsevier Inc.

Quality and Safety in Health Care, Part XXVI: The Adult Cardiac Surgery Database.

PubMed

Harolds, Jay A

2017-09-01

The Adult Cardiac Surgery Database of the Society of Thoracic Surgeons has provided highly useful information in quality and safety in general thoracic surgery, including ratings of the surgeons and institutions participating in this type of surgery. The Adult Cardiac Surgery Database information is very helpful for writing guidelines and determining optimal protocols and for many research projects. This article discusses the history and current status of this database.

Cardiac stress test as a risk-stratification tool for posttransplant cardiac outcomes in diabetic kidney transplant recipients.

PubMed

Singh, Neeraj; Parikh, Samir; Bhatt, Udayan; Vonvisger, Jon; Nori, Uday; Hasan, Ayesha; Samavedi, Srinivas; Andreoni, Kenneth; Henry, Mitchell; Pelletier, Ronald; Rajab, Amer; Elkhammas, Elmahdi; Pesavento, Todd

2012-12-27

The utility of cardiac stress testing as a risk-stratification tool before kidney transplantation remains debatable owing to discordance with coronary angiography and outcome yields at different centers. We conducted a retrospective study of 273 diabetic kidney transplant recipients from 2006 to 2010. By protocol, all diabetic patients underwent pharmacological radionucleotide stress test or dobutamine stress echocardiography before transplant. We compared the 1-year cardiac outcomes between those with negative stress test results and those with positive stress test results. Patients with a positive stress test result (n=67) underwent coronary angiogram, and significant coronary artery disease (≥70% coronary stenosis) was found in 35 (52.2%) patients. Of the latter, 32 (91.4%) underwent cardiac revascularization (24 underwent cardiac stenting and 8 underwent coronary artery bypass grafting). The rest (n=35) were treated medically. Within 1 year after transplant, the group with positive stress test results experienced more cardiac events (34.3% vs. 3.9%, P<0.001) including acute myocardial infarction (22.4% vs. 3.4%, P<0.001) and ventricular arrhythmias (8.9% vs. 0.05%, P=0.001), higher all-cause mortality (19.4% vs. 4.8%, P<0.001), and cardiac mortality (17.9% vs. 0.9%, P<0.001) compared with the group with negative stress test results. In this diabetic population, stress testing showed positive and negative predictive values of 34.3% and 96.1%, respectively. Pharmacological cardiac stress testing provided excellent risk stratification in diabetic kidney transplant recipients.

Patients with anomalous aortic origin of the coronary artery remain at risk after surgical repair.

PubMed

Nees, Shannon N; Flyer, Jonathan N; Chelliah, Anjali; Dayton, Jeffrey D; Touchette, Lorraine; Kalfa, David; Chai, Paul J; Bacha, Emile A; Anderson, Brett R

2018-02-08

Anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus of Valsalva is a rare cardiac anomaly associated with sudden cardiac death (SCD). Single-center studies describe surgical repair as safe, although medium- and long-term effects on symptoms and risk of SCD remain unknown. We sought to describe outcomes of surgical repair of AAOCA. We reviewed institutional records for patients who underwent AAOCA repair, from 2001 to 2016, at 2 affiliated institutions. Patients with associated heart disease were excluded. In total, 60 patients underwent AAOCA repair. Half of the patients (n = 30) had an anomalous left coronary artery arising from the right sinus of Valsalva and half had an anomalous right. Median age at surgery was 15.4 years (interquartile range, 11.9-17.9 years; range, 4 months to 68 years). The most common presenting symptoms were chest pain (n = 38; 63%) and shortness of breath (n = 17; 28%); aborted SCD was the presenting symptom in 4 patients (7%). Follow-up data were available for 54 patients (90%) over a median of 1.6 years. Of 53 patients with symptoms at presentation, 34 (64%) had complete resolution postoperatively. Postoperative mild or greater aortic insufficiency was present in 8 patients (17%) and moderate supravalvar aortic stenosis in 1 (2%). One patient required aortic valve replacement for aortic insufficiency. Two patients required reoperation for coronary stenosis at 3 months and 6 years postoperatively. Surgical repair of AAOCA is generally safe and adverse events are rare. Restenosis, and even sudden cardiac events, can occur and long-term surveillance is critical. Multi-institutional collaboration is vital to identify at-risk subpopulations and refine current recommendations for long-term management. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Less Is More: Results of a Statewide Analysis of the Impact of Blood Transfusion on Coronary Artery Bypass Grafting Outcomes.

PubMed

Crawford, Todd C; Magruder, J Trent; Fraser, Charles; Suarez-Pierre, Alejandro; Alejo, Diane; Bobbitt, Jennifer; Fonner, Clifford E; Canner, Joseph K; Horvath, Keith; Wehberg, Kurt; Taylor, Bradley; Kwon, Christopher; Whitman, Glenn J; Conte, John V; Salenger, Rawn

2018-01-01

Debate persists over the association between blood transfusions, especially those considered discretionary, and outcomes after cardiac operations. Using data from the Maryland Cardiac Surgery Quality Initiative, we sought to determine whether outcomes differed among coronary artery bypass grafting (CABG) patients receiving 1 U of red blood cells (RBCs) vs none. We used a statewide database to review patients who underwent isolated CABG from July 1, 2011, to June 30, 2016, across 10 Maryland cardiac surgery centers. We included patients who received 1 U or fewer of RBCs from the time of the operation through discharge. Propensity scoring, using 20 variables to control for treatment effect, was performed among patients who did and did not receive a transfusion. These two groups were matched 1:1 to assess for differences in our primary outcomes: operative death, prolonged postoperative length of stay (>14 days), and a composite postoperative respiratory complication of pneumonia or reintubation, or both. Of 10,877 patients who underwent CABG, 6,124 (56%) received no RBCs (group 1) during their operative hospitalization, and 981 (9.0%) received 1 U of RBCs (group 2), including 345 of 981 patients (35%) who received a transfusion intraoperatively. Propensity score matching generated 937 well-matched pairs. Compared with group 2, propensity-matched analysis revealed significantly greater 30-day survival in group 1 (99% vs 98%, p = 0.02) and reduced incidence of prolonged length of stay (3.7% vs 4.0%, p < 0.01). Our collaborative statewide analysis demonstrated that even 1 unit of blood was associated with significantly worse survival and longer length of stay after CABG. Multiinstitutional quality initiatives may seek to address discretionary transfusions and possess the potential to improve patient outcomes. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Radial mean arterial pressure reliably reflects femoral mean arterial pressure in uncomplicated pediatric cardiac surgery.

PubMed

Cetin, Secil; Pirat, Arash; Kundakci, Aycan; Camkiran, Aynur; Zeyneloglu, Pinar; Ozkan, Murat; Arslan, Gulnaz

2014-02-01

To see if radial mean arterial pressure reliably reflects femoral mean arterial pressure in uncomplicated pediatric cardiac surgery. An ethics committee-approved prospective interventional study. Operating room of a tertiary care hospital. Forty-five children aged 3 months to 4 years who underwent pediatric cardiac surgery with hypothermic cardiopulmonary bypass. Simultaneous femoral and radial arterial pressures were recorded at 10-minute intervals intraoperatively. A pressure gradient>5mmHg was considered to be clinically significant. The patients' mean age was 14±11 months and and mean weight was 8.0±3.0kg. A total of 1,816 simultaneous measurements of arterial pressure from the radial and femoral arteries were recorded during the pre-cardiopulmonary bypass, cardiopulmonary bypass, and post-cardiopulmonary bypass periods, including 520 (29%) systolic arterial pressures, 520 (29%) diastolic arterial pressures, and 776 (43%) mean arterial pressures. The paired mean arterial pressure measurements across the 3 periods were significantly and strongly correlated, and this was true for systolic arterial pressures and diastolic arterial pressures as well (r>0.93 and p<0.001 for all). Bland-Altman plots demonstrated good agreement between femoral and radial mean arterial pressures during the pre-cardiopulmonary bypass, cardiopulmonary bypass, and post-cardiopulmonary bypass periods. A significant radial-to-femoral pressure gradient was observed in 150 (8%) of the total 1,816 measurements. These gradients occurred most frequently between pairs of systolic arterial pressure measurements (n = 113, 22% of all systolic arterial pressures), followed by mean arterial pressure measurements (n = 28, 4% of all mean arterial pressures) and diastolic arterial pressures measurements (n = 9, 2% of all diastolic arterial pressures). These significant gradients were not sustained (ie, were not recorded at 2 or more successive time points). The results suggested that radial mean arterial pressure provided an accurate estimate of central mean arterial pressure in uncomplicated pediatric cardiac surgery. There was a significant gradient between radial and femoral mean arterial pressure measurements in only 4% of the mean arterial pressure measurements, and these significant gradients were not sustained. Copyright © 2014 Elsevier Inc. All rights reserved.

[Anesthetic Management Using Transesophageal Echocardiography and EV1000 in a Patient with Ebstein's Anomary Undergoing Scoliosis Surgery].

PubMed

Tanimura, Kazuki; Miura, Yukiko; Ishii, Hisanari

2016-02-01

An 18-year-old female patinet with Ebstein anomaly underwent surgical repair of scoliosis under total intravenous anesthesia. In addtition to normal monitors, we used transesophageal echocardiography (TEE) and EV1000 (Edwards Lifesciences, Irvine, USA), which show stroke volume variation and stroke volume index simultaneously in a rectangular coordinates. TEE detected reversal of intracardiac shunt which caused SpO2 decrease during fixing screws at thoracic vertebrae, then manual ventilation with oxygen unproved SpO2. Because of a high venous pressure due to Ebstein anomaly, surgical bleeding seemed to be larger than usual. By using EV1000, volume status and cardiac contractility were estimated and adequate volume loading and inoptrope injection were performed to stabilize circulatory condition. The operation was completed without any cardiac and respiratory complications.

Mitral restenosis in the early postoperative period of a patient with systemic lupus erythematosus.

PubMed

Pomerantzeff, P M; Corrêa, J D; Brandão, C M; de Assis, R V; Jatene, A D

1999-04-01

A forty-eight year old woman, who had undergone mitral comissurotomy and subsequently developed early restenosis, presented with major comissural fusion and verrucous lesions on the cuspid edges of the mitral valve, with normal subvalvar apparatus. Patient did well for the first six months after surgery when she began to present dyspnea on light exertion. A clinical diagnosis of restenosis was made, which was confirmed by an echocardiogram and cardiac catheterization. She underwent surgery, and a stenotic mitral valve with verrucous lesions suggesting Libman-Sacks' endocarditis was found. Because the diagnosis of systemic lupus erythematosus (SLE) had not been confirmed at that time, a bovine pericardium bioprosthesis (FISICS-INCOR) was implanted. The patient did well in the late follow-up and is now in NYHA Class I.

Atelectasis after airway extubation during veno-arterial extracorporeal membrane oxygenation support.

PubMed

Wang, Hong; Jia, Ming; Mao, Bin; Hou, Xiaotong

2017-09-01

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is used in cardiopulmonary failure patients to provide temporary assisted circulation. Usually, prolonged intubation and invasive mechanical ventilation are required in patients with ECMO support. We report on two cases of patients who had no pre-existing injuries of the affected lung, underwent VA ECMO support after open-heart surgery and received airway extubation (AE) or awake ECMO with the recovery of left ventricular ejection fraction. Atelectasis happened after AE and non-invasive positive pressure ventilation attenuated the atelectasis of one patient. The atelectasis of the other patient was corrected 10 hours after weaning from ECMO. Both patients were discharged successfully. Awake VA ECMO for post-cardiac surgery patients should be performed with prudence and needs further research.

Recycling of internal thoracic arteries in reoperative coronary surgery: in-hospital and midterm results.

PubMed

El Oumeiri, Bachar; Glineur, David; Price, Joel; Boodhwani, Munir; Etienne, Pierre Yves; Poncelet, Alain; De Kerchove, Laurent; Papadatos, Spiridon; Noirhomme, Philippe; El Khoury, Gebrine

2011-04-01

Selected patients, presenting for reoperative coronary surgery with patent internal thoracic arteries (ITAs), may benefit from techniques to salvage and reuse these ITA grafts. We have termed this practice the recycling of ITAs. The purpose of this study is to report our short-term and midterm results using various recycling techniques. Between April 1996 and February 2009, 60 patients underwent ITA recycling at our institution. Information regarding survival and cardiac events was obtained from a prospectively maintained, institutional database. Survival and freedom from major adverse cardiac events were calculated using Kaplan-Meier analysis. Mean follow-up duration was 60 ± 36 months. Mean age was 64 ± 9 years and the mean time to reoperation was 117 ± 68 months. The patent ITA served as an inflow for a composite Y graft in 39 patients and was distally reimplanted on the same coronary vessel in 9 patients. A combination of these two techniques was used in 8 patients. Other techniques were used in the remaining 4 patients. Freedom from cardiac death was 93% ± 7% and 85% ± 9% at 1 and 5 years and freedom from major adverse cardiac events was 93% ± 7% and 81% ± 11% at 1 and 5 years, respectively. Recycling of ITA grafts during reoperative coronary artery bypass grafting is safe and feasible in selected patients. These techniques can be useful in selected young patients to avoid saphenous vein graft or in patients with a lack of graft conduits. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Exposure to high stress in the intensive care unit may have negative effects on health-related quality-of-life outcomes after cardiac surgery.

PubMed

Schelling, Gustav; Richter, Markus; Roozendaal, Benno; Rothenhäusler, Hans-Bernd; Krauseneck, Till; Stoll, Christian; Nollert, Georg; Schmidt, Michael; Kapfhammer, Hans-Peter

2003-07-01

Up to 20% of patients do not show improvements in health-related quality of life (HRQL) after cardiac surgery, despite apparently successful surgical procedures. We sought to determine whether failed improvements in HRQL after cardiac surgery are associated with the development of traumatic memories and chronic stress states as a result of high perioperative stress exposure. Prospective cohort study. A 10-bed cardiovascular intensive care unit of a tertiary care university hospital. A total of 148 cardiac surgical patients. None. The patients were evaluated for traumatic memories from postoperative treatment in the cardiovascular intensive care unit (defined as the subjective recollection of pain, respiratory distress, anxiety/panic, and nightmares), symptoms of chronic stress, including those of posttraumatic stress disorder, and HRQL preoperatively (at baseline) and at 6 months after cardiac surgery. A state of chronic stress was defined as the development of posttraumatic stress disorder at 6 months after surgery. Factors predicting the decline in HRQL were determined by multivariable linear regression. Twenty-seven patients (18.2%) had posttraumatic stress disorder at 6 months after cardiac surgery; seven of these patients (4.8%) had evidence of preexisting posttraumatic stress disorder before undergoing cardiac surgery. Patients with new posttraumatic stress disorder at 6 months after cardiac surgery had a significantly higher number of traumatic memories from postoperative treatment in the cardiovascular intensive care unit (p =.01). A multiple regression model included the number of traumatic memories from the intensive care unit and stress symptom scores at 6 months after heart surgery as predictors for variations in physical HRQL outcome scores (R2 =.30, p <.04). Stress symptom scores were the most significant predictors of mental health HRQL outcomes (R2 =.52, p <.01). Exposure to high stress in the cardiovascular intensive care unit can have negative effects on HRQL outcomes of cardiac surgery.

Blood glucose management in the patient undergoing cardiac surgery: A review

PubMed Central

Reddy, Pingle; Duggar, Brian; Butterworth, John

2014-01-01

Both diabetes mellitus and hyperglycemia per se are associated with negative outcomes after cardiac surgery. In this article, we review these associations, the possible mechanisms that lead to adverse outcomes, and the epidemiology of diabetes focusing on those patients requiring cardiac surgery. We also examine outpatient and perioperative management of diabetes with the same focus. Finally, we discuss our own efforts to improve glycemic management of patients undergoing cardiac surgery at our institution, including keys to success, results of implementation, and patient safety concerns. PMID:25429332

Epworth HealthCare cardiac surgery audit report 2011.

PubMed

Chorley, T; Baker, L

2012-10-01

2011 is the first year Epworth has contributed to Australian and New Zealand Society of Cardiac and Thoracic Surgeons cardiac surgery database. There is now a 30-day follow-up data for all cardiac surgical patients as well as benchmarking of our results with 19 public hospitals and 6 private hospitals contributing data to the Australian and New Zealand Society of Cardiac and Thoracic Surgeons. This is an extension of the John Fuller Melbourne University database that has compiled cardiac surgery data for the last 30 years. © 2012 The Authors; Internal Medicine Journal © 2012 Royal Australasian College of Physicians.

Comparison of Levosimendan, Milrinone and Dobutamine in treating Low Cardiac Output Syndrome Following Valve Replacement Surgeries with Cardiopulmonary Bypass

PubMed Central

Sunny; Karim, Habib Md Reazaul; Saikia, Manuj Kumar; Bhattacharyya, Prithwis; Dey, Samarjit

2016-01-01

Introduction Low Cardiac Output Syndrome (LCOS) following Cardiopulmonary Bypass (CPB) is common and associated with increased mortality. Maintenance of adequate cardiac output is one of the primary objectives in management of such patients. Aim To compare Levosimendan, Milrinone and Dobutamine for the treatment of LCOS after CPB in patients who underwent valve replacement surgeries. Materials and Methods Sixty eligible patients meeting LCOS were allocated into three treatment groups: Group A-Levosimendan (loading dose 10μg/kg over 10 minutes, followed by 0.1μg/kg/min); Group B-Milrinone (loading dose 50 mcg/kg over 10 minutes followed by 0.5mcg/kg/min) and Group C-Dobutamine @ 5μg/kg/min to achieve target cardiac index (CI) of > 2.5 L/min/m2. In case of failure, other drugs were added as required. Hemodynamic parameters were monitored using EV1000TM clinical platform till 30 minutes post CPB. INSTAT software was used for statistics and p<0.05 was considered significant. Results The mean±standard deviation of time taken by Dobutamine, Levosimendan and Milrinone to bring the CI to target were 11.1±8.79, 11.3±6.34 and 16.62±9.33 minutes respectively (p=0.064). Levosimendan was equally effective in increasing and maintaining adequate CI as compared to Dobutamine (p>0.05). Levosimendan and Milrinone increased MAP (Mean Arterial Pressure) equally while Dobutamine was more effective as compared to both Levosimendan and Milrinone 20th minute onwards (p<0.01). Milrinone was less effective in increasing the stroke volume as compared to Dobutamine and Levosimendan while Dobutamine and Levosimendan were equally effective. There was no difference in the HR (Heart Rate) achieved with all these three drugs. Conclusion Levosimendan is equally effective to Dobutamine and better than Milrinone for the treatment of LCOS following CPB in patients undergoing valve replacement surgeries. PMID:28208977

Heart block and cardiac embolization of fractured inferior vena cava filter.

PubMed

Abudayyeh, Islam; Takruri, Yessar; Weiner, Justin B

2016-01-01

A 66-year-old man underwent a placement of an inferior vena cava filter before a gastric surgery 9 years prior, presented to the emergency room with a complete atrioventricular block. Chest x-ray and transthoracic echocardiogram showed struts migrating to right ventricle with tricuspid regurgitation. Cardiothoracic surgery was consulted and declined an open surgical intervention due to the location of the embolized fragments and the patient's overall condition. It was also felt that the fragments had migrated chronically and were adhered to the cardiac structures. The patient underwent a dual-chamber permanent pacemaker implantation. Post-implant fluoroscopy showed no displacement of the inferior vena cava filter struts due to the pacemaker leads indicating that the filter fracture had likely been a chronic process. This case highlights a rare combination of complications related to inferior vena cava filter fractures and the importance of assessing for such fractures in chronic placements. Inferior vena cava filter placement for a duration greater than 1 month can be associated with filter fractures and strut migration which may lead to, although rare, serious or fatal complications such as complete atrioventricular conduction system disruption and valvular damage including significant tricuspid regurgitation. Assessing for inferior vena cava filter fractures in chronic filter placement is important to avoid such complications. When possible, retrieval of the filter should be considered in all patients outside the acute setting in order to avoid filter-related complications. Filter retrieval rates remain low even when a retrievable filter is in place and the patient no longer has a contraindication to anticoagulation.

An Interdisciplinary Education Initiative to Promote Blood Conservation in Cardiac Surgery.

PubMed

Goda, Tamara S; Sherrod, Brad; Kindell, Linda

Transfusion practices vary extensively for patients undergoing cardiac surgical procedures, leading to high utilization of blood products despite evidence that transfusions negatively impact outcomes. An important factor affecting transfusion practice is recognition of the importance of teams in cardiac surgery care delivery. This article reports an evidenced-based practice (EBP) initiative constructed using the Society of Thoracic Surgery (STS) 2011 Blood Conservation Clinical Practice Guidelines (CPGs) to standardize transfusion practice across the cardiac surgery team at a large academic medical center. Project outcomes included: a) Improvement in clinician knowledge related to the STS Blood Conservation CPGs; and b) Decreased blood product utilization for patients undergoing cardiac surgical procedures. Participants' scores reflected an improvement in the overall knowledge of the STS CPGs noting a 31.1% (p = 0.012) increase in the number of participants whose practice reflected the Blood Conservation CPGs post intervention. Additionally, there was a reduction in overall blood product utilization for all patients undergoing cardiac surgery procedures post intervention (p = 0.005). Interdisciplinary education based on the STS Blood Conservation CPGs is an effective way to reduce transfusion practice variability and decrease utilization of blood products during cardiac surgery.

[Effects of multidisciplinary blood management strategy on transfusion and outcomes in patients undergoing valvular heart surgery].

PubMed

Ji, Hongwen; Li, Zhiyuan; Sun, Hansong; Li, Lihuan; Long, Cun; Ma, Li; Chen, Lei; Wang, Wei; Hu, Shengshou

2014-02-25

To evaluate the effect of multidisciplinary blood management strategy in adults patients undergoing valvular heart surgery. A multidisciplinary patient blood management (PBM) strategy was instituted in Fuwai Hospital since January 2009. It includes Establishment of a multidisciplinary blood transfusion management team and designation of a coordinator; Enactment perioperative transfusion triggers (Hb < 80 g/L) for adults patients undergoing cardiac surgery; recommendation of antifibrinolytics, cell salvage, reduced cardiopulmonary bypass circuit; setting up Blood Consumption Announcement and Scoring System, which regularly publishes notifications of blood volume consumed per case, per single procedure and per surgeon. Clinical date before and after multidisciplinary patient blood management strategy will be presented. A total of 3 951 consecutive patients underwent Valvular Heart Surgery were analyzed. 1 713 cases were in pre-PBM group, and 2 238 cases were in post-PBM group. Both incidence and average units of allogeneic red blood cell transfusion perioperatively in post-PBM group were decreased (28.5% vs 75.3%, P = 0.000, and 1.2 U vs 4.0 U, P = 0.000). The postoperative length of stay in hospital and incidence of pneumonia were reduced in post-PBM group (8.2 d vs 10.5 d, P = 0.02, and 2.7% vs 3.5%, P = 0.04). The post-PBM group had lower in-hospital mortality (0.6% vs 1.2%, P = 0.000). Multidisciplinary patient blood management strategy significantly reduced blood transfusion, morbidity and mortality in patients underwent valvular heart surgery. It save plenty of blood resources.

The operating surgeon is an independent predictor of chest tube drainage following cardiac surgery.

PubMed

Dixon, Barry; Reid, David; Collins, Marnie; Newcomb, Andrew E; Rosalion, Alexander; Yap, Cheng-Hon; Santamaria, John D; Campbell, Duncan J

2014-04-01

Bleeding into the chest is a major cause of blood transfusion and adverse outcomes following cardiac surgery. The authors investigated predictors of bleeding following cardiac surgery to identify potentially correctable factors. Data were retrieved from the medical records of patients undergoing cardiac surgery over the period of 2002 to 2008. Multivariate analysis was used to identify the independent predictors of chest tube drainage. Tertiary hospital. Two thousand five hundred seventy-five patients. Cardiac surgery. The individual operating surgeon was independently associated with the extent of chest tube drainage. Other independent factors included internal mammary artery grafting, cardiopulmonary bypass time, urgency of surgery, tricuspid valve surgery, redo surgery, left ventricular impairment, male gender, lower body mass index and higher preoperative hemoglobin levels. Both a history of diabetes and administration of aprotinin were associated with reduced levels of chest tube drainage. The individual operating surgeon was an independent predictor of the extent of chest tube drainage. Attention to surgeon-specific factors offers the possibility of reduced bleeding, fewer transfusions, and improved patient outcomes. © 2014 The Authors. Published by Elsevier Inc. All rights reserved.

Cardiac surgery-associated acute kidney injury.

PubMed

Vives, Marc; Wijeysundera, Duminda; Marczin, Nandor; Monedero, Pablo; Rao, Vivek

2014-05-01

Acute kidney injury develops in up to 30% of patients who undergo cardiac surgery, with up to 3% of patients requiring dialysis. The requirement for dialysis after cardiac surgery is associated with an increased risk of infection, prolonged stay in critical care units and long-term need for dialysis. The development of acute kidney injury is independently associated with substantial short- and long-term morbidity and mortality. Its pathogenesis involves multiple pathways. Haemodynamic, inflammatory, metabolic and nephrotoxic factors are involved and overlap each other leading to kidney injury. Clinical studies have identified predictors for cardiac surgery-associated acute kidney injury that can be used effectively to determine the risk for acute kidney injury in patients undergoing cardiac surgery. High-risk patients can be targeted for renal protective strategies. Nonetheless, there is little compelling evidence from randomized trials supporting specific interventions to protect or prevent acute kidney injury in cardiac surgery patients. Several strategies have shown some promise, including less invasive procedures in those at greatest risk, natriuretic peptide, fenoldopam, preoperative hydration, preoperative optimization of anaemia and postoperative early use of renal replacement therapy. The efficacy of larger-scale trials remains to be confirmed.

Preoperative dehydration increases risk of postoperative acute renal failure in colon and rectal surgery.

PubMed

Moghadamyeghaneh, Zhobin; Phelan, Michael J; Carmichael, Joseph C; Mills, Steven D; Pigazzi, Alessio; Nguyen, Ninh T; Stamos, Michael J

2014-12-01

There is limited data regarding the effects of preoperative dehydration on postoperative renal function. We sought to identify associations between hydration status before operation and postoperative acute renal failure (ARF) in patients undergoing colorectal resection. The NSQIP database was used to examine the data of patients undergoing colorectal resection from 2005 to 2011. We used preoperative blood urea nitrogen (BUN)/creatinine ratio >20 as a marker of relative dehydration. Multivariate analysis using logistic regression was performed to quantify the association of BUN/Cr ratio with ARF. We sampled 27,860 patients who underwent colorectal resection. Patients with dehydration had higher risk of ARF compared to patients with BUN/Cr <10 (AOR, 1.23; P = 0.04). Dehydration was associated with an increase in mortality of the affected patients (AOR, 2.19; P < 0.01). Postoperative complication of myocardial infarction (MI) (AOR, 1.46; P < 0.01) and cardiac arrest (AOR, 1.39; P < 0.01) was higher in dehydrated patients. Open colorectal procedures (AOR, 2.67; P = 0.01) and total colectomy procedure (AOR, 1.62; P < 0.01) had associations with ARF. Dehydration before operation is a common condition in colorectal surgery (incidence of 27.7 %). Preoperative dehydration is associated with increased rates of postoperative ARF, MI, and cardiac arrest. Hydrotherapy of patients with dehydration may decrease postoperative complications in colorectal surgery.

Surgical treatment for infective endocarditis in elderly patients.

PubMed

Ramírez-Duque, N; García-Cabrera, E; Ivanova-Georgieva, R; Noureddine, M; Lomas, J M; Hidalgo-Tenorio, C; Plata, A; Gálvez-Acebal, J; Ruíz-Morales, J; de la Torre-Lima, J; Reguera, J M; Martínez-Marcos, F J; de Alarcón, A

2011-08-01

We evaluate the clinical, echographic and prognostic characteristics of infective endocarditis (IE) in a large population of elderly patients, and the results of surgical approach. Multicentric, prospective, observational cohort study with 961 consecutive left-sided IE: 356 patients aged ≥65 years were compared with 605 younger. Indications for cardiac surgery, potential surgical risk, time and outcome, were compared. Hospital-acquired endocarditis, comorbidity, renal failure and septic shock were more frequent in elderly, but embolisms were less. Intracardiac destruction and ventricular failure were similar in both groups, but significantly fewer elderly patients underwent cardiac surgery (36% vs 51%; p < 0.01), and this group showed a worse outcome (43.2% of mortality vs 27% in younger; p < 0.01), resulting age as an independent predictor of mortality (OR: 1.02 CI95%: 1.01-1.03). Compared with medical treatment, surgery showed lower percentages of mortality compared with medical treatment (23.3% vs 31.3%; p = 0.03) in younger group, but a high mortality was observed with both procedures (47.6% vs 40.3%; p = 0.1) in the elderly. Although similar percentages of heart failure and intracardiac complications, increasing age is associated with higher mortality in IE. Lower rates of surgical treatment and a worse outcome after operation are common features in elderly patients. Copyright © 2011 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Extracardiac conduit obstruction: initial experience in the use of Doppler echocardiography for noninvasive estimation of pressure gradient.

PubMed

Reeder, G S; Currie, P J; Fyfe, D A; Hagler, D J; Seward, J B; Tajik, A J

1984-11-01

Extracardiac valved conduits are often employed in the repair of certain complex congenital heart defects; late obstruction is a well recognized problem that usually requires catheterization for definitive diagnosis. A reliable noninvasive method for detecting conduit stenosis would be clinically useful in identifying the small proportion of patients who develop this problem. Continuous wave Doppler echocardiography has been used successfully to estimate cardiac valvular obstructive lesions noninvasively. Twenty-three patients with prior extracardiac conduit placement for complex congenital heart disease underwent echocardiographic and continuous wave Doppler echocardiographic examinations to determine the presence and severity of conduit stenosis. In 20 of the 23 patients, an adequate conduit flow velocity profile was obtained, and in 10 an abnormally increased conduit flow velocity was present. All but one patient had significant obstruction proven at surgery and in one patient, surgery was planned. In three patients, an adequate conduit flow velocity profile could not be obtained but obstruction was still suspected based on high velocity tricuspid regurgitant Doppler signals. In these three patients, subsequent surgery also proved that conduit stenosis was present. Doppler-predicted gradients and right ventricular pressures showed an overall good correlation (r = 0.90) with measurements at subsequent cardiac catheterization. Continuous wave Doppler echocardiography appears to be a useful noninvasive tool for the detection and semiquantitation of extracardiac conduit stenosis.

Effects of Massage in Reducing the Pain and Anxiety of the Cardiac Surgery Critically Ill-a Randomized Controlled Trial.

PubMed

Boitor, Madalina; Martorella, Géraldine; Maheu, Christine; Laizner, Andréa Maria; Gélinas, Céline

2018-03-30

To evaluate the effectiveness of hand massage on the pain and anxiety of the cardiac surgery critically ill. A three-arm randomized controlled trial. This study was conducted in a medical-surgical intensive care unit in Canada. Adult patients who underwent elective cardiac surgery, who were able to speak French/English and to self-report symptoms, without a high risk of postoperative complications were eligible. Patients were randomly allocated to standard care plus either two 20-minute hand massages (experimental), two 20-minute hand holdings (active control), or two 20-minute rest periods (passive control/standard care). Pain intensity, pain unpleasantness, anxiety, muscle tension, and vital signs were evaluated before, after, and 30 minutes later for each intervention. From the 83 patients recruited, 60 were randomized (20 massage, 19 hand holding, 21 standard care). After controlling for baseline scores, the massage group reported significantly lower pain intensity, pain unpleasantness, and anxiety for the first data collection set compared with both hand holding and standard care (analysis of covariance, P < 0.02), with an average decrease of two points on a 0-10 scale. No statistically significant differences were noted between hand holding and standard care for any of the symptoms. Similar results were observed for the second data collection set (N = 43). Patients had decreased muscle tension post massage. Vital signs did not differ significantly between groups. Findings suggest that a 20-minute hand massage in addition to routine postoperative pain management can concomitantly reduce pain intensity, pain unpleasantness, and anxiety by two points on average on a 0-10 scale.

Poor performances of EuroSCORE and CARE score for prediction of perioperative mortality in octogenarians undergoing aortic valve replacement for aortic stenosis.

PubMed

Chhor, Vibol; Merceron, Sybille; Ricome, Sylvie; Baron, Gabriel; Daoud, Omar; Dilly, Marie-Pierre; Aubier, Benjamin; Provenchere, Sophie; Philip, Ivan

2010-08-01

Although results of cardiac surgery are improving, octogenarians have a higher procedure-related mortality and more complications with increased length of stay in ICU. Consequently, careful evaluation of perioperative risk seems necessary. The aims of our study were to assess and compare the performances of EuroSCORE and CARE score in the prediction of perioperative mortality among octogenarians undergoing aortic valve replacement for aortic stenosis and to compare these predictive performances with those obtained in younger patients. This retrospective study included all consecutive patients undergoing cardiac surgery in our institution between November 2005 and December 2007. For each patient, risk assessment for mortality was performed using logistic EuroSCORE, additive EuroSCORE and CARE score. The main outcome measure was early postoperative mortality. Predictive performances of these scores were assessed by calibration and discrimination using goodness-of-fit test and area under the receiver operating characteristic curve, respectively. During this 2-year period, we studied 2117 patients, among whom 134/211 octogenarians and 335/1906 nonoctogenarians underwent an aortic valve replacement for aortic stenosis. When considering patients with aortic stenosis, discrimination was poor in octogenarians and the difference from nonoctogenarians was significant for each score (0.58, 0.59 and 0.56 vs. 0.82, 0.81 and 0.77 for additive EuroSCORE, logistic EuroSCORE and CARE score in octogenarians and nonoctogenarians, respectively, P < 0.05). Moreover, in the whole cohort, logistic EuroSCORE significantly overestimated mortality among octogenarians. Predictive performances of these scores are poor in octogenarians undergoing cardiac surgery, especially aortic valve replacement. Risk assessment and therapeutic decisions in octogenarians should not be made with these scoring systems alone.

Effects of Cold Therapy on Pain and Breathing Exercises Among Median Sternotomy Patients.

PubMed

Zencir, Gülbanu; Eser, Ismet

2016-12-01

The most painful activities during the days following cardiac surgery are coughing and deep breathing exercises. Cold therapy is an effective nonpharmacological method that decreases the pain during coughing and mobilization. In this study, the effects of cold therapy on pain and breathing exercises among patients with median sternotomy following cardiac surgery were investigated in a randomized crossover clinical trial. Data were collected from patients with median sternotomy (N = 34) in the first two postoperative days. Because of the crossover design of the study, each patient was taken as a simultaneous control. Gel pack application was used as the cold therapy. Patients underwent four episodes of deep breathing and coughing exercises using an incentive spirometer (volumetric). Patients were evaluated according to the visual analogue scale for pain intensity before and after deep breathing and coughing exercise sessions. The pain score was 3.44 ± 2.45 at baseline for deep breathing and coughing exercises on the first day. The reported postoperative pain in the gel-pack group was not significantly different before and after the deep breathing and coughing exercises, but it significantly increased in the no-gel-pack group (p < .001). Although the interaction between the treatment and time was significant (partial eta-squared: .09), the gel-pack group had a lower change in average pain levels. This interaction was not significant in terms of spirometric values. In conclusion, cold therapy had a positive effect on pain management in the early period of post-cardiac surgery but was not effective for the pain associated with breathing exercises. Copyright © 2016 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Acute kidney injury is associated with higher morbidity and resource utilization in pediatric patients undergoing heart surgery.

PubMed

Tóth, Roland; Breuer, Tamás; Cserép, Zsuzsanna; Lex, Dániel; Fazekas, Levente; Sápi, Erzsébet; Szatmári, András; Gál, János; Székely, Andrea

2012-06-01

The RIFLE (risk, injury, failure, loss, and end-stage renal disease) classification system was developed to standardize the definition of acute kidney injury (AKI) in adults. We hypothesized that AKI was associated with increased mortality and morbidity. Acute kidney injury was defined as a decrease in the amount of estimated creatinine clearance based on pediatric-modified RIFLE (pRIFLE) criteria. Using propensity score analysis, 325 patients who had AKI were matched to 325 patients who did not have AKI from a database of 1,510 consecutive pediatric patients who underwent cardiac surgery between January 2004 and December 2008 at a single center. The association between AKI and outcome was analyzed after propensity score matching of perioperative variables. Four hundred eighty-one patients (31.9%) had AKI according to the RIFLE categories. Of those 1,510, 173 (11.5%) reached pRIFLE criteria for risk; 26 (1.7%) reached the criteria for injury; and 282 (18.7%) reached the criteria for failure. Fifty-five patients (3.6%) died. The 2 matched groups were well balanced in terms of measured perioperative variables. Mortality rate was 5.2% in the AKI and 2.5% in the matched control group (p=0.09). Occurrence of low cardiac output syndrome (p=0.002), need for dialysis (p<0.001), and infection (p=0.03) were significantly higher, and duration of mechanical ventilation (p<0.001) and length of intensive care unit stay (p<0.001) were significantly longer compared with the matched control group. Acute kidney injury was independently associated with an increased occurrence of postoperative complications but not with mortality after pediatric cardiac surgery. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

[Complications in patients undergoing pulmonary oncological surgery].

PubMed

Mitás, L; Horváth, T; Sobotka, M; Garajová, B; Hanke, I; Kala, Z; Penka, I; Ivicic, J; Vomela, J

2010-02-01

A survey evaluating incidence and risk factors of complications in persons underwent complete open lung resection because of primary or secondary lung malignancy. Retrospective study of 189 open surgery procedures in 128 males and 61 females, mean age males 61 years (range 21-78), females 64 years (range 33-80) during a five-years period (2003-2007). Data processing and analysis were performed with the statistical software system Statistica and compared by parametres odds ratio a chi2 test. Complications were divided into five groups. First group was defined as complications in perioperative period and was composed of three events 1.5%: endotracheal tube dysfunction (i.e. 0.5%), heavy cardiac arrhytmia 0.5% and serious haemorrhage, that occurred immediately after operation 0.5%. Second group includes complications within period of 7 days after surgery: prolonged air leak (PAL > 7 days) 7.4%, bronchopneumonia 6.9%, cardiac arrhythmia 6.9%, postoperative delirium 4.2%, atelectasis 2.6%, wound infection 1.1%, bleeding 1.1% and chylothorax 0.5%. Third group contains events between 8th and 30th postoperative days: thoracic empyema 2.1%, dysphonia 2.1%, painfull shoulder 1.1%, alimentary tract infection 0.5% and bronchial closure insufficiency 0.5%. Fourth group contains patients with severe complications, that led to death during 30 days after operation: ischemic stroke 0.5% and pulmonary embolism 0.5%. Patients without any complication formed the fifth group of 60.5%. Main risk factors for complications in postoperative period after lung resection due to primary or secondary lung malignancy in our group of patients are COPD, corticotherapy, time of operation over 3 hours, BMI over 25, left side tumor localization and bronchoplastic procedure. For cardiac arrhytmia seems to be risk factor pneumonectomy and previous neoadjuvant radiochemotherapy.

Diabetic patients have increased perioperative cardiac risk in heart-type fatty acid-binding protein-based assessment.

PubMed

Sari, Munevver; Kilic, Harun; Ariturk, Ozlem Karakurt; Yazihan, Nuray; Akdemir, Ramazan

2015-01-01

To test the potential role of heart-type fatty acid-binding protein (H-FABP) in detecting increased perioperative cardiac risk in comparison with cardiac troponin I (cTnI) in the early postoperative period. Sixty-seven patients who had clinical risk factors and underwent elective intermediate - or high-risk noncardiac surgery were included in this study. Serum specimens were analyzed for H-FABP and cTnI levels before and at 8 h after surgery. None of the patients had chest pain; 27 had a history of ischemic heart disease, 3 of heart failure, 5 of cerebrovascular diseases, 40 of diabetes and 46 of hypertension. The mean duration of the operations was 2.33 ± 1.27 h (range 1-6). In the postoperative period, 27 (40.3%) patients had increased H-FABP levels (≥7.5 ng/ml); the median preoperative serum H-FABP level was 0.13 ng/ml (<0.1-5.9) and the median postoperative H-FABP level was 6.86 ng/ml (<0.1-13.7). Only 1 (1.5%) patient had cTnI >0.1 µg/l during the postoperative period. Correlation analysis revealed that the presence of diabetes was associated with an increased H-FABP level (r = 0.30, p = 0.01). Of the 27 patients with H-FABP ≥7.5 ng/ml, 21 (87%) had diabetes. There was no significant correlation with other clinical risk factors, type or duration of surgery. The H-FABP levels significantly increased in the postoperative period. Most patients with increased postoperative H-FABP levels were diabetic. High H-FABP levels could alert clinicians to increased perioperative cardiovascular risk and could prevent underdiagnosis, especially in diabetic patients. © 2014 S. Karger AG, Basel.

Positive predictive value of cardiac examination, procedure and surgery codes in the Danish National Patient Registry: a population-based validation study

PubMed Central

Adelborg, Kasper; Sundbøll, Jens; Munch, Troels; Frøslev, Trine; Sørensen, Henrik Toft; Bøtker, Hans Erik; Schmidt, Morten

2016-01-01

Objective Danish medical registries are widely used for cardiovascular research, but little is known about the data quality of cardiac interventions. We computed positive predictive values (PPVs) of codes for cardiac examinations, procedures and surgeries registered in the Danish National Patient Registry during 2010–2012. Design Population-based validation study. Setting We randomly sampled patients from 1 university hospital and 2 regional hospitals in the Central Denmark Region. Participants 1239 patients undergoing different cardiac interventions. Main outcome measure PPVs with medical record review as reference standard. Results A total of 1233 medical records (99% of the total sample) were available for review. PPVs ranged from 83% to 100%. For examinations, the PPV was overall 98%, reflecting PPVs of 97% for echocardiography, 97% for right heart catheterisation and 100% for coronary angiogram. For procedures, the PPV was 98% overall, with PPVs of 98% for thrombolysis, 92% for cardioversion, 100% for radiofrequency ablation, 98% for percutaneous coronary intervention, and 100% for both cardiac pacemakers and implantable cardiac defibrillators. For cardiac surgery, the overall PPVs was 99%, encompassing PPVs of 100% for mitral valve surgery, 99% for aortic valve surgery, 98% for coronary artery bypass graft surgery, and 100% for heart transplantation. The accuracy of coding was consistent within age, sex, and calendar year categories, and the agreement between independent reviewers was high (99%). Conclusions Cardiac examinations, procedures and surgeries have high PPVs in the Danish National Patient Registry. PMID:27940630

Excessive bleeding predictors after cardiac surgery in adults: integrative review.

PubMed

Lopes, Camila Takao; Dos Santos, Talita Raquel; Brunori, Evelise Helena Fadini Reis; Moorhead, Sue A; Lopes, Juliana de Lima; Barros, Alba Lucia Bottura Leite de

2015-11-01

To integrate literature data on the predictors of excessive bleeding after cardiac surgery in adults. Perioperative nursing care requires awareness of the risk factors for excessive bleeding after cardiac surgery to assure vigilance prioritising and early correction of those that are modifiable. Integrative literature review. Articles were searched in seven databases. Seventeen studies investigating predictive factors for excessive bleeding after open-heart surgery from 2004-2014 were included. Predictors of excessive bleeding after cardiac surgery were: Patient-related: male gender, higher preoperative haemoglobin levels, lower body mass index, diabetes mellitus, impaired left ventricular function, lower amount of prebypass thrombin generation, lower preoperative platelet counts, decreased preoperative platelet aggregation, preoperative platelet inhibition level >20%, preoperative thrombocytopenia and lower preoperative fibrinogen concentration. Procedure-related: the operating surgeon, coronary artery bypass surgery with three or more bypasses, use of the internal mammary artery, duration of surgery, increased cross-clamp time, increased cardiopulmonary bypass time, lower intraoperative core body temperature and bypass-induced haemostatic disorders. Postoperative: fibrinogen levels and metabolic acidosis. Patient-related, procedure-related and postoperative predictors of excessive bleeding after cardiac surgery were identified. The predictors summarised in this review can be used for risk stratification of excessive bleeding after cardiac surgery. Assessment, documentation and case reporting can be guided by awareness of these factors, so that postoperative vigilance can be prioritised. Timely identification and correction of the modifiable factors can be facilitated. © 2015 John Wiley & Sons Ltd.

Outcomes associated with postoperative delirium after cardiac surgery.

PubMed

Mangusan, Ralph Francis; Hooper, Vallire; Denslow, Sheri A; Travis, Lucille

2015-03-01

Delirium after surgery is a common condition that leads to poor outcomes. Few studies have examined the effect of postoperative delirium on outcomes after cardiac surgery. To assess the relationship between delirium after cardiac surgery and the following outcomes: length of stay after surgery, prevalence of falls, discharge to a nursing facility, discharge to home with home health services, and use of inpatient physical therapy. Electronic medical records of 656 cardiac surgery patients were reviewed retrospectively. Postoperative delirium occurred in 161 patients (24.5%). Patients with postoperative delirium had significantly longer stays (P < .001) and greater prevalence of falls (P < .001) than did patients without delirium. Patients with delirium also had a significantly greater likelihood for discharge to a nursing facility (P < .001) and need for home health services if discharged to home (P < .001) and a significantly higher need for inpatient physical therapy (P < .001). Compared with patients without postoperative delirium, patients who had this complication were more likely to have received zolpidem and benzodiazepines postoperatively and to have a history of arrhythmias, renal disease, and congestive heart failure. Patients who have delirium after cardiac surgery have poorer outcomes than do similar patients without this complication. Development and implementation of an extensive care plan to address postoperative delirium is necessary for cardiac surgery patients who are at risk for or have delirium after the surgery. ©2015 American Association of Critical-Care Nurses.

Microvascular autonomic dysfunction may justify false-positive stress myocardial perfusion imaging in patients with liver cirrhosis undergoing liver transplantation.

PubMed

Senzolo, M; Bassanello, M; Graziotto, A; Zucchetta, P; Cillo, U; Maraglino, G; Loreno, M; Bellotto, F; Davià, G; Burra, P

2008-01-01

Up to 15% of liver transplant candidates have asymptomatic coronary artery diseases, which increase the risk of cardiac complications during and after transplantation. The aim of this study was to prospectively investigate the usefulness of an integrated cardiological approach in cirrhotic patients undergoing liver transplantation. Twenty-four consecutive patients undergoing evaluation for liver transplantation were studied by assessing risk factors for coronary artery diseases, electrocardiogram with QTc interval determination, chest X-ray, echocardiography, 24-hour Holter monitor, myocardial perfusion scintigraphy (99mTc)MIBI-GSPECT at rest and after dipyridamole infusion. Cardiac (123)I-metaiodobenzylguanidine (MIBG) scan and coronarography were performed in patients with myocardial perfusion defects. Twenty three of 24 patients underwent successful liver transplantation; one patient died on the waiting list. Before liver transplantation, 29% of patients were diabetic and 41% were smokers. Eleven of 24 patients had a prolonged QTc interval, and 3/24 had positive myocardioscintigraphy after dipyridamole infusion: in two coronarography was negative, while the (123)I-MIBG washout was altered. No cardiac events were recorded during the short-and long-term follow-up after surgery. Predictive value of positive cardiac (99mTc)MIBI-GSPECT in patients with liver cirrhosis is low, and this may be due to alterations of cardiac microvascular tone as showed by cardiac (123)I-MIBG scan.

The effects of preoperative cardiology consultation prior to elective abdominal aortic aneurysm repair on patient morbidity.

PubMed

Boniakowski, Anna E; Davis, Frank M; Phillips, Amanda R; Robinson, Adina B; Coleman, Dawn M; Henke, Peter K

2017-08-01

Objectives The relationship between preoperative medical consultations and postoperative complications has not been extensively studied. Thus, we investigated the impact of preoperative consultation on postoperative morbidity following elective abdominal aortic aneurysm repair. Methods A retrospective review was conducted on 469 patients (mean age 72 years, 20% female) who underwent elective abdominal aortic aneurysm repair from June 2007 to July 2014. Data elements included detailed medical history, preoperative cardiology consultation, and postoperative complications. Primary outcomes included 30-day morbidity, consult-specific morbidity, and mortality. A bivariate probit regression model accounting for the endogeneity of binary preoperative medical consult and patient variability was estimated with a maximum likelihood function. Results Eighty patients had preoperative medical consults (85% cardiology); thus, our analysis focuses on the effect of cardiac-related preoperative consults. Hyperlipidemia, increased aneurysm size, and increased revised cardiac risk index increased likelihood of referral to cardiology preoperatively. Surgery type (endovascular versus open repair) was not significant in development of postoperative complications when controlling for revised cardiac risk index ( p = 0.295). After controlling for patient comorbidities, there was no difference in postoperative cardiac-related complications between patients who did and did not undergo cardiology consultation preoperatively ( p = 0.386). Conclusions When controlling for patient disease severity using revised cardiac risk index risk stratification, preoperative cardiology consultation is not associated with postoperative cardiac morbidity.

Structural, Nursing, and Physician Characteristics and 30-Day Mortality for Patients Undergoing Cardiac Surgery in Pennsylvania.

PubMed

Lane-Fall, Meghan B; Ramaswamy, Tara S; Brown, Sydney E S; He, Xu; Gutsche, Jacob T; Fleisher, Lee A; Neuman, Mark D

2017-09-01

Cardiac surgery ICU characteristics and clinician staffing patterns have not been well characterized. We sought to describe Pennsylvania cardiac ICUs and to determine whether ICU characteristics are associated with mortality in the 30 days after cardiac surgery. From 2012 to 2013, we conducted a survey of cardiac surgery ICUs in Pennsylvania to assess ICU structure, care practices, and clinician staffing patterns. ICU data were linked to an administrative database of cardiac surgery patient discharges. We used logistic regression to measure the association between ICU variables and death in 30 days. Cardiac surgery ICUs in Pennsylvania. Patients having coronary artery bypass grafting and/or cardiac valve repair or replacement from 2009 to 2011. None. Of the 57 cardiac surgical ICUs in Pennsylvania, 43 (75.4%) responded to the facility survey. Rounds included respiratory therapists in 26 of 43 (60.5%) and pharmacists in 23 of 43 (53.5%). Eleven of 41 (26.8%) reported that at least 2/3 of their nurses had a bachelor's degree in nursing. Advanced practice providers were present in most of the ICUs (37/43; 86.0%) but residents (8/42; 18.6%) and fellows (7/43; 16.3%) were not. Daytime intensivists were present in 21 of 43 (48.8%) responding ICUs; eight of 43 (18.6%) had nighttime intensivists. Among 29,449 patients, there was no relationship between mortality and nurse ICU experience, presence of any intensivist, or absence of residents after risk adjustment. To exclude patients who may have undergone transcatheter aortic valve replacement, we conducted a subgroup analysis of patients undergoing only coronary artery bypass grafting, and results were similar. Pennsylvania cardiac surgery ICUs have variable structures, care practices, and clinician staffing, although none of these are statistically significantly associated with mortality in the 30 days following surgery after adjustment.

Fast-track cardiac anesthesia in patients with sickle cell abnormalities.

PubMed

Djaiani, G N; Cheng, D C; Carroll, J A; Yudin, M; Karski, J M

1999-09-01

We conducted a retrospective review of 10 patients with sickle cell trait (SCT) and 30 patients (cohort control) without SCT undergoing first-time coronary artery bypass graft surgery with cardiopulmonary bypass. Demographic, perioperative management, and outcome data were collected. Both groups were matched according to age, weight, duration of surgery, and preoperative hemoglobin (Hb) concentration. Distribution of gender, medical conditions, pharmacological treatment, and preoperative left ventricular function were similar between the groups. The comparisons were analyzed in respect to postoperative blood loss and transfusion rates, as well as duration of intubation, intensive care unit, and hospital length of stay (LOS). All patients underwent fast-track cardiac anesthesia. A combination of cold crystalloid and blood cardioplegia was used. The lowest nasopharyngeal temperature was 33 degrees C. There were no episodes of significant hypoxemia, hypercarbia, or acidosis. None of the patients had sickling crisis during the perioperative period. The postoperative blood loss was 687 +/- 135 vs 585 +/-220 mL in the SCT and control groups, respectively. The trigger for blood transfusion during cardiopulmonary bypass was hematocrit <20% and Hb <75 g/L postoperatively. Three SCT patients (30%) and 10 control patients (33%) received a blood transfusion. Median extubation time was 4.0 vs 3.9 h; intensive care unit LOS was 27 vs 28 h; and hospital LOS was 6.0 vs 5.5 days in the SCT and control groups, respectively. There were no intraoperative deaths. One patient in the SCT group died from multiorgan failure 2 mo after surgery. Fast-track cardiac anesthesia can be used safely in patients with sickle cell trait undergoing first-time coronary artery bypass graft surgery. Extubation time and intensive care unit and hospital length of stay are comparable to those of matched controls, and blood loss and transfusion requirements are not increased. A hematocrit of 20% seems to be a safe transfusion trigger during cardiopulmonary bypass in these patients.

Mitral valve surgery in emergency for severe acute regurgitation: analysis of postoperative results from a multicentre study.

PubMed

Lorusso, Roberto; Gelsomino, Sandro; De Cicco, Giuseppe; Beghi, Cesare; Russo, Claudio; De Bonis, Michele; Colli, Andrea; Sala, Andrea

2008-04-01

To evaluate postoperative outcome of emergency surgery for acute severe mitral regurgitation (ASMR) from a multicentre experience. In six centres, 279 patients (mean age 62+/-14 years, 62% female) undergoing emergency surgery for ASMR from December 1986 to March 2007 were analysed and followed up. Aetiology included acute myocardial infarction (AMI) in 126 patients (group 1, 45%), degenerative mitral valve disease in 74 (group 2, 26%), and acute endocarditis (AE) in 79 (group 3, 28%). Preoperatively, all patients were in haemodynamic instability, with 185 patients in cardiogenic shock (66%), 184 (66%) intubated, and 61 (22%) on IABP, respectively. Valve repair was performed in 76 (27%), whereas 203 (73%) underwent valve replacement. Median follow-up (98% complete) was 70.8 months (inter-quartile range 59.8-86.66 months). Overall 30-day mortality was 22.5% (63/279). Early death was significantly lower in group 2 (p<0.001 and p=0.005 vs group 1 and 3, respectively) whereas no difference was detected between group 1 and 3. At logistic regression analysis AMI, AE, shock, left ventricular dysfunction, and coronary artery disease were predictors of early death. Overall 15-year survival was 67+/-10%. Survival was lower in group 1 (39+/-11%) than in group 2 (75+/-9%) and group 3 (77+/-10%). Cox regression found AMI, and associated coronary artery disease to be predictors of late death. Overall 15-year actuarial and actual freedom from cardiac-related events were 44+/-9% and 28+/-10%, respectively, with the worst outcome in the presence of AE. Associated coronary artery disease, AE, AMI, preoperative atrial fibrillation, and chronic renal failure were independent predictors of cardiac-related events. Emergency surgery for ASMR remains a surgical challenge for high incidence of early and late cardiac-related events, particularly in patients with associated coronary artery disease and acute endocarditis. Apparently, type of mitral valve surgical approaches (repair or replacement) did not provide any influence on postoperative outcome.

Comparison of outcomes in Australian indigenous and non-indigenous children and adolescents undergoing cardiac surgery.

PubMed

Justo, Edward R; Reeves, Benjamin M; Ware, Robert S; Johnson, Janelle C; Karl, Tom R; Alphonso, Nelson D; Justo, Robert N

2017-11-01

Population-based registries report 95% 5-year survival for children undergoing surgery for CHD. This study investigated paediatric cardiac surgical outcomes in the Australian indigenous population. All children who underwent cardiac surgery between May, 2008 and August, 2014 were studied. Demographic information including socio-economic status, diagnoses and co-morbidities, and treatment and outcome data were collected at time of surgery and at last follow-up. A total of 1528 children with a mean age 3.4±4.6 years were studied. Among them, 123 (8.1%) children were identified as indigenous, and 52.7% (62) of indigenous patients were in the lowest third of the socio-economic index compared with 28.2% (456) of non-indigenous patients (p⩽0.001). The indigenous sample had a significantly higher Comprehensive Aristotle Complexity score (indigenous 9.4±4.2 versus non-indigenous 8.7±3.9, p=0.04). The probability of having long-term follow-up did not differ between groups (indigenous 93.8% versus non-indigenous 95.6%, p=0.17). No difference was noted in 30-day mortality (indigenous 3.2% versus non-indigenous 1.4%, p=0.13). The 6-year survival for the entire cohort was 95.9%. The Cox survival analysis demonstrated higher 6-year mortality in the indigenous group - indigenous 8.1% versus non-indigenous 5.0%; hazard ratio (HR)=2.1; 95% confidence intervals (CI): 1.1, 4.2; p=0.03. Freedom from surgical re-intervention was 79%, and was not significantly associated with the indigenous status (HR=1.4; 95% CI: 0.9, 1.9; p=0.11). When long-term survival was adjusted for the Comprehensive Aristotle Complexity score, no difference in outcomes between the populations was demonstrated (HR=1.6; 95% CI: 0.8, 3.2; p=0.19). The indigenous population experienced higher late mortality. This apparent relationship is explained by increased patient complexity, which may reflect negative social and environmental factors.

Pheochromocytoma Crisis With Severe Cyclic Blood Pressure Fluctuations in a Cardiac Pheochromocytoma Patient Successfully Resuscitated by Extracorporeal Membrane Oxygenation

PubMed Central

Zhou, Xiang; Liu, Dawei; Su, Longxiang; Long, Yun; Du, Wei; Miao, Qi; Li, Fang; Jin, Zhengyu; Zeng, Zhengpei; Luo, Ailun; Huang, Yuguang

2015-01-01

Abstract Cardiac pheochromocytoma is relatively rare. Few reports describe the intraoperative and postoperative progression of patients experiencing a life-threatening pheochromocytoma crisis treated with extracorporeal membrane oxygenation (ECMO). A 35-year-old man was referred to our facility for paroxysmal hypertension with a 10-year history of sweating, headaches, cardiac palpitations, and postexercise dyspnea. The patient initially underwent urine catecholamine measurement and an isotope scan, somatostatin receptor scintigraphy, and 18F-fluorodeoxyglucose positron emission tomography/computer tomography (CT), which indicated a multiple, cardiac pheochromocytoma. Echocardiography, cardiac magnetic resonance imaging (MRI), CT reconstruction, and a coronary CT angiography revealed several lesions at the aortic root and along the cardiac vasculature. Multifocal cardiac pheochromocytoma was diagnosed and pheochromocytoma crisis with severe cyclic blood pressure fluctuation occurred during surgery. Surgical resection of multiple pheochromocytomas in the right medial carotid sheath, mediastinum between the main and pulmonary arteries, and between the abdominal aorta and inferior vena artery was performed. To ensure cardiac perfusion and avoid severe circulatory fluctuation, the cardiac paraganglioma resection was prioritized. After resecting the cardiac pheochromocytoma, a severe pheochromocytoma crisis with rapid cyclic blood pressure fluctuation developed. ECMO and intraaortic balloon pump (IABP) were initiated to stabilize circulation and perfusion. Phenoxybenzamine, norepinephrine, epinephrine, and fluid resuscitation were administered to support cardiovascular function. The magnitude of blood pressure fluctuation steadily decreased with treatment. IABP was discontinued after 3 days, and ECMO was discontinued after 16 days. The patient was discharged 3 months postoperatively. This case indicates that mechanical life support with ECMO is a valuable option for pheochromocytoma-induced cardiac shock and should be considered as an effective therapeutic choice in patients with highly unstable hemodynamic function. PMID:25929929

Perioperative Care of the Obese Cardiac Surgical Patient.

PubMed

Chacon, M Megan; Cheruku, Sreekanth R; Neuburger, Peter J; Lester, Laeben; Shillcutt, Sasha K

2017-12-13

Morbid obesity is associated with impairment of cardiovascular, pulmonary, gastrointestinal, and renal physiology with significant perioperative consequences and has been linked with higher morbidity and mortality after cardiac surgery. Cardiac surgery patients have a higher incidence of difficult airway and difficult laryngoscopy than general surgery patients do, and obesity is associated with difficult mask ventilation and direct laryngoscopy. Positioning injuries occur more frequently because obese patients are at greater risk of pressure injury, such as rhabdomyolysis and compartment syndrome. Despite the association between obesity and several chronic disease states, the effects of obesity on perioperative outcomes are conflicting. Studies examining outcomes of overweight and obese patients in cardiac surgery have reported varying results. An "obesity paradox" has been described, in which the mortality for overweight and obese patients is lower compared with patients of normal weight. This review describes the physiologic abnormalities and clinical implications of obesity in cardiac surgery and summarizes recommendations for anesthesiologists to optimize perioperative care of the obese cardiac surgical patient. Copyright © 2017 Elsevier Inc. All rights reserved.

[ Modern condition and prospects of development of cardiac surgery in the Armed Forces].

PubMed

Khubulava, G G; Ryzhman, N N; Ovchinnikov, Iu V; Tyrenko, V V; Peleshko, A S

2014-04-01

Authors consider the problem of delivery cardiac surgical care to contingent of the Defence Ministry. Perspective directions of development of cardiac surgery in the Armed Forces of the Russian Federation are the development of minimally invasive cardio surgery, endovascular development of modern methods of diagnosis and treatment, further development of electrophysiological methods for diagnosis and treatment of disorders of rhythm and conduction, the introduction of various kinds of auxiliary mechanical circulatory support systems in acute and chronic heart failure, development of transplantation in cardiac surgery, improvement of algorithm selection and referral of patients requiring cardiac care by providing primary health care to troop central military medical institutions, creating a single register of cardiac patients as part of the Armed Forces in order to determine the order and place of treatment, etc.

A randomized controlled trial of levosimendan to reduce mortality in high-risk cardiac surgery patients (CHEETAH): Rationale and design.

PubMed

Zangrillo, Alberto; Alvaro, Gabriele; Pisano, Antonio; Guarracino, Fabio; Lobreglio, Rosetta; Bradic, Nikola; Lembo, Rosalba; Gianni, Stefano; Calabrò, Maria Grazia; Likhvantsev, Valery; Grigoryev, Evgeny; Buscaglia, Giuseppe; Pala, Giovanni; Auci, Elisabetta; Amantea, Bruno; Monaco, Fabrizio; De Vuono, Giovanni; Corcione, Antonio; Galdieri, Nicola; Cariello, Claudia; Bove, Tiziana; Fominskiy, Evgeny; Auriemma, Stefano; Baiocchi, Massimo; Bianchi, Alessandro; Frontini, Mario; Paternoster, Gianluca; Sangalli, Fabio; Wang, Chew-Yin; Zucchetti, Maria Chiara; Biondi-Zoccai, Giuseppe; Gemma, Marco; Lipinski, Michael J; Lomivorotov, Vladimir V; Landoni, Giovanni

2016-07-01

Patients undergoing cardiac surgery are at risk of perioperative low cardiac output syndrome due to postoperative myocardial dysfunction. Myocardial dysfunction in patients undergoing cardiac surgery is a potential indication for the use of levosimendan, a calcium sensitizer with 3 beneficial cardiovascular effects (inotropic, vasodilatory, and anti-inflammatory), which appears effective in improving clinically relevant outcomes. Double-blind, placebo-controlled, multicenter randomized trial. Tertiary care hospitals. Cardiac surgery patients (n = 1,000) with postoperative myocardial dysfunction (defined as patients with intraaortic balloon pump and/or high-dose standard inotropic support) will be randomized to receive a continuous infusion of either levosimendan (0.05-0.2 μg/[kg min]) or placebo for 24-48 hours. The primary end point will be 30-day mortality. Secondary end points will be mortality at 1 year, time on mechanical ventilation, acute kidney injury, decision to stop the study drug due to adverse events or to start open-label levosimendan, and length of intensive care unit and hospital stay. We will test the hypothesis that levosimendan reduces 30-day mortality in cardiac surgery patients with postoperative myocardial dysfunction. This trial is planned to determine whether levosimendan could improve survival in patients with postoperative low cardiac output syndrome. The results of this double-blind, placebo-controlled randomized trial may provide important insights into the management of low cardiac output in cardiac surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Multimedia Exercise Training Program Improves Distance Walked, Heart Rate Recovery, and Self-efficacy in Cardiac Surgery Patients.

PubMed

Wang, Li-Wei; Ou, Shu-Hua; Tsai, Chien-Sung; Chang, Yue-Cune; Kao, Chi-Wen

2016-01-01

Patient education has been shown to be more effective when delivered using multimedia than written materials. However, the effects of using multimedia to assist patients in cardiac rehabilitation have not been investigated. The purpose of this study is to examine the effect of an inpatient multimedia exercise training program on distance walked in the 6-minute walking test (6MWT), heart rate recovery, and walking self-efficacy of patients who had undergone heart surgery. For this longitudinal quasi-experimental study, 60 consecutive patients were assigned to an experimental (n = 20; inpatient multimedia exercise training program) or control (n = 40; routine care) group. Data were collected at 3 times (before surgery, 1 to 2 days before hospital discharge, and 1 month after hospital discharge) and analyzed with the generalized estimating equation approach. Most subjects were men (66.7%), had a mean age of 61.32 ± 13.4 years and left ventricular ejection fraction of 56.96% ± 13.28%, and underwent coronary artery bypass graft surgery (n = 34, 56.7%). Subjects receiving the exercise training program showed significantly greater improvement than those in the control group in the 6MWT walking distance (P < .001), heart rate recovery (P = .04), and self-efficacy (P = .002) at hospital discharge. Furthermore, the intervention effects on 6MWT distance (P < .001) and self-efficacy (P < .001) were sustained at 1 month after hospital discharge. Our inpatient multimedia exercise training program safely improved distance walked in the 6MWT, heart rate recovery, and self-efficacy at hospital discharge in patients after heart surgery and maintained their improvement in 6MWT and self-efficacy 1 month later.

Apoptosis of circulating lymphocytes during pediatric cardiac surgery

NASA Astrophysics Data System (ADS)

Bocsi, J.; Pipek, M.; Hambsch, J.; Schneider, P.; Tárnok, A.

2006-02-01

There is a constant need for clinical diagnostic systems that enable to predict disease course for preventative medicine. Apoptosis, programmed cell death, is the end point of the cell's response to different induction and leads to changes in the cell morphology that can be rapidly detected by optical systems. We tested whether apoptosis of T-cells in the peripheral blood is useful as predictor and compared different preparation and analytical techniques. Surgical trauma is associated with elevated apoptosis of circulating leukocytes. Increased apoptosis leads to partial removal of immune competent cells and could therefore in part be responsible for reduced immune defence. Cardiovascular surgery with but not without cardiopulmonary bypass (CPB) induces transient immunosuppression. Its effect on T-cell apoptosis has not been shown yet. Flow-cytometric data of blood samples from 107 children (age 3-16 yr.) who underwent cardiac surgery with (78) or without (29) CPB were analysed. Apoptotic T-lymphocytes were detected based on light scatter and surface antigen (CD45/CD3) expression (ClinExpImmunol2000;120:454). Results were compared to staining with CD3 antibodies alone and in the absence of antibodies. T-cell apoptosis rate was comparable when detected with CD45/CD3 or CD3 alone, however not in the absence of CD3. Patients with but not without CPB surgery had elevated lymphocyte apoptosis. T-cell apoptosis increased from 0.47% (baseline) to 0.97% (1 day postoperatively). In CPB patients with complication 1.10% significantly higher (ANOVA p=0.01) comparing to CPB patients without complications. Quantitation of circulating apoptotic cells based on light scatter seems an interesting new parameter for diagnosis. Increased apoptosis of circulating lymphocytes and neutrophils further contributes to the immune suppressive response to surgery with CPB. (Support: MP, Deutsche Herzstiftung, Frankfurt, Germany)

British Columbia sends patients to Seattle for coronary artery surgery. Bypassing the queue in Canada.

PubMed

Katz, S J; Mizgala, H F; Welch, H G

1991-08-28

Concern about waiting lists for elective procedures has become a highly visible challenge to the universal health insurance program in Canada. In response to lengthening queues for patients waiting for cardiac surgery, British Columbia made contracts with four Seattle hospitals to send a total of 200 patients for coronary artery bypass surgery. This article examines the cause of the queue for cardiac surgery in British Columbia and the events that led to outside contracting. Global hospital budgets and restrictions on capital expansion have limited hospital capacity for cardiac surgery. This constrained supply, combined with periodic shortages in critical care nurses and cardiac perfusion technologists, has resulted in a rapid increase in the waiting list. Reducing wide variations in the lengths of queues for individual surgeons may afford an opportunity to reduce long waits. While the patient queue for cardiac surgery has sparked a public debate about budget limits and health care needs, its clinical impact remains uncertain.

A focus group study investigating medical decision making in octogenarians of high socioeconomic status with successful outcomes following cardiac surgery.

PubMed

Oldroyd, John C; Levinson, Michele R; Stephenson, Gemma; Rouse, Alice; Leeuwrik, Tina

2014-09-01

To explore medical decision making in octogenarians having cardiac surgery. Five focus groups conducted in a private hospital setting with octogenarians of high socioeconomic status who had successful cardiac surgery in the previous 3-13 months. Octogenarian's motivations for having cardiac surgery include survival, relief of symptoms, convenience and improving quality of life. The decision to have surgery involved clinical advice by doctors that the time had come to take up a surgical option. Patient's decisions did not take into account alternative treatment options either because these had not been presented by doctors or because medical management had failed. The final decision was made by patients. Decisions to have cardiac surgery in octogenarians are made by patients after discussions with family based on their risks as communicated by their doctors. This underlines the importance of effective risk communication by doctors to help patients make appropriate medical decisions. © 2013 The Authors. Australasian Journal on Ageing © 2013 ACOTA.

Long-term results (up to 14 years) of the clover technique for the treatment of complex tricuspid valve regurgitation.

PubMed

De Bonis, Michele; Lapenna, Elisabetta; Di Sanzo, Stefania; Del Forno, Benedetto; Pappalardo, Federico; Castiglioni, Alessandro; Vicentini, Luca; Pozzoli, Alberto; Giambuzzi, Ilaria; Latib, Azeem; Schiavi, Davide; La Canna, Giovanni; Alfieri, Ottavio

2017-07-01

To report the long-term results of the clover technique for the treatment of complex forms of tricuspid regurgitation (TR). Ninety-six consecutive patients (mean age 60 ± 16.4, left ventricular ejection fraction 58 ± 8.8%) with severe or moderately-severe TR due to important leaflets prolapse/flail (81 patients), tethering (13 patients) or mixed (2 patients) lesions underwent clover repair combined with annuloplasty. The aetiology of TR was degenerative in 74 cases (77.1%), post-traumatic in 9 (9.4%) and secondary to dilated cardiomyopathy in 13 (13.5%). All patients but 3 (96.8%) underwent ring (59 patients, 61.5%) or suture (34 patients, 35.4%) annuloplasty. Concomitant procedures (mainly mitral surgery) were performed in 82 patients (85.4%). Hospital mortality was 7.2%. At hospital discharge 92 (95.8%) patients had no or mild TR. Follow-up was 98% complete (median 9 years, interquartile range 5.1; 10.9). At 12 years the overall survival was 71.6 ± 7.22% and the cumulative incidence function of cardiac death with non-cardiac death as competing risk 16 ± 4.1% [95% confidence interval (95% CI) 9.5-25.7]. At 12 years the cumulative incidence function of TR ≥ 3+ and TR ≥ 2+ with death as competing risk were 1.2 ± 1.2% (95% CI 0.1-5.8) and 28 ± 7.7% (95% CI 14.3-43.5), respectively. Preoperative left ventricular ejection fraction (hazard ratio 0.9, CI 0.9-1, P  = 0.05) and previous cardiac surgery (hazard ratio 2.7, 95% CI 1-7.1, P  = 0.03) were predictors of recurrent TR ≥ 2+ at univariable but not at multivariable analysis. Complex forms of TR due to severe prolapse or tethering of the leaflets can be effectively treated with the clover technique with very satisfactory long-term results and extremely low recurrence of severe TR. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Gargantuan left atrium: a sequela of mitral regurgitation and mitral stenosis.

PubMed

Omslaer, Brian T; Biederman, Robert W W

2015-06-01

Cardiac magnetic resonance imaging and echocardiography revealed a gargantuan left atrium measuring 18.9 cm × 15.7 cm × 11.3 cm in a 56-year-old patient diagnosed with severe rheumatic mitral stenosis, severe pulmonary hypertension, and permanent atrial fibrillation. A chest x-ray also revealed a cardiothoracic ratio approaching 1.0 and a transthoracic echocardiogram measured diameters as large as 19.2 cm. The patient then underwent mitral valve replacement and left atrial reduction surgery and has had no further admissions or complications. © 2015, Wiley Periodicals, Inc.

Mechanical cause for acute left lung atelectasis after neonatal aortic arch repair with arterial switch operation: Conservative management.

PubMed

Maddali, Madan Mohan; Kandachar, Pranav Subbaraya; Al-Hanshi, Said; Al Ghafri, Mohammed; Valliattu, John

2017-01-01

Respiratory complications due to mechanical obstruction of the airways can occur following pediatric cardiac surgery. Clinically significant intrathoracic vascular compression of the airway can occur when extensive dissection and mobilization of arch and neck vessels is involved as in repair of interrupted aortic arch. This case report describes a neonate who underwent interrupted aortic arch repair along with an arterial switch operation and developed a left lung collapse immediately after tracheal extubation. Fiber-optic bronchoscopy revealed vascular compression as the real culprit. The child was successfully managed conservatively.

Awareness of antiplatelet resistance in patient with repeated episodes of thrombotic events

NASA Astrophysics Data System (ADS)

Dalimunthe, N. N.; Hamonangan, R.; Antono, D.; Prasetya, I.; Rusdi, L.

2018-03-01

Antiplatelet has been the cornerstones management of acute coronary syndrome. However, numbers of patients on these agents had episodes of adverse cardiovascular events. A 65-year-old woman post cardiac coronary bypass surgery on dual antiplatelet therapy, Aspirin, and Clopidogrel underwent several episodes of thrombotic events despite good adhered to thedailyantiplatelet regimen.These recurrent events had led to clinical suspicious of antiplatelet resistance. Platelet function test was performed which indicates a poor platelet response to Clopidogrel. Clopidogrelwas discontinued and Ticagrelor was prescribed together with Aspirin. During two months of follow up, there is no episode of chest discomfort.

Early audit of renal complications in a new cardiac surgery service in Australia.

PubMed

Bolsin, Stephen N; Stow, Peter; Bucknell, Sarah

2004-09-01

To assess the incidence of renal failure in a cardiac surgery service commencing in Australia. Prospective data collection and retrospective database analysis. A tertiary referral, university teaching hospital in the state of Victoria, Australia. The first 502 patients undergoing cardiac surgery in this institution from commencement of the service. The overall rate of renal failure was low in comparison to other studies at 0.2% (95% CI 0.04-1.3%). The rate of postoperative renal dysfunction was also low at 4.2% (95% CI 2.7-6.5%). The safety of the new service with respect to this complication of cardiac surgery was good when compared with published data. However the lack of uniform definitions of renal failure following cardiac surgery make comparisons between studies difficult. Uniform reporting of this complication would facilitate comparisons between units and quality assurance activities in this field.

Cardiac robotics: a review and St. Mary's experience.

PubMed

Deeba, S; Aggarwal, R; Sains, P; Martin, S; Athanasiou, T; Casula, R; Darzi, A

2006-03-01

The introduction of the laparoscope led to the progress of surgery to a new era, where surgeries that were deemed major are now being performed through keyhole incisions with comparable outcomes to open surgery. However, with this new technique rose several problems like inaccurate depth perception, diminished tactile feedback, need for experienced assistance, and reduction in degrees of motion of the surgeons hands all of which inspired surgeons and engineers to look for mechanical tools to help in reducing these problems. Henceforth; came the application of robotics in surgery. A PubMed and Medline search was performed on cardiac robotic surgery and its applications in mitral valve repair and coronary artery surgery. A total of twenty one articles were picked that allude to the subject. A history of robotic surgery was outlined followed by applications of robotic manipulation in cardiac surgery was narrated. A quick overview of this technology in telemedicine was then outlined followed by future prospects of this technology in surgery was contemplated. The experience of the group from St. Mary's Hospital, London in this field was outlined. During the period of 4 years a total of 102 cases of robotic cardiac surgery were performed. The mean length of hospital stay was 3.1 days with a standard deviation of 1.4 days and the morbidity of the series explained. There was no mortality. Early studies have shown that minimally invasive cardiac surgery is feasible and yields results similar to conventional cardiac surgery, yet it is more technically demanding on the surgeon. As advantageous as this new modality is, further multicenter studies are needed to prove its efficacy. Copyright 2006 John Wiley & Sons, Ltd.

Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery.

PubMed

Myles, Paul S; Smith, Julian A; Forbes, Andrew; Silbert, Brendan; Jayarajah, Mohandas; Painter, Thomas; Cooper, D James; Marasco, Silvana; McNeil, John; Bussières, Jean S; McGuinness, Shay; Byrne, Kelly; Chan, Matthew T V; Landoni, Giovanni; Wallace, Sophie

2017-01-12

Tranexamic acid reduces the risk of bleeding among patients undergoing cardiac surgery, but it is unclear whether this leads to improved outcomes. Furthermore, there are concerns that tranexamic acid may have prothrombotic and proconvulsant effects. In a trial with a 2-by-2 factorial design, we randomly assigned patients who were scheduled to undergo coronary-artery surgery and were at risk for perioperative complications to receive aspirin or placebo and tranexamic acid or placebo. The results of the tranexamic acid comparison are reported here. The primary outcome was a composite of death and thrombotic complications (nonfatal myocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction) within 30 days after surgery. Of the 4662 patients who were enrolled and provided consent, 4631 underwent surgery and had available outcomes data; 2311 were assigned to the tranexamic acid group and 2320 to the placebo group. A primary outcome event occurred in 386 patients (16.7%) in the tranexamic acid group and in 420 patients (18.1%) in the placebo group (relative risk, 0.92; 95% confidence interval, 0.81 to 1.05; P=0.22). The total number of units of blood products that were transfused during hospitalization was 4331 in the tranexamic acid group and 7994 in the placebo group (P<0.001). Major hemorrhage or cardiac tamponade leading to reoperation occurred in 1.4% of the patients in the tranexamic acid group and in 2.8% of the patients in the placebo group (P=0.001), and seizures occurred in 0.7% and 0.1%, respectively (P=0.002 by Fisher's exact test). Among patients undergoing coronary-artery surgery, tranexamic acid was associated with a lower risk of bleeding than was placebo, without a higher risk of death or thrombotic complications within 30 days after surgery. Tranexamic acid was associated with a higher risk of postoperative seizures. (Funded by the Australian National Health and Medical Research Council and others; ATACAS Australia New Zealand Clinical Trials Registry number, ACTRN12605000557639 .).

Virtual surgical planning, flow simulation, and 3-dimensional electrospinning of patient-specific grafts to optimize Fontan hemodynamics.

PubMed

Siallagan, Dominik; Loke, Yue-Hin; Olivieri, Laura; Opfermann, Justin; Ong, Chin Siang; de Zélicourt, Diane; Petrou, Anastasios; Daners, Marianne Schmid; Kurtcuoglu, Vartan; Meboldt, Mirko; Nelson, Kevin; Vricella, Luca; Johnson, Jed; Hibino, Narutoshi; Krieger, Axel

2018-04-01

Despite advances in the Fontan procedure, there is an unmet clinical need for patient-specific graft designs that are optimized for variations in patient anatomy. The objective of this study is to design and produce patient-specific Fontan geometries, with the goal of improving hepatic flow distribution (HFD) and reducing power loss (P loss ), and manufacturing these designs by electrospinning. Cardiac magnetic resonance imaging data from patients who previously underwent a Fontan procedure (n = 2) was used to create 3-dimensional models of their native Fontan geometry using standard image segmentation and geometry reconstruction software. For each patient, alternative designs were explored in silico, including tube-shaped and bifurcated conduits, and their performance in terms of P loss and HFD probed by computational fluid dynamic (CFD) simulations. The best-performing options were then fabricated using electrospinning. CFD simulations showed that the bifurcated conduit improved HFD between the left and right pulmonary arteries, whereas both types of conduits reduced P loss . In vitro testing with a flow-loop chamber supported the CFD results. The proposed designs were then successfully electrospun into tissue-engineered vascular grafts. Our unique virtual cardiac surgery approach has the potential to improve the quality of surgery by manufacturing patient-specific designs before surgery, that are also optimized with balanced HFD and minimal P loss , based on refinement of commercially available options for image segmentation, computer-aided design, and flow simulations. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Late post-AVR progression of bicuspid aortopathy: link to hemodynamics.

PubMed

Naito, Shiho; Gross, Tatiana; Disha, Kushtrim; von Kodolitsch, Yskert; Reichenspurner, Hermann; Girdauskas, Evaldas

2017-05-01

The ascending aortic dilatation may progress after aortic valve replacement (AVR) in bicuspid aortic valve (BAV) patients. Our aim was to evaluate rheological flow patterns and histological characteristics of the aneurysmal aorta in BAV patients at the time of reoperative aortic surgery. 13 patients (mean age: 42 ± 9 years, 10 (77%) male) with significant progression of proximal aortopathy after isolated AVR surgery for BAV disease (i.e., 16.7 ± 8.1 years post-AVR) were identified by cardiac phase-contrast cine magnetic resonance imaging (MRI) in our hospital. A total of nine patients (69%) underwent redo aortic surgery. Based on the MRI data, the aortic area of the maximal flow-induced stress (jet sample) and the opposite site (control sample) were identified and corresponding samples were collected intraoperatively. Histological sum-score values [i.e. aortic wall changes were graded based on a summation of seven histological criteria (each scored from 0 to 3)] were compared between these samples. Mean proximal aortic diameter at MRI follow-up was 55 ± 6 mm (range 47-66mm). Preoperative cardiac MRI demonstrated eccentric systolic flow pattern directed towards right-lateral/right posterior wall of the proximal aorta in 9/13 (69%) patients. Histological sum-score values were significantly higher in the jet sample vs control sample (i.e., 8.3 ± 3.8 vs 5.6 ± 2.4, respectively, p = 0.04). Hemodynamic factors may still be involved in the late progression of bicuspid aortopathy even after isolated AVR surgery for BAV disease.

Healthcare-Associated Mycobacterium chimaera Infection Subsequent to Heater-Cooler Device Exposure During Cardiac Surgery.

PubMed

Ninh, Allen; Weiner, Menachem; Goldberg, Andrew

2017-10-01

A SERIES of reports in the United States and Europe have linked Mycobacterium chimaera infections to contaminated heater-cooler devices used during cardiac surgery. Heater-cooler devices commonly are used for cardiopulmonary bypass during cardiac surgery. M. chimaera is a slow-growing nontuberculous mycobacterium that has been shown to cause cardiac complications that can lead to fatal disease following cardiac surgery. Given that more than 250,000 cardiothoracic surgical procedures requiring cardiopulmonary bypass take place each year in the United States, the estimated number of patient exposures to M. chimaera has prompted a public health crisis. The goal of this review is to summarize the present status of the M. chimaera outbreak and provide cardiothoracic surgeons, cardiac anesthesiologists, and other clinicians with current approaches to patient management and to discuss risk mitigation. Copyright © 2017 Elsevier Inc. All rights reserved.

Reoperative Cardiac Surgery: Part I - Preoperative Planning.

PubMed

Tribble, Curt

2018-02-26

While reoperative cardiac surgery has become safer in recent years, it is still more difficult and dangerous than a primary operation. In a recent review of the Cleveland Clinic's experience, 7% of the patients undergoing cardiac reoperations had major intraoperative adverse events (IAEs). In that report, if an IAE occurred, there was a 5% mortality and a 19% incidence of myocardial infarction (MI), stroke, or death [Roselli 2011]. Those are sobering statistics, particularly when reported by one of the busiest cardiac surgical services in the world. The take-home message is that reoperative cardiac surgery is riskier than primary cardiac operations and that there are strategies that should be employed at each juncture to lower the risks of a reoperation.However, many of these strategies and recommendations have been more implicit than explicit. In fact, surprisingly little has been written about reoperative cardiac surgery. Thus, it seems appropriate to collect some of the lessons, adages, tricks, and tools that might make reoperations a click safer.

Myocardial protection using diadenosine tetraphosphate with pharmacological preconditioning.

PubMed

Ahmet, I; Sawa, Y; Nishimura, M; Yamaguchi, T; Kitakaze, M; Matsuda, H

2000-09-01

We have reported a similar cardioprotective effect and mechanism of diadenosine tetraphosphate (AP4A) and ischemic preconditioning in rat hearts. In this study, the applicability of AP4A administration to cardiac surgery was tested by using a canine cardiopulmonary bypass model. Hearts underwent 60 minutes of cardioplegic arrest (34 degrees C) by a single dose of cardioplegia. Cardioplegia contained either AP4A (40 micromol/L; n = 6) or saline (n = 6). Beagles were weaned from cardiopulmonary bypass 30 minutes after reperfusion, and left ventricular function was evaluated after another 30 minutes by using the cardiac loop analysis system. Administration of AP4A significantly improved the postischemic recovery of cardiac function and reduced the leakage of serum creatine kinase compared with saline. Systemic vascular resistance, mean aortic blood pressure, and the electrocardiographic indices were not significantly altered by AP4A administration. Administration of AP4A was cardioprotective without apparent adverse effects. Because the cardioprotective mechanism may be similar to that of ischemic preconditioning, the addition of AP4A into cardioplegia may be a novel safe method for clinical application of preconditioning cardioprotection.

Early experience with open heart surgery in a pioneer private hospital in West Africa: the Biket medical centre experience.

PubMed

Onakpoya, Uvie Ufuoma; Adenle, Adebisi David; Adenekan, Anthony Taiwo

2017-01-01

More than forty years after the first open heart surgery in Nigeria, all open heart surgeries were carried out in government-owned hospitals before the introduction of such surgeries in 2013 at Biket Medical Centre, a privately owned hospital in Osogbo, South-western Nigeria. The aim of this paper is to review our initial experience with open heart surgery in this private hospital. All patients who underwent open heart surgery between August 2013 and January 2014 were included in this prospective study. The medical records of the patients were examined and data on age, sex, diagnosis, type of surgery, cardiopulmonary bypass details, complications and length of hospital stay were extracted and the data was analysed using SPSS version 16. Eighteen patients comprising of 12 males and 6 females with ages ranging between 8 months and 52 years (mean= of 15.7 +/- 15 years) were studied. Pericardial patch closure of isolated ventricular septal defect was done in 7 patients (38.9%) while total correction of isolated tetralogy of Fallot was carried out in 5 patients (27.8%). Two patients had mitral valve repair for rheumatic mitral regurgitation. Sixty day mortality was 0%. Safe conduct of open heart surgery in the private hospital setting is feasible in Nigeria. It may be our only guarantee of hitch free and sustainable cardiac surgery.

Right ventricular function after coronary artery bypass graft surgery--a magnetic resonance imaging study.

PubMed

Joshi, Subodh B; Roswell, Robert O; Salah, Ali K; Zeman, Peter R; Corso, Paul J; Lindsay, Joseph; Fuisz, Anthon R

2010-01-01

A reduction in right ventricular function commonly occurs in the early postoperative period after coronary artery bypass graft surgery (CABG). We sought to determine the longer-term effect of CABG on right ventricular function. Cardiac magnetic resonance imaging was performed before and approximately 3 months after surgery in 28 patients undergoing elective CABG. Right ventricular (RV) ejection fraction was assessed by planimetry of electrocardiographically gated cine images. There was a statistically significant increase in left ventricular ejection fraction from 50% to 58% (P=.003) after CABG. RV ejection fraction also increased from 54% to 60% (P=.002). In patients with lower baseline RV ejection fraction (below the median, < 53%), this parameter improved from 47% to 57% (P<.001). Both on-pump (47% vs. 62%, P=.003) as well as off-pump CABG (47% vs. 55%, P=.009) lead to an improvement in RV function in patients in the initial low RV ejection fraction group. Long-term right ventricular function was not adversely affected by CABG. An improvement in RV function occurred after surgery in patients with low baseline RV ejection fraction and was similar in patients who underwent surgery with or without cardiopulmonary bypass.

Off-pump coronary artery bypass surgery in severe left ventricular dysfunction.

PubMed

Azarfarin, Rasoul; Pourafkari, Leili; Parvizi, Rezayat; Alizadehasl, Azin; Mahmoodian, Roghaiyeh

2010-02-01

Our aim was to examine hospital outcomes of coronary artery bypass surgery in patients with and without left ventricular dysfunction, with regard to the surgical technique (off- or on-pump). Between March 2007 and March 2008, 689 consecutive patients underwent isolated first-time coronary artery bypass; 127 had ejection fractions < or = 30% (group 1) and 562 had ejection fractions >30% (group 2). Data of preoperative risk profiles and hospital outcomes were collected prospectively. Off-pump operations were performed in 49 (38.6%) patients in group 1 and 196 (34.9%) in group 2. The incidences of infectious, neurologic, and cardiac complications postoperatively were significantly higher in group 1. In multivariate analysis, preoperative ejection fraction < or = 30% was found to be an independent risk factor for postoperative complications and hospital mortality. The subgroup of patients undergoing off-pump surgery in both groups had a significantly lower rate of total complications than those undergoing conventional on-pump operations, but no significant difference in mortality was observed between those undergoing off-pump or conventional surgery in either group. Off-pump surgery helped to limit the increased morbidity rate after coronary bypass in patients with ventricular dysfunction.

Phase analysis in the Wolff-Parkinson-White syndrome with surgically proven accessory conduction pathways: concise communication

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nakajima, K.; Bunko, H.; Tada, A.

1984-01-01

Twenty-one patients with the Wolff-Parkinson-White (WPW) syndrome who underwent surgical division of the accessory conduction pathway (ACP) were studied by gated blood-pool scintigraphy. In each case, a functional image of the phase was generated, based on the fundamental frequency of the Fourier transform. The location of the ACP was confirmed by electrophysiologic study, epicardial mapping, and surgery. Phase analysis identified the side of preexcitation correctly in 16 out of 20 patients with WPW syndrome with a delta wave. All patients with right-cardiac type (N=9) had initial contraction in the right ventricle (RV). In patients with left-cardiac type (N=10), six hadmore » initial movement in the left ventricle (LV); but in the other four the ACPs in the anterior or lateral wall of the left ventricle (LV) could not be detected. In patients with multiple ACPs (N=2), one right-cardiac type had initial contraction in the RV, while in the other (with an intermittent WPW syndrome) the ACP was not detected. These observations indicate that abnormal wall motion is associated with the conduction anomalies of the WPW syndrome. We conclude that phase analysis can correctly identify the side of initial contraction in the WPW syndrome before and after surgery. However, as a method of preoperative study, it seems difficult to determine the precise site of the ACP by phase analysis alone.« less

Potential Risk Factors for Surgical Site Infection after Isolated Coronary Artery Bypass Grafting in a Bahrain Cardiac Centre: A Retrospective, Case-Controlled Study

PubMed Central

Abuzaid, Ahmed Abdulaziz; Zaki, Mahmood; Al Tarief, Habib

2015-01-01

Objective: The purposes of this study were to determine the incidence of surgical site infections (SSI) and associated risk factors in patients undergoing isolated coronary artery bypass grafting (CABG) in our cardiac center during a 2-year period. Materials and Methods: Retrospective case-control analysis for 80 patients who underwent isolated cardiac surgery CABG. These patients were divided into the SSI study group (n = 40) and the noninfected control group (n = 40). Eight potential perioperative risk variables were compared between the two groups using univariate logistic regression analysis. Results: Univariate analysis was carried out for eight potential risk factors. The risk factors found to be significant were: Impaired estimated glomerular filtration rate (P = 0.011) and impaired left ventricular ejection fraction (P = 0.015). However, Factors found to have no significant influence on the incidence of SSIs were: Perioperative length of hospital stay (days), urgency of surgery, use of bilateral internal mammary artery (BIMA) grafting, prolonged cardiopulmonary bypass duration, elevated body mass index. Conclusions: Patients with comorbidities of impaired renal function and/or impaired left ventricular systolic function are at high risk of developing SSI. There appears to be a relationship between SSIs in CABG patients and impaired renal or LV function (low ejection fraction). CABG with BIMA grafting could be performed safely even in diabetics. Future studies should consider further scrutiny of these and other factors in relation to SSIs in a larger surgical population. PMID:27326347

Mitral valve repair under cardiopulmonary bypass in small-breed dogs: 48 cases (2006-2009).

PubMed

Uechi, Masami; Mizukoshi, Takahiro; Mizuno, Takeshi; Mizuno, Masashi; Harada, Kayoko; Ebisawa, Takashi; Takeuchi, Junichirou; Sawada, Tamotsu; Uchida, Shuhei; Shinoda, Asako; Kasuya, Arane; Endo, Masaaki; Nishida, Miki; Kono, Shota; Fujiwara, Megumi; Nakamura, Takashi

2012-05-15

To determine whether mitral valve repair (MVR) under cardiopulmonary bypass would be an effective treatment for mitral regurgitation in small-breed dogs. Retrospective case series. 48 small-breed dogs (body weight, 1.88 to 4.65 kg [4.11 to 10.25 lb]; age, 5 to 15 years) with mitral regurgitation that underwent surgery between August 2006 and August 2009. Cardiopulmonary bypass was performed with a cardiopulmonary bypass circuit. After induction of cardiac arrest, a mitral annuloplasty was performed, and the chordae tendineae were replaced with expanded polytetrafluoroethylene chordal prostheses. After closure of the left atrium and declamping to restart the heart, the thorax was closed. Preoperatively, cardiac murmur was grade 3 of 6 to 6 of 6, thoracic radiography showed cardiac enlargement (median vertebral heart size, 12.0 vertebrae; range, 9.5 to 14.5 vertebrae), and echocardiography showed severe mitral regurgitation and left atrial enlargement (median left atrium-to-aortic root ratio, 2.6; range, 1.7 to 4.0). 45 of 48 dogs survived to discharge. Three months after surgery, cardiac murmur grade was reduced to 0/6 to 3/6, and the heart shadow was reduced (median vertebral heart size, 11.1 vertebrae, range, 9.2 to 13.0 vertebrae) on thoracic radiographs. Echocardiography confirmed a marked reduction in mitral regurgitation and left atrium-to-aortic root ratio (median, 1.7; range, 1.0 to 3.0). We successfully performed MVR under cardiopulmonary bypass in small-breed dogs, suggesting this may be an effective surgical treatment for dogs with mitral regurgitation. Mitral valve repair with cardiopulmonary bypass can be beneficial for the treatment of mitral regurgitation in small-breed dogs.

Surgical ablation of atrial fibrillation during mitral-valve surgery.

PubMed

Gillinov, A Marc; Gelijns, Annetine C; Parides, Michael K; DeRose, Joseph J; Moskowitz, Alan J; Voisine, Pierre; Ailawadi, Gorav; Bouchard, Denis; Smith, Peter K; Mack, Michael J; Acker, Michael A; Mullen, John C; Rose, Eric A; Chang, Helena L; Puskas, John D; Couderc, Jean-Philippe; Gardner, Timothy J; Varghese, Robin; Horvath, Keith A; Bolling, Steven F; Michler, Robert E; Geller, Nancy L; Ascheim, Deborah D; Miller, Marissa A; Bagiella, Emilia; Moquete, Ellen G; Williams, Paula; Taddei-Peters, Wendy C; O'Gara, Patrick T; Blackstone, Eugene H; Argenziano, Michael

2015-04-09

Among patients undergoing mitral-valve surgery, 30 to 50% present with atrial fibrillation, which is associated with reduced survival and increased risk of stroke. Surgical ablation of atrial fibrillation has been widely adopted, but evidence regarding its safety and effectiveness is limited. We randomly assigned 260 patients with persistent or long-standing persistent atrial fibrillation who required mitral-valve surgery to undergo either surgical ablation (ablation group) or no ablation (control group) during the mitral-valve operation. Patients in the ablation group underwent further randomization to pulmonary-vein isolation or a biatrial maze procedure. All patients underwent closure of the left atrial appendage. The primary end point was freedom from atrial fibrillation at both 6 months and 12 months (as assessed by means of 3-day Holter monitoring). More patients in the ablation group than in the control group were free from atrial fibrillation at both 6 and 12 months (63.2% vs. 29.4%, P<0.001). There was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrial maze procedure (61.0% and 66.0%, respectively; P=0.60). One-year mortality was 6.8% in the ablation group and 8.7% in the control group (hazard ratio with ablation, 0.76; 95% confidence interval, 0.32 to 1.84; P=0.55). Ablation was associated with more implantations of a permanent pacemaker than was no ablation (21.5 vs. 8.1 per 100 patient-years, P=0.01). There were no significant between-group differences in major cardiac or cerebrovascular adverse events, overall serious adverse events, or hospital readmissions. The addition of atrial fibrillation ablation to mitral-valve surgery significantly increased the rate of freedom from atrial fibrillation at 1 year among patients with persistent or long-standing persistent atrial fibrillation, but the risk of implantation of a permanent pacemaker was also increased. (Funded by the National Institutes of Health and the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00903370.).

Sleep-disordered breathing is associated with disturbed cardiac repolarization in patients with a coronary artery bypass graft surgery.

PubMed

Schmidleitner, Christina; Arzt, Michael; Tafelmeier, Maria; Ripfel, Sarah; Fauser, Miriam; Weizenegger, Teresa; Flörchinger, Bernhard; Camboni, Daniele; Wittmann, Sigrid; Zeman, Florian; Schmid, Christof; Maier, Lars S; Wagner, Stefan; Fisser, Christoph

2018-02-01

The development of malignant ventricular arrhythmias due to abnormal cardiac repolarization is a major complication after coronary artery bypass graft surgery (CABG). Sleep-disordered breathing (SDB) is linked to prolonged cardiac repolarization in non-surgical patients. This study evaluates cardiac repolarization in patients with and without SDB who underwent CABG. 100 patients who had received CABG (84% men, age 68 ± 10 years, body-mass-index [BMI] 28.7 ± 4.2 kg/m 2 ) were retrospectively evaluated. Polygraphy was recorded the night before CABG. SDB was defined as an apnea-hypopnea index (AHI) of ≥15/h and differentiated into central (CSA) and obstructive (OSA) sleep apnea. Cardiac repolarization was assessed by means of T-peak-to-end (TpTe) and QTc-intervals and TpTe/QT-ratios derived from 12-lead electrocardiography (ECG). 37% of patients had SDB, 14% CSA and 23% OSA. Before CABG, patients with CSA and OSA had longer TpTe intervals than those without SDB (TpTe: CSA 100 ± 26 vs. OSA 97 ± 19 vs. no SDB 85 ± 14 ms, p = 0.013). QTc intervals and TpTe/QT ratios differed between the two groups (QTc: 444 ± 54 vs. 462 ± 36 vs. 421 ± 32 ms, p < 0.001; TpTe/QT ratio: 0.24 ± 0.04 vs. 0.23 ± 0.05 vs. 0.21 ± 0.03, p = 0.045). SDB was associated with abnormal cardiac repolarization independent of known risk factors for cardiac arrhythmias, such as age, sex, BMI, N-terminal-pro-brain-natriuretic-peptide (NT-proBNP), and heart failure (TpTe: B-coefficient [95%CI]: 16.0, [7.6-24.3], p < 0.001; QTc: 27.2 [9.3-45.1], p = 0.003; TpTe/QT ratio: 2.9 [1.2-4.6], p < 0.001). Independent of known risk factors for cardiac arrhythmias, SDB was significantly associated with abnormal cardiac repolarization before CABG. Data suggest that SDB may contribute to an increased risk of ventricular arrhythmias after CABG. Copyright © 2018 Elsevier B.V. All rights reserved.

Robotic cardiac surgery: an anaesthetic challenge.

PubMed

Wang, Gang; Gao, Changqing

2014-08-01

Robotic cardiac surgery with the da Vinci robotic surgical system offers the benefits of a minimally invasive procedure, including a smaller incision and scar, reduced risk of infection, less pain and trauma, less bleeding and blood transfusion requirements, shorter hospital stay and decreased recovery time. Robotic cardiac surgery includes extracardiac and intracardiac procedures. Extracardiac procedures are often performed on a beating heart. Intracardiac procedures require the aid of peripheral cardiopulmonary bypass via a minithoracotomy. Robotic cardiac surgery, however, poses challenges to the anaesthetist, as the obligatory one-lung ventilation (OLV) and CO2 insufflation may reduce cardiac output and increase pulmonary vascular resistance, potentially resulting in hypoxaemia and haemodynamic compromise. In addition, surgery requires appropriate positioning of specialised cannulae such as an endopulmonary vent, endocoronary sinus catheter, and endoaortic clamp catheter under the guidance of transoesophageal echocardiography. Therefore, cardiac anaesthetists should have a working knowledge of these systems, OLV and haemodynamic support. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Inpatient cardiac rehabilitation programs' exercise therapy for patients undergoing cardiac surgery: National Korean Questionnaire Survey.

PubMed

Seo, Yong Gon; Jang, Mi Ja; Park, Won Hah; Hong, Kyung Pyo; Sung, Jidong

2017-02-01

Inpatient cardiac rehabilitation (ICR) has been commonly conducted after cardiac surgery in many countries, and has been reported a lots of results. However, until now, there is inadequacy of data on the status of ICR in Korea. This study described the current status of exercise therapy in ICR that is performed after cardiac surgery in Korean hospitals. Questionnaires modified by previous studies were sent to the departments of thoracic surgery of 10 hospitals in Korea. Nine replies (response rate 90%) were received. Eight nurses and one physiotherapist completed the questionnaire. Most of the education on wards after cardiac surgery was conducted by nurses. On postoperative day 1, four sites performed sitting on the edge of bed, sit to stand, up to chair, and walking in the ward. Only one site performed that exercise on postoperative day 2. One activity (stairs up and down) was performed on different days at only two sites. Patients received education preoperatively and predischarge for preventing complications and reducing muscle weakness through physical inactivity. The results of the study demonstrate that there are small variations in the general care provided by nurses after cardiac surgery. Based on the results of this research, we recommended that exercise therapy programs have to conduct by exercise specialists like exercise physiologists or physiotherapists for patients in hospitalization period.

A contemporary, single-institutional experience of surgical versus expectant management of congenital heart disease in trisomy 13 and 18 patients.

PubMed

Costello, John P; Weiderhold, Allison; Louis, Clauden; Shaughnessy, Conner; Peer, Syed M; Zurakowski, David; Jonas, Richard A; Nath, Dilip S

2015-06-01

The objective of this study was to examine a large institutional experience of patients with trisomy 13 and trisomy 18 in the setting of comorbid congenital heart disease and present the outcomes of surgical versus expectant management. It is a retrospective single-institution cohort study. Institutional review board approved this study. Thirteen consecutive trisomy 18 patients and three consecutive trisomy 13 patients (sixteen patients in total) with comorbid congenital heart disease who were evaluated by our institution's Division of Cardiovascular Surgery between January 2008 and December 2013 were included in the study. The primary outcome measures evaluated were operative mortality (for patients who received surgical management), overall mortality (for patients who received expectant management), and total length of survival during follow-up. Of the thirteen trisomy 18 patients, seven underwent surgical management and six received expectant management. With surgical management, operative mortality was 29 %, and 80 % of patients were alive after a median follow-up of 116 days. With expectant management, 50 % of patients died before hospital discharge. Of the three patients with trisomy 13, one patient underwent surgical management and two received expectant management. The patient who received surgical management with complete repair was alive at last follow-up over 2 years after surgery; both patients managed expectantly died before hospital discharge. Trisomy 13 and trisomy 18 patients with comorbid congenital heart disease can undergo successful cardiac surgical intervention. In this population, we advocate that nearly all patients with cardiovascular indications for operative congenital heart disease intervention should be offered complete surgical repair over palliative approaches for moderately complex congenital cardiac anomalies.

The Dutch Hospital Standardised Mortality Ratio (HSMR) method and cardiac surgery: benchmarking in a national cohort using hospital administration data versus a clinical database

PubMed Central

Siregar, S; Pouw, M E; Moons, K G M; Versteegh, M I M; Bots, M L; van der Graaf, Y; Kalkman, C J; van Herwerden, L A; Groenwold, R H H

2014-01-01

Objective To compare the accuracy of data from hospital administration databases and a national clinical cardiac surgery database and to compare the performance of the Dutch hospital standardised mortality ratio (HSMR) method and the logistic European System for Cardiac Operative Risk Evaluation, for the purpose of benchmarking of mortality across hospitals. Methods Information on all patients undergoing cardiac surgery between 1 January 2007 and 31 December 2010 in 10 centres was extracted from The Netherlands Association for Cardio-Thoracic Surgery database and the Hospital Discharge Registry. The number of cardiac surgery interventions was compared between both databases. The European System for Cardiac Operative Risk Evaluation and hospital standardised mortality ratio models were updated in the study population and compared using the C-statistic, calibration plots and the Brier-score. Results The number of cardiac surgery interventions performed could not be assessed using the administrative database as the intervention code was incorrect in 1.4–26.3%, depending on the type of intervention. In 7.3% no intervention code was registered. The updated administrative model was inferior to the updated clinical model with respect to discrimination (c-statistic of 0.77 vs 0.85, p<0.001) and calibration (Brier Score of 2.8% vs 2.6%, p<0.001, maximum score 3.0%). Two average performing hospitals according to the clinical model became outliers when benchmarking was performed using the administrative model. Conclusions In cardiac surgery, administrative data are less suitable than clinical data for the purpose of benchmarking. The use of either administrative or clinical risk-adjustment models can affect the outlier status of hospitals. Risk-adjustment models including procedure-specific clinical risk factors are recommended. PMID:24334377

The Risk of Oxygen during Cardiac Surgery (ROCS) trial: study protocol for a randomized clinical trial.

PubMed

Lopez, Marcos G; Pretorius, Mias; Shotwell, Matthew S; Deegan, Robert; Eagle, Susan S; Bennett, Jeremy M; Sileshi, Bantayehu; Liang, Yafen; Gelfand, Brian J; Kingeter, Adam J; Siegrist, Kara K; Lombard, Frederick W; Richburg, Tiffany M; Fornero, Dane A; Shaw, Andrew D; Hernandez, Antonio; Billings, Frederic T

2017-06-26

Anesthesiologists administer excess supplemental oxygen (hyper-oxygenation) to patients during surgery to avoid hypoxia. Hyper-oxygenation, however, may increase the generation of reactive oxygen species and cause oxidative damage. In cardiac surgery, increased oxidative damage has been associated with postoperative kidney and brain injury. We hypothesize that maintenance of normoxia during cardiac surgery (physiologic oxygenation) decreases kidney injury and oxidative damage compared to hyper-oxygenation. The Risk of Oxygen during Cardiac Surgery (ROCS) trial will randomly assign 200 cardiac surgery patients to receive physiologic oxygenation, defined as the lowest fraction of inspired oxygen (FIO 2 ) necessary to maintain an arterial hemoglobin saturation of 95 to 97%, or hyper-oxygenation (FIO 2  = 1.0) during surgery. The primary clinical endpoint is serum creatinine change from baseline to postoperative day 2, and the primary mechanism endpoint is change in plasma concentrations of F 2 -isoprostanes and isofurans. Secondary endpoints include superoxide production, clinical delirium, myocardial injury, and length of stay. An endothelial function substudy will examine the effects of oxygen treatment and oxidative stress on endothelial function, measured using flow mediated dilation, peripheral arterial tonometry, and wire tension myography of epicardial fat arterioles. The ROCS trial will test the hypothesis that intraoperative physiologic oxygenation decreases oxidative damage and organ injury compared to hyper-oxygenation in patients undergoing cardiac surgery. ClinicalTrials.gov, ID: NCT02361944 . Registered on the 30th of January 2015.

Open heart surgery in Nigeria; a work in progress.

PubMed

Falase, Bode; Sanusi, Michael; Majekodunmi, Adetinuwe; Animasahun, Barakat; Ajose, Ifeoluwa; Idowu, Ariyo; Oke, Adewale

2013-01-12

There has been limited success in establishing Open Heart Surgery programmes in Nigeria despite the high prevalence of structural heart disease and the large number of Nigerian patients that travel abroad for Open Heart Surgery. The challenges and constraints to the development of Open Heart Surgery in Nigeria need to be identified and overcome. The aim of this study is to review the experience with Open Heart Surgery at the Lagos State University Teaching Hospital and highlight the challenges encountered in developing this programme. This is a retrospective study of patients that underwent Open Heart Surgery in our institution. The source of data was a prospectively maintained database. Extracted data included patient demographics, indication for surgery, euroscore, cardiopulmonary bypass time, cross clamp time, complications and patient outcome. 51 Open Heart Surgery procedures were done between August 2004 and December 2011. There were 21 males and 30 females. Mean age was 29 ± 15.6 years. The mean euroscore was 3.8 ± 2.1. The procedures done were Mitral Valve Replacement in 15 patients (29.4%), Atrial Septal Defect Repair in 14 patients (27.5%), Ventricular Septal Defect Repair in 8 patients (15.7%), Aortic Valve Replacement in 5 patients (9.8%), excision of Left Atrial Myxoma in 2 patients (3.9%), Coronary Artery Bypass Grafting in 2 patients (3.9%), Bidirectional Glenn Shunts in 2 patients (3.9%), Tetralogy of Fallot repair in 2 patients (3.9%) and Mitral Valve Repair in 1 patient (2%). There were 9 mortalities (17.6%) in this series. Challenges encountered included the low volume of cases done, an unstable working environment, limited number of trained staff, difficulty in obtaining laboratory support, limited financial support and difficulty in moving away from the Cardiac Mission Model. The Open Heart Surgery program in our institution is still being developed but the identified challenges need to be overcome if this program is to be sustained. Similar challenges will need to be overcome by other cardiac stakeholders if other OHS programs are to be developed and sustained in Nigeria.

Percutaneous coronary intervention with off-site cardiac surgery backup for acute myocardial infarction as a strategy to reduce door-to-balloon time.

PubMed

Peels, Hans O; de Swart, Hans; Ploeg, Tjeerd V D; Hautvast, Raymond W; Cornel, Jan H; Arnold, Alf E; Wharton, Thomas P; Umans, Victor A

2007-11-01

We investigated whether primary percutaneous coronary intervention (PCI) for patients admitted with an acute ST-segment elevation myocardial infarction could be performed more rapidly and with comparable outcomes in a community hospital versus a tertiary center with cardiac surgery. We started the first PCI with an off-site surgery program in The Netherlands in 2002 and report the results of 439 consecutive patients. In the safety phase, 199 patients presenting with ST-segment elevation myocardial infarction were randomly assigned to treatment at our off-site center versus a more distant cardiac surgery center. In the confirmation phase, 240 consecutive patients were treated in the off-site hospital. Safety and efficacy end points were the rate of an angiographically successful PCI procedure (diameter stenosis <50% and Thrombolysis In Myocardial Infarction grade 3 flow) in the absence of major adverse cardiac and cerebrovascular events at 30 days. The randomization phase showed a 37-minute decrease in door-to-balloon time (p <0.001) with comparable procedural and clinical successes (91% Thrombolysis In Myocardial Infarction grade 3 flow in the 2 groups). In the confirmation phase, the 30-day rate without major adverse cardiac and cerebrovascular events was 95%. None of the 439 patients in the study required emergency surgery for failed primary PCI. In conclusion, time to treatment with primary PCI can be significantly shortened when treating patients in a community hospital setting with off-site cardiac surgery backup compared with transport for PCI to a referral center with on-site surgery. PCI at hospitals with off-site cardiac surgery backup can be considered a needed strategy to improve access to primary PCI for a larger segment of the population and can be delivered with a very favorable safety profile.

Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery.

PubMed

Duceppe, Emmanuelle; Parlow, Joel; MacDonald, Paul; Lyons, Kristin; McMullen, Michael; Srinathan, Sadeesh; Graham, Michelle; Tandon, Vikas; Styles, Kim; Bessissow, Amal; Sessler, Daniel I; Bryson, Gregory; Devereaux, P J

2017-01-01

The Canadian Cardiovascular Society Guidelines Committee and key Canadian opinion leaders believed there was a need for up to date guidelines that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of evidence assessment for patients who undergo noncardiac surgery. Strong recommendations included: 1) measuring brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) before surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45-64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index score ≥ 1; 2) against performing preoperative resting echocardiography, coronary computed tomography angiography, exercise or cardiopulmonary exercise testing, or pharmacological stress echocardiography or radionuclide imaging to enhance perioperative cardiac risk estimation; 3) against the initiation or continuation of acetylsalicylic acid for the prevention of perioperative cardiac events, except in patients with a recent coronary artery stent or who will undergo carotid endarterectomy; 4) against α 2 agonist or β-blocker initiation within 24 hours before surgery; 5) withholding angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker starting 24 hours before surgery; 6) facilitating smoking cessation before surgery; 7) measuring daily troponin for 48 to 72 hours after surgery in patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have a Revised Cardiac Risk Index score ≥1, age 45-64 years with significant cardiovascular disease, or age 65 years or older; and 8) initiating of long-term acetylsalicylic acid and statin therapy in patients who suffer myocardial injury/infarction after surgery. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Current Evidence about Nutrition Support in Cardiac Surgery Patients-What Do We Know?

PubMed

Hill, Aileen; Nesterova, Ekaterina; Lomivorotov, Vladimir; Efremov, Sergey; Goetzenich, Andreas; Benstoem, Carina; Zamyatin, Mikhail; Chourdakis, Michael; Heyland, Daren; Stoppe, Christian

2018-05-11

Nutrition support is increasingly recognized as a clinically relevant aspect of the intensive care treatment of cardiac surgery patients. However, evidence from adequate large-scale studies evaluating its clinical significance for patients’ mid- to long-term outcome remains sparse. Considering nutrition support as a key component in the perioperative treatment of these critically ill patients led us to review and discuss our understanding of the metabolic response to the inflammatory burst induced by cardiac surgery. In addition, we discuss how to identify patients who may benefit from nutrition therapy, when to start nutritional interventions, present evidence about the use of enteral and parenteral nutrition and the potential role of pharmaconutrition in cardiac surgery patients. Although the clinical setting of cardiac surgery provides advantages due to its scheduled insult and predictable inflammatory response, researchers and clinicians face lack of evidence and several limitations in the clinical routine, which are critically considered and discussed in this paper.

[Analysis of surgical treatment with pectoralis major muscle flap for deep sternal infection after cardiac surgery: a case series of 189 patients].

PubMed

Liu, Dong; Wang, Wenzhang; Cai, Aibing; Han, Zhiyi; Li, Xiyuan; Ma, Jiagui

2015-03-01

To analyze and summarize the clinical features and experience in surgical treatment of deep sternal infection (DSWI). This was a retrospective study. From January 2008 to December 2013, 189 patients with secondary DSWI after cardiac surgery underwent the pectoralis major muscle flap transposition in our department. There were 116 male and 73 female patients. The mean age was (54 ± 21) years, the body mass index was (26. 1 ± 1. 3) kg/m2. The incidence of postoperation DSWI were after isolated coronary artery bypass grafting (CABG) in 93 patients, after other heart surgery plus CABG in 13 patients, after valve surgery in 47 patients, after thoracic aortic surgery in 16 patients, after congenital heart disease in 18 patients, and after cardiac injury in 2 patients. Clean patients' wound and extract secretions, clear the infection thoroughly by surgery and select antibiotics based on susceptibility results, and then repair the wound with appropriate muscle flap, place drain tube with negative pressure. Of all the 189 patients, 184 used isolate pectoralis, 1 used isolate rectus, and 4 used pectoralis plus rectus. The operative wounds of 179 patients were primary healing (94. 7%). Hospital discharge was postponed by 1 week for 7 patients, due to subcutaneous wound infection. Subcutaneous wound infection occurred again in 8 patients 1 week after hospital discharge, and their wounds healed after wound dressing. Nine patients (4. 7%) did not recover, due to residue of the sequestrum and costal chondritis, whom were later cured by undergoing a second treatment of debridement and pectoralis major muscle flap transposition. Eight patients died, in which 2 died of respiratory failure, 2 died of bacterial endocarditis with septicemia, 2 died of renal failure, 1 died of intraoperative bleeding leading to brain death and the 1 died of heart failure. The mortality rate was 4. 2% . The average length of postoperative hospital stay was (14 ± 5) days. The longest postoperative follow-up period was 40 months, the median time was 26 months, the follow-up rate was 83. 9% . Totally 179 patients were no-reinfected, 2 patients were reinfected because of artificial vascular rejection. To perform surgical debridement and then reconstruct the sternal defect with pectoralis major muscle flap actively for the patient is an effective measure to improve patient's survival rate.

A case of transient central diabetes insipidus after aorto-coronary bypass operation.

PubMed

Yu, Chung-Hoon; Cho, Jang-Hee; Jung, Hee-Yeon; Lim, Jeong-Hoon; Jin, Mi-Kyung; Kwon, Owen; Hong, Kyung-Deuk; Choi, Ji-Young; Yoon, Se-Hee; Kim, Chan-Duck; Kim, Yong-Lim; Kim, Gun-Jik; Park, Sun-Hee

2012-09-01

Diabetes insipidus (DI) is characterized by excessive urination and thirst. This disease results from inadequate output of antidiuretic hormone (ADH) from the pituitary gland or the absence of the normal response to ADH in the kidney. We present a case of transient central DI in a patient who underwent a cardiopulmonary bypass (CPB) for coronary artery bypass grafting (CABG). A 44-yr-old male underwent a CABG operation. An hour after the operation, the patient developed polyuria and was diagnosed with central DI. The patient responded to desmopressin and completely recovered five days after surgery. It is probable that transient cerebral ischemia resulted in the dysfunction of osmotic receptors in the hypothalamus or hypothalamus-pituitary axis during CPB. It is also possible that cardiac standstill altered the left atrial non-osmotic receptor function and suppressed ADH release. Therefore, we suggest that central DI is a possible cause of polyuria after CPB.

A Case of Transient Central Diabetes Insipidus after Aorto-Coronary Bypass Operation

PubMed Central

Yu, Chung-Hoon; Cho, Jang-Hee; Jung, Hee-Yeon; Lim, Jeong-Hoon; Jin, Mi-Kyung; Kwon, Owen; Hong, Kyung-Deuk; Choi, Ji-Young; Yoon, Se-Hee; Kim, Chan-Duck; Kim, Yong-Lim; Kim, Gun-Jik

2012-01-01

Diabetes insipidus (DI) is characterized by excessive urination and thirst. This disease results from inadequate output of antidiuretic hormone (ADH) from the pituitary gland or the absence of the normal response to ADH in the kidney. We present a case of transient central DI in a patient who underwent a cardiopulmonary bypass (CPB) for coronary artery bypass grafting (CABG). A 44-yr-old male underwent a CABG operation. An hour after the operation, the patient developed polyuria and was diagnosed with central DI. The patient responded to desmopressin and completely recovered five days after surgery. It is probable that transient cerebral ischemia resulted in the dysfunction of osmotic receptors in the hypothalamus or hypothalamus-pituitary axis during CPB. It is also possible that cardiac standstill altered the left atrial non-osmotic receptor function and suppressed ADH release. Therefore, we suggest that central DI is a possible cause of polyuria after CPB. PMID:22969261

Antibiotic prophylaxis for surgical site infections as a risk factor for infection with Clostridium difficile.

PubMed

Balch, Aubrey; Wendelboe, Aaron M; Vesely, Sara K; Bratzler, Dale W

2017-01-01

We aimed to measure the association between 2013 guideline concordant prophylactic antibiotic use prior to surgery and infection with Clostridium difficile. We conducted a retrospective case-control study by selecting patients who underwent a surgical procedure between January 1, 2012 and December 31, 2013. Large urban community hospital. Cases and controls were patients age 18+ years who underwent an eligible surgery (i.e., colorectal, neurosurgery, vascular/cardiac/thoracic, hysterectomy, abdominal/pelvic and orthopedic surgical procedures) within six months prior to infection diagnosis. Cases were diagnosed with C. difficile infection while controls were not. The primary exposure was receiving (vs. not receiving) the recommended prophylactic antibiotic regimen, based on type and duration. Potential confounders included age, sex, length of hospital stay, comorbidities, type of surgery, and prior antibiotic use. Crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression. We enrolled 68 cases and 220 controls. The adjusted OR among surgical patients between developing C. difficile infection and not receiving the recommended prophylactic antibiotic regimen (usually receiving antimicrobial prophylaxis for more than 24 hours) was 6.7 (95% CI: 2.9-15.5). Independent risk factors for developing C. difficile infection included having severe comorbidities, receiving antibiotics within the previous 6 months, and undergoing orthopedic surgery. Adherence to the recommended prophylactic antibiotics among surgical patients likely reduces the probability of being case of C. difficile. Antibiotic stewardship should be a priority in strategies to decrease the morbidity, mortality, and costs associated with C. difficile infection.

Antibiotic prophylaxis for surgical site infections as a risk factor for infection with Clostridium difficile

PubMed Central

Balch, Aubrey; Vesely, Sara K.; Bratzler, Dale W.

2017-01-01

Objective We aimed to measure the association between 2013 guideline concordant prophylactic antibiotic use prior to surgery and infection with Clostridium difficile. Design We conducted a retrospective case-control study by selecting patients who underwent a surgical procedure between January 1, 2012 and December 31, 2013. Setting Large urban community hospital. Patients Cases and controls were patients age 18+ years who underwent an eligible surgery (i.e., colorectal, neurosurgery, vascular/cardiac/thoracic, hysterectomy, abdominal/pelvic and orthopedic surgical procedures) within six months prior to infection diagnosis. Cases were diagnosed with C. difficile infection while controls were not. Methods The primary exposure was receiving (vs. not receiving) the recommended prophylactic antibiotic regimen, based on type and duration. Potential confounders included age, sex, length of hospital stay, comorbidities, type of surgery, and prior antibiotic use. Crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression. Results We enrolled 68 cases and 220 controls. The adjusted OR among surgical patients between developing C. difficile infection and not receiving the recommended prophylactic antibiotic regimen (usually receiving antimicrobial prophylaxis for more than 24 hours) was 6.7 (95% CI: 2.9–15.5). Independent risk factors for developing C. difficile infection included having severe comorbidities, receiving antibiotics within the previous 6 months, and undergoing orthopedic surgery. Conclusions Adherence to the recommended prophylactic antibiotics among surgical patients likely reduces the probability of being case of C. difficile. Antibiotic stewardship should be a priority in strategies to decrease the morbidity, mortality, and costs associated with C. difficile infection. PMID:28622340

Anesthesia and Duchenne or Becker muscular dystrophy: review of 117 anesthetic exposures.

PubMed

Segura, Leal G; Lorenz, Jessica D; Weingarten, Toby N; Scavonetto, Federica; Bojanić, Katarina; Selcen, Duygu; Sprung, Juraj

2013-09-01

Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are associated with life-threatening perioperative complications, including rhabdomyolysis, hyperkalemia, and hyperthermia. Current recommendations contraindicate use of succinylcholine and volatile anesthetics; however, the latter recommendation remains controversial. To review the perioperative outcomes of patients with DMD and BMD. We reviewed records of patients with DMD or BMD who underwent anesthetic management at our institution from January 1990 through December 2011. We identified 47 patients (DMD, 37; BMD, 10) who underwent 117 anesthetic exposures (DMD, 101; BMD, 16). Volatile anesthetic agents were used 66 times (DMD, 59; BMD, 7). One patient with undiagnosed BMD received succinylcholine and developed acute rhabdomyolysis and hyperkalemic cardiac arrest. All other major complications were attributed to the procedure (i.e., large bleeding), to preexisting comorbidities (i.e., respiratory failure, cardiac disease), or to both. Use of succinylcholine in children with dystrophinopathy is contraindicated. These patients have significant comorbidities and are frequently undergoing extensive operations; complications related to these factors can develop, as evidenced by our series. These complications may occur with use of volatile and nonvolatile anesthetics. However, because most of our patients were older than 8 years at the time of surgery, our observation cannot be generalized to younger dystrophin-deficient children. © 2013 John Wiley & Sons Ltd.

Acute cellular insulin resistance and hyperglycemia associated with hypophosphatemia after cardiac surgery.

PubMed

Garazi, Esther; Bridge, Suzanne; Caffarelli, Anthony; Ruoss, Stephen; Van der Starre, Pieter

2015-01-15

Successful glycemic control reduces morbidity and mortality in cardiac surgery patients. Protocols that include insulin infusions are commonly followed to achieve target blood glucose levels. Insulin resistance has been reported and linked to low serum phosphate levels in animal models and studies in diabetic outpatients, but not in postoperative patients. The following case series is a retrospective observational review of 8 cardiac surgery patients who developed insulin resistance early after surgery; this resistance was reversed by correcting serum hypophosphatemia. We discuss the multiple underlying mechanisms causing hypophosphatemia.

Pre-anesthetic echocardiographic findings in children undergoing non-cardiac surgery at the University of Benin Teaching Hospital, Nigeria

PubMed Central

Wilson, E Sadoh,; Paul, Ikhurionan; Charles, Imarengiaye,

2016-01-01

Summary Background A pre-anaesthestic echocardiogram (echo) is requested for most non-cardiac surgeries to identify possible cardiac structural anomalies Objective To describe the prevalence and spectrum of structural cardiac abnormalities seen in various non-cardiac conditions Methods We carried out a retrospective review of pre-anaesthetic echos performed over five years on children scheduled for non-cardiac surgery. The requests were categorised according to referring specialities, and the biodata and echo findings were noted Results A total of 181 children and 181 echocardiograms were studied, and 100 (55.2%) of the patients were male. Most of the children (87, 48.1%) with oro-facial clefts were referred from dentistry. Of the 181 children, 39 (21.5%) had cardiac abnormalities, most (34, 87.2%) of whom had congenital heart disease (CHD). Ophthalmic requests with suspected congenital rubella syndrome (CRS) had the highest prevalence of 8/12 (66.7%) while the lowest was oro-facial clefts at 15/87 (17.2%). Atrial septal defect was the commonest abnormality, found in 14 patients (35.9%) Conclusion Pre-anaesthetic echo should be performed, especially for children with suspected CRS and other congenital anomalies, requiring non-cardiac surgery. PMID:27701485

Preoperative education interventions to reduce anxiety and improve recovery among cardiac surgery patients: a review of randomised controlled trials.

PubMed

Guo, Ping

2015-01-01

To update evidence of the effectiveness of preoperative education among cardiac surgery patients. Patients awaiting cardiac surgery may experience high levels of anxiety and depression, which can adversely affect their existing disease and surgery and result in prolonged recovery. There is evidence that preoperative education interventions can lead to improved patient experiences and positive postoperative outcomes among a mix of general surgical patients. However, a previous review suggested limited evidence to support the positive impact of preoperative education on patients' recovery from cardiac surgery. Comprehensive review of the literature. The Cochrane Central Register of Controlled Trials from the Cochrane Library, MEDLINE, CINAHL, PsycINFO, EMBASE and Web of Science were searched for English-language articles published between 2000-2011. Original articles were included reporting randomised controlled trials of cardiac preoperative education interventions. Six trials were identified and have produced conflicting findings. Some trials have demonstrated the effects of preoperative education on improving physical and psychosocial recovery of cardiac patients, while others found no evidence that patients' anxiety is reduced or of any effect on pain or hospital stay. Evidence of the effectiveness of preoperative education interventions among cardiac surgery patients remains inconclusive. Further research is needed to evaluate cardiac preoperative education interventions for sustained effect and in non-Western countries. A nurse-coordinated multidisciplinary preoperative education approach may offer a way forward to provide a more effective and efficient service. Staff training in developing and delivering such interventions is a priority. © 2014 John Wiley & Sons Ltd.

Xenon triggers pro-inflammatory effects and suppresses the anti-inflammatory response compared to sevoflurane in patients undergoing cardiac surgery.

PubMed

Breuer, Thomas; Emontzpohl, Christoph; Coburn, Mark; Benstoem, Carina; Rossaint, Rolf; Marx, Gernot; Schälte, Gereon; Bernhagen, Juergen; Bruells, Christian S; Goetzenich, Andreas; Stoppe, Christian

2015-10-15

Cardiac surgery encompasses various stimuli that trigger pro-inflammatory mediators, reactive oxygen species and mobilization of leucocytes. The aim of this study was to evaluate the effect of xenon on the inflammatory response during cardiac surgery. This randomized trial enrolled 30 patients who underwent elective on-pump coronary-artery bypass grafting in balanced anaesthesia of either xenon or sevoflurane. For this secondary analysis, blood samples were drawn prior to the operation, intra-operatively and on the first post-operative day to measure the pro- and anti-inflammatory cytokines interleukin-6 (IL-6), interleukin-8/C-X-C motif ligand 8 (IL-8/CXCL8), and interleukin-10 (IL-10). Chemokines such as C-X-C motif ligand 12/ stromal cell-derived factor-1α (CXCL12/SDF-1α) and macrophage migration inhibitory factor (MIF) were measured to characterize xenon's perioperative inflammatory profile and its impact on migration of peripheral blood mononuclear cells (PBMC). Xenon enhanced the postoperative increase of IL-6 compared to sevoflurane (Xenon: 90.7 versus sevoflurane: 33.7 pg/ml; p = 0.035) and attenuated the increase of IL-10 (Xenon: 127.9 versus sevoflurane: 548.3 pg/ml; p = 0.028). Both groups demonstrated a comparable intraoperative increase of oxidative stress (intra-OP: p = 0.29; post-OP: p = 0.65). While both groups showed an intraoperative increase of the cardioprotective mediators MIF and CXCL12/SDF-1α, only MIF levels decreased in the xenon group on the first postoperative day (50.0 ng/ml compared to 23.3 ng/ml; p = 0.012), whereas it remained elevated after sevoflurane anaesthesia (58.3 ng/ml to 53.6 ng/ml). Effects of patients' serum on chemotactic migration of peripheral mononuclear blood cells taken from healthy volunteers indicated a tendency towards enhanced migration after sevoflurane anaesthesia (p = 0.07). Compared to sevoflurane, balanced xenon anaesthesia triggers pro-inflammatory effects and suppresses the anti-inflammatory response in cardiac surgery patients even though the clinical significance remains unknown. This clinical trial was approved by the European Medicines Agency (EudraCT-number: 2010-023942-63) and at ClinicalTrials.gov ( NCT01285271 ; first received: January 24, 2011).

Characterizing cardiac arrest in children undergoing cardiac surgery: A single-center study.

PubMed

Gupta, Punkaj; Wilcox, Andrew; Noel, Tommy R; Gossett, Jeffrey M; Rockett, Stephanie R; Eble, Brian K; Rettiganti, Mallikarjuna

2017-02-01

To characterize cardiac arrest in children undergoing cardiac surgery using single-center data from the Society of Thoracic Surgeons and Pediatric Advanced Life Support Utstein-Style Guidelines. Patients aged 18 years or less having a cardiac arrest for 1 minute or more during the same hospital stay as heart operation qualified for inclusion (2002-2014). Patients having a cardiac arrest both before or after heart operation were included. Heart operations were classified on the basis of the first cardiovascular operation of each hospital admission (the index operation). The primary outcome was survival to hospital discharge. A total of 3437 children undergoing at least 1 heart operation were included. Overall rate of cardiac arrest among these patients was 4.5% (n = 154) with survival to hospital discharge of 84 patients (66.6%). Presurgery cardiac arrest was noted among 28 patients, with survival of 21 patients (75%). Among the 126 patients with postsurgery cardiac arrest, survival was noted among 84 patients (66.6%). Regardless of surgical case complexity, the median days between heart operation and cardiac arrest, duration of cardiac arrest, and survival after cardiac arrest were similar. The independent risk factors associated with improved chances of survival included shorter duration of cardiac arrest (odds ratio, 1.12; 95% confidence interval, 1.05-1.20; P = .01) and use of defibrillator (odds ratio, 4.51; 95% confidence interval, 1.08-18.87; P = .03). This single-center study demonstrates that characterizing cardiac arrest in children undergoing cardiac surgery using definitions from 2 societies helps to increase data granularity and understand the relationship between cardiac arrest and heart operation in a better way. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Mortality prediction in patients with acute kidney injury requiring renal replacement therapy after cardiac surgery.

PubMed

Skarupskienė, Inga; Adukauskienė, Dalia; Kuzminskienė, Jurgita; Rimkutė, Laima; Balčiuvienė, Vilma; Žiginskienė, Edita; Kuzminskis, Vytautas; Adukauskaitė, Agnė; Pentiokinienė, Daiva; Bumblytė, Inga Arūnė

2017-01-01

Acute kidney injury (AKI) is a common and potentially serious postoperative complication after cardiac surgery, and it remains a cause of major morbidity and mortality. The aim of our study was to assess the prognostic illness severity score and to estimate the significant risk factors for poor outcome of patients with AKI requiring renal replacement therapy (RRT) after cardiac surgery. We retrospectively analyzed data of adult (>18 years) patients (n=111) who underwent open heart surgery and had developed AKI with need for RRT. Prognostic illness severity scores were calculated and perioperative risk factors of lethal outcome were assessed at the RRT initiation time. We defined three illness severity scores: Acute Physiology and Chronic Health Evaluation (APACHE II) as a general score, Sequential Organ Failure Assessment (SOFA) as an organ failure score, and Liano score as a kidney-specific disease severity score. Logistic regression was also used for the multivariate analysis of mortality risk factors. Hospital mortality was 76.5%. More than 7% of patients remained dialysis-dependent after their discharge from the hospital. The prognostic abilities of the scores were assessed for their discriminatory power. The area under the receiver-operating characteristic (ROC) curve of SOFA score was 0.719 (95% CI, 0.598-0.841), of Liano was 0.661 (95% CI, 0.535-0.787) and 0.668 (95% CI, 0.550-0.785) of APACHE II scores. From 16 variables analyzed for model selection, we reached a final logistic regression model, which demonstrated four variables significantly associated with patients' mortality. Glasgow coma score<14 points (OR=3.304; 95% CI, 1.130-9.662; P=0.003), mean arterial blood pressure (MAP)<63.5mmHg (OR=3.872; 95% CI, 1.011-13.616; P=0.035), serum creatinine>108.5μmol/L (OR=0.347; 95% CI, 0.123-0.998; P=0.046) and platelet count<115×10 9 /L (OR=3.731; 95% CI, 1.259-11.054; P=0.018) were independent risk factors for poor patient outcome. Our study demonstrated that SOFA score estimation is the most accurate to predict the fatal outcome in patients with AKI requiring RRT after cardiac surgery. Lethal patient outcome is related to Glasgow coma score, mean arterial blood pressure, preoperative serum creatinine and postoperative platelet count. Copyright © 2017 The Lithuanian University of Health Sciences. Production and hosting by Elsevier Sp. z o.o. All rights reserved.

Different Sequences of Fractionated Low-Dose Proton and Single Iron-Radiation-Induced Divergent Biological Responses in the Heart.

PubMed

Sasi, Sharath P; Yan, Xinhua; Zuriaga-Herrero, Marian; Gee, Hannah; Lee, Juyong; Mehrzad, Raman; Song, Jin; Onufrak, Jillian; Morgan, James; Enderling, Heiko; Walsh, Kenneth; Kishore, Raj; Goukassian, David A

2017-08-01

Deep-space travel presents risks of exposure to ionizing radiation composed of a spectrum of low-fluence protons ( 1 H) and high-charge and energy (HZE) iron nuclei (e.g., 56 Fe). When exposed to galactic cosmic rays, each cell in the body may be traversed by 1 H every 3-4 days and HZE nuclei every 3-4 months. The effects of low-dose sequential fractionated 1 H or HZE on the heart are unknown. In this animal model of simulated ionizing radiation, middle-aged (8-9 months old) male C57BL/6NT mice were exposed to radiation as follows: group 1, nonirradiated controls; group 2, three fractionated doses of 17 cGy 1 H every other day ( 1 H × 3); group 3, three fractionated doses of 17 cGy 1 H every other day followed by a single low dose of 15 cGy 56 Fe two days after the final 1 H dose ( 1 H × 3 + 56 Fe); and group 4, a single low dose of 15 cGy 56 Fe followed (after 2 days) by three fractionated doses of 17 cGy 1 H every other day ( 56 Fe + 1 H × 3). A subgroup of mice from each group underwent myocardial infarction (MI) surgery at 28 days postirradiation. Cardiac structure and function were assessed in all animals at days 7, 14 and 28 after MI surgery was performed. Compared to the control animals, the treatments that groups 2 and 3 received did not induce negative effects on cardiac function or structure. However, compared to all other groups, the animals in group 4, showed depressed left ventricular (LV) functions at 1 month with concomitant enhancement in cardiac fibrosis and induction of cardiac hypertrophy signaling at 3 months. In the irradiated and MI surgery groups compared to the control group, the treatments received by groups 2 and 4 did not induce negative effects at 1 month postirradiation and MI surgery. However, in group 3 after MI surgery, there was a 24% increase in mortality, significant decreases in LV function and a 35% increase in post-infarction size. These changes were associated with significant decreases in the angiogenic and cell survival signaling pathways. These data suggest that fractionated doses of radiation induces cellular and molecular changes that result in depressed heart functions both under basal conditions and particularly after myocardial infarction.

Evaluation of supply-side initiatives to improve access to coronary bypass surgery.

PubMed

Sobolev, Boris G; Fradet, Guy; Kuramoto, Lisa; Sobolyeva, Rita; Rogula, Basia; Levy, Adrian R

2012-09-11

Guided by the evidence that delaying coronary revascularization may lead to symptom worsening and poorer clinical outcomes, expansion in cardiac surgery capacity has been recommended in Canada. Provincial governments started providing one-time and recurring increases in budgets for additional open heart surgeries to reduce waiting times. We sought to determine whether the year of decision to proceed with non-emergency coronary bypass surgery had an effect on time to surgery. Using records from a population-based registry, we studied times between decision to operate and the procedure itself. We estimated changes in the length of time that patients had to wait for non-emergency operation over 14 calendar periods that included several years when supplementary funding was available. We studied waiting times separately for patients who access surgery through a wait list and through direct admission. During two periods when supplementary funding was available, 1998-1999 and 2004-2005, the weekly rate of undergoing surgery from a wait list was, respectively, 50% and 90% higher than in 1996-1997, the period with the longest waiting times. We also observed a reduction in the difference between 90th and 50th percentiles of the waiting-time distributions. Forty percent of patients in the 1998, 1999, 2004 and 2005 cohorts (years when supplementary funding was provided) underwent surgery within 16 to 20 weeks following the median waiting time, while it took between 27 and 37 weeks for the cohorts registered in the years when supplementary funding was not available. Times between decision and surgery were shorter for direct admissions than for wait-listed patients. Among patients who were directly admitted to hospital, time between decision and surgery was longest in 1992-1993 and then has been steadily decreasing through the late nineties. The rate of surgery among these patients was the highest in 1998-1999, and has not changed afterwards, even for years when supplementary funding was provided. Waiting times for non-emergency coronary bypass surgery shortened after supplementary funding was granted to increase volume of cardiac surgical care in a health system with publicly-funded universal coverage for the procedure. The effect of the supplementary funding was not uniform for patients that access the services through wait lists and through direct admission.

Effects of levosimendan on mortality in patients undergoing cardiac surgery: A systematic review and meta-analysis.

PubMed

Chen, Peili; Wu, Xiaoqiang; Wang, Zhiwei; Li, Zhenya; Tian, Xiangyong; Wang, Junpeng; Yan, Tianzhong

2018-06-01

We sought to determine the impact of levosimendan on mortality following cardiac surgery based on large-scale randomized controlled trials (RCTs). We searched PubMed, Web of Science, Cochrane databases, and ClinicalTrials.gov for RCTs published up to December 2017, on levosimendan for patients undergoing cardiac surgery. A total of 25 RCTs enrolling 2960 patients met the inclusion criteria; data from 15 placebo-controlled randomized trials were included for meta-analysis. Pooled analysis showed that the all-cause mortality rate was 6.4% (71 of 1106) in the levosimendan group and 8.4% (93 of 1108) in the placebo group (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.55-1.04; P = 0.09). There were no significant differences between the two groups in the rates of myocardial infarction (OR: 0.91; 95% CI, 0.68-1.21; P = 0.52), serious adverse events (OR: 0.84; 95% CI, 0.66-1.07; P = 0.17), hypotension (OR: 1.69; 95% CI, 0.94-3.03; P = 0.08), and low cardiac output syndrome (OR: 0.47; 95% CI, 0.22-1.02; P = 0.05). Levosimendan did not result in a reduction in mortality in adult cardiac surgery patients. Well designed, adequately powered, multicenter trials are necessary to determine the role of levosimendan in adult cardiac surgery. © 2018 The Authors. Journal of Cardiac Surgery Published by Wiley Periodicals Inc.

Myocardial protection during minimally invasive cardiac surgery through right mini-thoracotomy.

PubMed

De Palo, Micaela; Guida, Pietro; Mastro, Florinda; Nanna, Daniela; Quagliara, Teresa A P; Rociola, Ruggiero; Lionetti, Giosuè; Paparella, Domenico

2017-04-01

Myocardial damage is an independent predictor of adverse outcome following cardiac surgery and myocardial protection is one of the key factors to achieve successful outcomes. Cardioplegia with Custodiol is currently the most used cardioplegia during minimally invasive cardiac surgery (MICS). Different randomized controlled trials compared blood and Custodiol cardioplegia in the context of traditional cardiac surgery. No data are available for MICS. The aim of this study was to compare the efficacy of cold blood versus Custodiol cardioplegia during MICS. We retrospectively evaluated 90 patients undergoing MICS through a right mini-thoracotomy in a three-year period. Myocardial protection was performed using cold blood (44 patients, CBC group) or Custodiol (46 patients, Custodiol group) cardioplegia, based on surgeon preference and complexity of surgery. The primary outcomes were post-operative cardiac troponin I (cTnI) and creatine kinase MB (CKMB) serum release and the incidence of Low Cardiac Output Syndrome (LCOS). Aortic cross-clamp and cardiopulmonary bypass times were higher in the Custodiol group. No difference was observed in myocardial injury enzyme release (peak cTnI value was 18±46 ng/ml in CBC and 21±37 ng/ml in Custodiol; p=0.245). No differences were observed for mortality, LCOS, atrial or ventricular arrhythmias onset, transfusions, mechanical ventilation time duration, intensive care unit and total hospital stay. Custodiol and cold blood cardioplegic solutions seem to assure similar myocardial protection in patients undergoing cardiac surgery through a right mini-thoracotomy approach.

[Hygienic handling in cardiac surgery].

PubMed

Shimasaki, T; Masaoka, T; Hirooka, S; Abe, H; Watanabe, T; Washio, M

1993-04-01

Some points regarding the hygienic handling in cardiac surgery are mentioned. The sternal infection or mediastinitis is still one of the most important complications after cardiac operation especially when ITA is used for CABG. After we paid much attention to these points, the postoperative sternal infection has decreased obviously.

Source-case investigation of Mycobacterium wolinskyi cardiac surgical site infection.

PubMed

Dupont, C; Terru, D; Aguilhon, S; Frapier, J-M; Paquis, M-P; Morquin, D; Lamy, B; Godreuil, S; Parer, S; Lotthé, A; Jumas-Bilak, E; Romano-Bertrand, S

2016-07-01

The non-tuberculous mycobacteria (NTM) Mycobacterium wolinskyi caused bacteraemia and massive colonization of an aortic prosthesis in a patient 16 days after cardiac surgery, necessitating repeat surgery and targeted antimicrobial chemotherapy. The infection control team investigated the source and conditions of infection. Peri-operative management of the patient complied with recommendations. The environmental investigation showed that although M. wolinskyi was not recovered, diverse NTM species were present in water from point-of-use taps and heater-cooler units for extracorporeal circulation. This case and increasing evidence of emerging NTM infections in cardiac surgery led to the implementation of infection control procedures in cardiac surgery wards. Copyright © 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Ketorolac as an analgesic agent for infants and children after cardiac surgery: safety profile and appropriate patient selection.

PubMed

Jalkut, Meredith K

2014-01-01

Ketorolac has been used safely as an analgesic agent for children following cardiac surgery in selected populations. Controversy exists among institutions about the risks involved with this medication in this patient group. This article reviews the current literature regarding the safety of ketorolac for postoperative pain management in children after cardiac surgery. Specifically, concerns about renal dysfunction and increased bleeding risk are addressed. Additionally, the article details pharmacokinetics and potential benefits of ketorolac, such as its opioid-sparing effect. The literature reflects that the use of this medication is not well studied in certain pediatric cardiac patients such as neonates and those with single-ventricle physiology, and the safety of this medication in regards to these special populations is reviewed. In conclusion, ketorolac can be used in specific pediatric patients after cardiac surgery with minimal risk of bleeding or renal dysfunction with appropriate dosing and duration of use.

Concomitant coronary artery bypass graft and aortic and mitral valve replacement for rheumatic heart disease: short- and mid-term outcomes.

PubMed

Davarpasand, Tahereh; Hosseinsabet, Ali; Jalali, Arash

2015-09-01

It has been reported that the short-term mortality of concomitant aortic and mitral valve replacement (AVR and MVR) is considerable and concomitant coronary artery bypass graft (CABG) has adverse effects on the survival of patients with valve replacement surgery. We summarize the short- and mid-term outcome after concomitant CABG, AVR and MVR in our centre. Between 2003 and 2013, 103 patients (68 males, 35 females, age: 60.1 ± 10.1 years) underwent CABG, AVR and MVR for rheumatic heart disease (RHD) and coronary artery disease (CAD). The median follow-up was 47.6 months. Most of the patients were asymptomatic at rest. We analysed demographic, clinical and operative data of patients to define independent predictors of overall survival, cardiac event-free survival as well as cardiac death. The rate of 30-day survival was 93% (n = 96). The corresponding rates of overall survival and cardiac event-free survival and the cumulative incidence rate of cardiac death at 1 year were 80.2, 77.3 and 10.9%; the same at 4 years were 73.7, 64.6 and 15.8%. The corresponding freedom rates from anticoagulation-associated major haemorrhage; a composite of major bleeding events, thromboemboli and valvular thrombosis; cardiac rehospitalization; major adverse valve-associated events; and significant malfunction of the prosthetic valve were 96.2, 95.3, 94.7, 81.6 and 97.7% at 1 year. The corresponding freedom rates from anticoagulation-associated major haemorrhage; a composite of major bleeding events, thromboemboli and valvular thrombosis; cardiac rehospitalization; major adverse valve-associated events; and significant malfunction of the prosthetic valve were 93.5, 91.0, 91.4, 73.5 and 95.5% at 4 years. The independent predictors of overall survival were age, cigarette smoking, chronic kidney diseases and balloon pump insertion. The independent predictors of cardiac event-free survival were age and previous myocardial infarction, while age, cigarette smoking, history of cerebrovascular accident and balloon pump insertion were the independent predictors of cardiac death. Concomitant CABG, AVR and MVR for rheumatic heart disease accompanied by CAD appear to have acceptable short- and mid-term outcomes with symptomatic amelioration. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Recombinant activated factor VII in cardiac surgery: a systematic review.

PubMed

Warren, Oliver; Mandal, Kaushik; Hadjianastassiou, Vassilis; Knowlton, Lisa; Panesar, Sukhmeet; John, Kokotsakis; Darzi, Ara; Athanasiou, Thanos

2007-02-01

Postoperative hemorrhage is a common complication in cardiac surgery, and it is associated with a considerable increase in morbidity, mortality, and cost. Recombinant activated factor VII (rFVIIa) is an emerging hemostatic agent, increasingly used in cardiac surgery. This article systematically reviews the evidence regarding the efficacy, safety, and cost of rFVIIa in this setting. Although definitive evidence from randomized controlled trials is lacking, the use of rFVIIa in patients experiencing refractory postoperative hemorrhage seems promising and relatively safe. However further research is required to definitively establish its clinical utility in the postoperative cardiac patient.

Self-reported physical activity and lung function two months after cardiac surgery--a prospective cohort study.

PubMed

Jonsson, Marcus; Urell, Charlotte; Emtner, Margareta; Westerdahl, Elisabeth

2014-03-28

Physical activity has well-established positive health-related effects. Sedentary behaviour has been associated with postoperative complications and mortality after cardiac surgery. Patients undergoing cardiac surgery often suffer from impaired lung function postoperatively. The association between physical activity and lung function in cardiac surgery patients has not previously been reported. Patients undergoing cardiac surgery were followed up two months postoperatively. Physical activity was assessed on a four-category scale (sedentary, moderate activity, moderate regular exercise, and regular activity and exercise), modified from the Swedish National Institute of Public Health's national survey. Formal lung function testing was performed preoperatively and two months postoperatively. The sample included 283 patients (82% male). Two months after surgery, the level of physical activity had increased (p < 0.001) in the whole sample. Patients who remained active or increased their level of physical activity had significantly better recovery of lung function than patients who remained sedentary or had decreased their level of activity postoperatively in terms of vital capacity (94 ± 11% of preoperative value vs. 91 ± 9%; p = 0.03), inspiratory capacity (94 ± 14% vs. 88 ± 19%; p = 0.008), and total lung capacity (96 ± 11% vs. 90 ± 11%; p = 0.01). An increased level of physical activity, compared to preoperative level, was reported as early as two months after surgery. Our data shows that there could be a significant association between physical activity and recovery of lung function after cardiac surgery. The relationship between objectively measured physical activity and postoperative pulmonary recovery needs to be further examined to verify these results.

Cardiac surgery in patients with congenital heart disease is associated with acute kidney injury and the risk of chronic kidney disease.

PubMed

Madsen, Nicolas L; Goldstein, Stuart L; Frøslev, Trine; Christiansen, Christian F; Olsen, Morten

2017-09-01

Cardiac surgery associated-acute kidney injury (CS-AKI) occurs in 30-50% of patients undergoing surgery for congenital heart disease. Here we determine if CS-AKI is associated with chronic kidney disease (CKD) in patients with congenital heart disease. Using Danish regional population-based registries, our cohort study included patients with congenital heart disease born between 1990-2010 with first cardiac surgery between 2005 and 2010 (under 15 years of age). Utilizing in- and out-patient laboratory serum creatinine data, we identified individuals fulfilling KDIGO stages of AKI within 5 days of cardiac surgery. A unique personal identifier enabled unambiguous data linkage and virtually complete follow-up. The cumulative incidences of CKD stages 2-5 according to presence of CS-AKI were computed utilizing serum creatinine values and Pottel's formula. Using Cox regression, the corresponding hazard ratios were computed, adjusting for sex, age at first cardiac surgery, calendar period of surgery, and congenital heart disease severity. Of 382 patients with congenital heart disease undergoing cardiac surgery, 127 experienced CS-AKI within 5 days of surgery. Median follow-up was 4.9 years. The five-year cumulative incidence of CKD for patients with CS-AKI was 12% (95% confidence interval 7%-20%), significantly higher than the 3% (1%-5%) for those without CS-AKI with a significant adjusted hazard ratio of 3.8 (1.4-10.4). Thus, CS-AKI in patients with congenital heart disease is common and is associated with an increased risk for CKD. Copyright © 2017 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.

Outcome of cardiac surgery in patients with congenital heart disease in England between 1997 and 2015

PubMed Central

Dimopoulos, Konstantinos; Uebing, Anselm; Diller, Gerhard-Paul; Rosendahl, Ulrich; Belitsis, George

2017-01-01

Background The number of patients with congenital heart disease (CHD) is increasing worldwide and most of them will require cardiac surgery, once or more, during their lifetime. The total volume of cardiac surgery in CHD patients at a national level and the associated mortality and predictors of death associated with surgery are not known. We aimed to investigate the surgical volume and associated mortality in CHD patients in England. Methods Using a national hospital episode statistics database, we identified all CHD patients undergoing cardiac surgery in England between 1997 and 2015. Results We evaluated 57,293 patients (median age 11.9years, 46.7% being adult, 56.7% female). There was a linear increase in the number of operations performed per year from 1,717 in 1997 to 5,299 performed in 2014. The most common intervention at the last surgical event was an aortic valve procedure (9,276; 16.2%), followed by repair of atrial septal defect (9,154; 16.0%), ventricular septal defect (7,746; 13.5%), tetralogy of Fallot (3,523; 6.1%) and atrioventricular septal defect (3,330; 5.8%) repair. Associated mortality remained raised up to six months following cardiac surgery. Several parameters were predictive of post-operative mortality, including age, complexity of surgery, need for emergency surgery and socioeconomic status. The relationship of age with mortality was “U”-shaped, and mortality was highest amongst youngest children and adults above 60 years of age. Conclusions The number of cardiac operations performed in CHD patients in England has been increasing, particularly in adults. Mortality remains raised up to 6-months after surgery and was highest amongst young children and seniors. PMID:28628610

Impaired Olfaction and Risk for Delirium or Cognitive Decline After Cardiac Surgery

PubMed Central

Brown, Charles H.; Morrissey, Candice; Ono, Masahiro; Yenokyan, Gayane; Selnes, Ola A.; Walston, Jeremy; Max, Laura; LaFlam, Andrew; Neufeld, Karin; Gottesman, Rebecca F.; Hogue, Charles W.

2014-01-01

Summary Statement Impaired olfaction, identified in 33% of patients undergoing cardiac surgery, was associated with the adjusted risk for postoperative delirium but not cognitive decline. Objectives The prevalence and significance of impaired olfaction is not well characterized in patients undergoing cardiac surgery. Because impaired olfaction has been associated with underlying neurologic disease, impaired olfaction may identify patients who are vulnerable to poor neurological outcomes in the perioperative period. The objective of this study was to determine the prevalence of impaired olfaction among patients presenting for cardiac surgery and the independent association of impaired olfaction with postoperative delirium and cognitive decline. Design Nested prospective cohort study Setting Academic hospital Participants 165 patients undergoing coronary artery bypass and/or valve surgery Measurements Olfaction was measured using the Brief Smell Identification Test, with impaired olfaction defined as an olfactory score < 5th percentile of normative data. Delirium was assessed using a validated chart-review method. Cognitive performance was assessed using a neuropsychological testing battery at baseline and 4–6 weeks after surgery. Results Impaired olfaction was identified in 54 of 165 patients (33%) prior to surgery. Impaired olfaction was associated with increased adjusted risk for postoperative delirium (relative risk [RR] 1.90, 95% CI 1.17–3.09; P=0.009). There was no association between impaired olfaction and change in composite cognitive score in the overall study population. Conclusion Impaired olfaction is prevalent in patients undergoing cardiac surgery and is associated with increased adjusted risk for postoperative delirium, but not cognitive decline. Impaired olfaction may identify unrecognized vulnerability for postoperative delirium among patients undergoing cardiac surgery. PMID:25597555

Physiotherapy-supervised mobilization and exercise following cardiac surgery: a national questionnaire survey in Sweden.

PubMed

Westerdahl, Elisabeth; Möller, Margareta

2010-08-25

Limited published data are available on how patients are mobilized and exercised during the postoperative hospital stay following cardiac surgery. The aim of this survey was to determine current practice of physiotherapy-supervised mobilization and exercise following cardiac surgery in Sweden. A prospective survey was carried out among physiotherapists treating adult cardiac surgery patients. A total population sample was identified and postal questionnaires were sent to the 33 physiotherapists currently working at the departments of thoracic surgery in Sweden. In total, 29 physiotherapists (response rate 88%) from eight hospitals completed the survey. The majority (90%) of the physiotherapists offered preoperative information. The main rationale of physiotherapy treatment after cardiac surgery was to prevent and treat postoperative complications, improve pulmonary function and promote physical activity. In general, one to three treatment sessions were given by a physiotherapist on postoperative day 1 and one to two treatment sessions were given during postoperative days 2 and 3. During weekends, physiotherapy was given to a lesser degree (59% on Saturdays and 31% on Sundays to patients on postoperative day 1). No physiotherapy treatment was given in the evenings. The routine use of early mobilization and shoulder range of motion exercises was common during the first postoperative days, but the choice of exercises and duration of treatment varied. Patients were reminded to adhere to sternal precautions. There were great variations of instructions to the patients concerning weight bearing and exercises involving the sternotomy. All respondents considered physiotherapy necessary after cardiac surgery, but only half of them considered the physiotherapy treatment offered as optimal. The results of this survey show that there are small variations in physiotherapy-supervised mobilization and exercise following cardiac surgery in Sweden. However, the frequency and duration of exercises and recommendations for sternal precautions reinforced for the healing period differ between physiotherapists. This survey provides an initial insight into physiotherapy management in Sweden. Comparison with surveys in other countries is warranted to improve the physiotherapy management and postoperative recovery of the cardiac surgery patient.

Physiotherapy-supervised mobilization and exercise following cardiac surgery: a national questionnaire survey in Sweden

PubMed Central

2010-01-01

Background Limited published data are available on how patients are mobilized and exercised during the postoperative hospital stay following cardiac surgery. The aim of this survey was to determine current practice of physiotherapy-supervised mobilization and exercise following cardiac surgery in Sweden. Methods A prospective survey was carried out among physiotherapists treating adult cardiac surgery patients. A total population sample was identified and postal questionnaires were sent to the 33 physiotherapists currently working at the departments of thoracic surgery in Sweden. In total, 29 physiotherapists (response rate 88%) from eight hospitals completed the survey. Results The majority (90%) of the physiotherapists offered preoperative information. The main rationale of physiotherapy treatment after cardiac surgery was to prevent and treat postoperative complications, improve pulmonary function and promote physical activity. In general, one to three treatment sessions were given by a physiotherapist on postoperative day 1 and one to two treatment sessions were given during postoperative days 2 and 3. During weekends, physiotherapy was given to a lesser degree (59% on Saturdays and 31% on Sundays to patients on postoperative day 1). No physiotherapy treatment was given in the evenings. The routine use of early mobilization and shoulder range of motion exercises was common during the first postoperative days, but the choice of exercises and duration of treatment varied. Patients were reminded to adhere to sternal precautions. There were great variations of instructions to the patients concerning weight bearing and exercises involving the sternotomy. All respondents considered physiotherapy necessary after cardiac surgery, but only half of them considered the physiotherapy treatment offered as optimal. Conclusions The results of this survey show that there are small variations in physiotherapy-supervised mobilization and exercise following cardiac surgery in Sweden. However, the frequency and duration of exercises and recommendations for sternal precautions reinforced for the healing period differ between physiotherapists. This survey provides an initial insight into physiotherapy management in Sweden. Comparison with surveys in other countries is warranted to improve the physiotherapy management and postoperative recovery of the cardiac surgery patient. PMID:20738852

Anomalous Coronary Arteries and Myocardial Bridges: Risk Stratification in Children Using Novel Cardiac Catheterization Techniques.

PubMed

Agrawal, Hitesh; Molossi, Silvana; Alam, Mahboob; Sexson-Tejtel, S Kristen; Mery, Carlos M; McKenzie, E Dean; Fraser, Charles D; Qureshi, Athar M

2017-03-01

The evaluation of the vast majority of children with anomalous aortic origin of a coronary artery (AAOCA) and/or myocardial bridges is performed with non-invasive testing. However, a subset of these patients may benefit from invasive testing for risk stratification. All patients included in the Coronary Anomalies Program (CAP) at Texas Children's Hospital who underwent cardiac catheterization were included. Techniques included selective coronary angiograms (SCA), intravascular ultrasound (IVUS), and fractional flow reserve (FFR) measurements with provocative testing using adenosine and/or dobutamine infusions. Out of the 131 patients followed by the CAP between 12/12-4/16, 8 (6%) patients underwent 9 cath investigations at median age 13.1 (2.6-18.7) years and median weight 49.5 (11.4-142.7) kg. Six patients presented with cardiac signs/symptoms. Four patients had myocardial bridges of the left anterior descending (LAD) coronary artery, 2 patients had isolated AAOCA, and 2 patients had an anomalous left coronary artery (LCA) with an intramyocardial course of the LAD. SCA was performed in all patients. FFR was positive in 4/6 patients: IVUS showed >70% intraluminal narrowing in 3/5 patients. One patient had hemodynamic instability that reversed with catheter removal from the coronary ostium. Based on the catheterization data obtained, findings were reassuring in three patients, surgery was performed in three patients, and two patients are being medically managed/restricted from competitive sports. In our small cohort of patients, we demonstrated that IVUS and FFR can safely be performed in children and may help to risk stratify some patients with AAOCA and myocardial bridges.

Impact of minimized extracorporeal circulation on outcome in patients with preoperative anemia undergoing coronary artery bypass surgery.

PubMed

Haneya, Assad; Philipp, Alois; Von Suesskind-Schwendi, Marietta; Diez, Claudius; Hirt, Stephan W; Kolat, Philipp; Attmann, Tim; Schoettler, Jan; Zausig, York; Ried, Michael; Schmid, Christof

2013-01-01

Preoperative anemia and low hematocrit during cardiopulmonary bypass have been associated with worse outcome in patients undergoing cardiac surgery. The minimized extracorporeal circulation (MECC) allows a reduction of the negative effects associated with conventional extracorporeal circulation (CECC). In this study, the impact of the MECC on outcome of anemic patients after coronary artery bypass grafting (CABG) was assessed. Between January 2004 and December 2011, 1,945 consecutive patients with preoperative anemia underwent isolated CABG using CECC (44.8%) or MECC (55.2%). The cutoff point for anemia was 13 g/dl for men and 12 g/dl for women. The postoperative creatine kinase and lactate levels were significantly lower in the MECC group (p < 0.001). There was no difference in postoperative blood loss between the groups. However, the intraoperative and postoperative transfusion requirements were significantly lower in the MECC group (p < 0.05). Furthermore, MECC patients had lower incidences of postoperative acute renal failure, and low cardiac output syndrome, shorter intensive care unit lengths of stay and reduced 30-day mortality (p < 0.05). In conclusion, a reduced postoperative mortality, lower transfusion requirements, and less renal and myocardial damage encourage the use of MECC for CABG, especially in the specific high-risk subgroup of patients with anemia.

Surgical resection of cardiac myxoma-a 30-year single institutional experience.

PubMed

Lee, Kyo Seon; Kim, Gwan Sic; Jung, Yochun; Jeong, In Seok; Na, Kook Joo; Oh, Bong Suk; Ahn, Byung Hee; Oh, Sang Gi

2017-03-27

Primary cardiac tumors are rare and myxoma constitutes the majority. The present study summarizes our 30-year clinical outcomes of surgical myxoma resection. Between January 1986 and December 2015, 93 patients (30 men, 63 women; mean age, 54.7 ± 16.6 years) underwent surgical myxoma resection. The most common origin site was the left atrium. Surgery was performed via a biatrial approach in 74.2%, atrial septotomy through right atriotomy in 17.2%, and left atriotomy only in 8.6%. Mean myxoma size based on longest length was 4.73 ± 1.92 cm (range, 1.2-11.0 cm). The mean follow-up duration was 9.9 ± 7.8 years (range, 0-29 years). In-hospital mortality was 3.2%. The most common postoperative complication was atrial fibrillation (4.3%). The 5-, 10-, and 30-year survival rates were 92.9%, 87.2%, and 75.5%, respectively. Recurrence occurred in two patients (2.1%), which were detected at 20 and 79 months after the first surgery, respectively. Long-term survival after myxoma resection was excellent and recurrence was rare. Based on our experience, surgical method did not affect the outcome.

Genetic polymorphisms and the risk of stroke after cardiac surgery.

PubMed

Grocott, Hilary P; White, William D; Morris, Richard W; Podgoreanu, Mihai V; Mathew, Joseph P; Nielsen, Dahlia M; Schwinn, Debra A; Newman, Mark F

2005-09-01

Stroke represents a significant cause of morbidity and mortality after cardiac surgery. Although the risk of stroke varies according to both patient and procedural factors, the impact of genetic variants on stroke risk is not well understood. Therefore, we tested the hypothesis that specific genetic polymorphisms are associated with an increased risk of stroke after cardiac surgery. Patients undergoing cardiac surgery utilizing cardiopulmonary bypass surgery were studied. DNA was isolated from preoperative blood and analyzed for 26 different single-nucleotide polymorphisms. Multivariable logistic regression modeling was used to determine the association of clinical and genetic characteristics with stroke. Permutation analysis was used to adjust for multiple comparisons inherent in genetic association studies. A total of 1635 patients experiencing 28 strokes (1.7%) were included in the final genetic model. The combination of the 2 minor alleles of C-reactive protein (CRP; 3'UTR 1846C/T) and interleukin-6 (IL-6; -174G/C) polymorphisms, occurring in 583 (35.7%) patients, was significantly associated with stroke (odds ratio, 3.3; 95% CI, 1.4 to 8.1; P=0.0023). In a multivariable logistic model adjusting for age, the CRP and IL-6 single-nucleotide polymorphism combination remained significantly associated with stroke (P=0.0020). We demonstrate that common genetic variants of CRP (3'UTR 1846C/T) and IL-6 (-174G/C) are significantly associated with the risk of stroke after cardiac surgery, suggesting a pivotal role of inflammation in post-cardiac surgery stroke.

Genetic factors contribute to bleeding after cardiac surgery.

PubMed

Welsby, I J; Podgoreanu, M V; Phillips-Bute, B; Mathew, J P; Smith, P K; Newman, M F; Schwinn, D A; Stafford-Smith, M

2005-06-01

Postoperative bleeding remains a common, serious problem for cardiac surgery patients, with striking inter-patient variability poorly explained by clinical, procedural, and biological markers. We tested the hypothesis that genetic polymorphisms of coagulation proteins and platelet glycoproteins are associated with bleeding after cardiac surgery. Seven hundred and eighty patients undergoing aortocoronary surgery with cardiopulmonary bypass were studied. Clinical covariates previously associated with bleeding were recorded and DNA isolated from preoperative blood. Matrix Assisted Laser Desorption/Ionization, Time-Of-Flight (MALDI-TOF) mass spectroscopy or polymerase chain reaction were used for genotype analysis. Multivariable linear regression modeling, including all genetic main effects and two-way gene-gene interactions, related clinical and genetic predictors to bleeding from the thorax and mediastinum. Nineteen candidate polymorphisms were assessed; seven [GPIaIIa-52C>T and 807C>T, GPIb alpha 524C>T, tissue factor-603A>G, prothrombin 20210G>A, tissue factor pathway inhibitor-399C>T, and angiotensin converting enzyme (ACE) deletion/insertion] demonstrate significant association with bleeding (P < 0.01). Adding genetic to clinical predictors results improves the model, doubling overall ability to predict bleeding (P < 0.01). We identified seven genetic polymorphisms associated with bleeding after cardiac surgery. Genetic factors appear primarily independent of, and explain at least as much variation in bleeding as clinical covariates; combining genetic and clinical factors double our ability to predict bleeding after cardiac surgery. Accounting for genotype may be necessary when stratifying risk of bleeding after cardiac surgery.

Selective Cerebro-Myocardial Perfusion in Complex Neonatal Aortic Arch Pathology: Midterm Results.

PubMed

Hoxha, Stiljan; Abbasciano, Riccardo Giuseppe; Sandrini, Camilla; Rossetti, Lucia; Menon, Tiziano; Barozzi, Luca; Linardi, Daniele; Rungatscher, Alessio; Faggian, Giuseppe; Luciani, Giovanni Battista

2018-04-01

Aortic arch repair in newborns and infants has traditionally been accomplished using a period of deep hypothermic circulatory arrest. To reduce neurologic and cardiac dysfunction related to circulatory arrest and myocardial ischemia during complex aortic arch surgery, an alternative and novel strategy for cerebro-myocardial protection was recently developed, where regional low-flow perfusion is combined with controlled and independent coronary perfusion. The aim of the present retrospective study was to assess short-term and mid-term results of selective and independent cerebro-myocardial perfusion in neonatal aortic arch surgery. From April 2008 to August 2015, 28 consecutive neonates underwent aortic arch surgery under cerebro-myocardial perfusion. There were 17 male and 11 female, with median age of 15 days (3-30 days) and median body weight of 3 kg (1.6-4.2 kg), 9 (32%) of whom with low body weight (<2.5 kg). The spectrum of pathologies treated was heterogeneous and included 13 neonates having single-stage biventricular repair (46%), 7 staged biventricular repair (25%), and 8 single-ventricle repair (29%). All operations were performed under moderate hypothermia and with a "beating heart and brain." Average cardiopulmonary bypass time was 131 ± 64 min (42-310 min). A period of cardiac arrest to complete intra-cardiac repair was required in nine patients (32%), and circulatory arrest in 1 to repair total anomalous pulmonary venous connection. Average time of splanchnic ischemia during cerebro-myocardial perfusion was 30 ± 11 min (15-69 min). Renal dysfunction, requiring a period of peritoneal dialysis was observed in 10 (36%) patients, while liver dysfunction was noted only in 3 (11%). There were three (11%) early and two late deaths during a median follow-up of 2.9 years (range 6 months-7.7 years), with an actuarial survival of 82% at 7 years. At latest follow-up, no patient showed signs of cardiac or neurologic dysfunction. The present experience shows that a strategy of selective and independent cerebro-myocardial perfusion is safe, versatile, and feasible in high-risk neonates with complex congenital arch pathology. Encouraging outcomes were noted in terms of cardiac and neurological function, with limited end-organ morbidity. © 2018 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Perinatal Decision Making for Preterm Infants with Congenital Heart Disease: Determinable Risk Factors for Mortality.

PubMed

Lynema, Stephanie; Fifer, Carlen G; Laventhal, Naomi T

2016-06-01

For premature infants with congenital heart disease (CHD), it may be unclear when the burdens of treatment outweigh potential benefits. Parents may thus have to choose between comfort care at birth and medical stabilization until surgical repair is feasible. Better defined outcome data, including risk factors for mortality, are needed to counsel expectant parents who are considering intensive care for premature infants with CHD. We sought to evaluate outcomes in this population to inform expectant parents considering intensive versus palliative care at birth. We performed a retrospective cohort study of infants born <34 weeks who received intensive care with critical or moderately severe CHD predicted to require surgery in the neonatal period or the first 6 months of life. 46 % of 54 infants survived. Among non-survivors, 74 % died prior to surgery (median age 24 days). Of the infants that underwent surgery, 75 % survived. Survival was lower among infants <32 weeks gestational age (GA) (p = 0.013), with birth weight (BW) <1500 g (p = 0.011), or with extra-cardiac anomalies (ECA) (p = 0.015). GA and ECA remained significant risk factors for mortality in multiple logistic regression analysis. In summary, GA < 32 weeks, BW < 1500 g, and ECA are determinable prenatally and were significant risk factors for mortality. The majority of infants who survived to cardiac intervention survived neonatal hospitalization, whereas most of the infants who died did so prior to surgery. For some expectant parents, this early declaration of mortality may support a trial of intensive care while avoiding burdensome interventions.

Concomitant surgical closure of left atrial appendage: A systematic review and meta-analysis.

PubMed

Ando, Masahiko; Funamoto, Masaki; Cameron, Duke E; Sundt, Thoralf M

2018-03-12

Although percutaneous closure of the left atrial appendage is supported as a potential alternative to lifelong anticoagulation in patients with atrial fibrillation, comprehensive evidence on surgical left atrial appendage closure in heart surgery is limited. We conducted a meta-analysis of studies comparing patients who underwent open cardiac surgery with or without left atrial appendage closure. A literature search was performed on PubMed, Embase, and Cochrane Trials databases. Outcomes of interest were 30-day/in-hospital mortality and cerebrovascular accident. I 2 statistics were used to evaluate heterogeneity, and publication bias was evaluated by Begg's and Egger's tests. We reviewed 1284 articles and selected for main analysis 7 articles including 3897 patients (1963 in the left atrial appendage closure group and 1934 in the non-left atrial appendage closure group). Among the 7 studies, 3 were randomized-controlled studies, 3 were propensity-matched studies, and 1 was a case-matching study. At 30-day/in-hospital follow-up, left atrial appendage closure was significantly associated with decreased risk of mortality and cerebrovascular accident (odds ratio, 0.384, 95% confidence interval, 0.233-0.631 for mortality, and odds ratio, 0.622, 95% confidence interval, 0.388-0.998 for cerebrovascular accident). Stratified analysis demonstrated that this association was more prominent in preoperative atrial fibrillation strata. Concomitant surgical left atrial appendage closure should be considered at the time of open cardiac surgery, particularly among those in atrial fibrillation preoperatively. The benefit of left atrial appendage closure for patients not in atrial fibrillation and for those undergoing nonvalvular surgery is still unclear. Further prospective investigations are indicated. Copyright © 2018. Published by Elsevier Inc.

Cefazolin Concentration in the Mediastinal Adipose Tissue of Patients Undergoing Cardiac Surgery

PubMed Central

Tchaick, Rodrigo Mezzalira; Sá, Michel Pompeu Barros Oliveira; Figueira, Fernando Ribeiro de Moraes; Paz, Kilma Coelho; Ferraz, Álvaro Antonio Bandeira; de Moraes Neto, Fernando Ribeiro

2017-01-01

Objective To measure the concentration of cefazolin in the anterior mediastinal adipose tissue of patients undergoing cardiac surgery, determining the variation of cefazolin concentration. Methods Two samples of approximately 1g of subcutaneous tissue were collected from 19 patients who underwent surgery in December 2015: the first sample was collected right after sternotomy and the second one, before sternal synthesis with steel wires. Antibiotic dosage was administered through high performance liquid chromatography. Results We observed a positive and statistically significant correlation between time 1 and cefazolin concentration (r=0.489 and P=0.039). For time 2 and cefazolin concentration, there was a negative and statistically significant correlation between both variables (r=-0.793 and P<0.001). A negative correlation was also observed between body mass index and cefazolin concentration at time 2 (r=-0.510 and P=0.031). The regression model showed that every 1-minute increase in time 1 corresponded to an increase of 0.240 µg/dL in cefazolin concentration, whereas every 1-minute increase in time 2 corresponded to a reduction of 0.046 µg/dL in cefazolin concentration. As for body mass index, every 1 kg/m2 increase corresponded to a reduction of about 0.510 µg/dL in cefazolin concentration. Conclusion There was a positive and significant correlation between the initial time of surgery and cefazolin level in the first dosage. The evaluation of the second dosage showed a negative and significant correlation between cefazolin level and the second time of dosage. The concentration of cefazolin is under the influence of body mass index. PMID:28977194

Persistent institutional difficulties in surgery for transposition of the great arteries in guatemala: analysis with the aristotle basic and comprehensive scores.

PubMed

Leon-Wyss, Juan; Lo Rito, Mauro; Barnoya, Joaquin; Castañeda, Aldo R

2011-07-01

Background. Neonates with complex congenital cardiac lesions are largely inadequately managed in Guatemala. Methods. Between 1997 and 2009, 79 patients who underwent operations for transposition of the great arteries were identified; 51 (63.3%) had an arterial switch operation (ASO) and 28 (36%) an atrial switch operation (ATSO). The Aristotle Basic Complexity score (ABC score) and the Aristotle Comprehensive Complexity score (ACC score) have been used to aid in the evaluation of quality of care associated with pediatric cardiac surgery by adjusting for operative complexity. Results. In-hospital mortality was 47% for the ASO and 25% for the ATSO group; 36.7% were beyond 1 month of age and many exhibited increased preoperative risk factors. The mean ABC score was 9.75 ± 0.89 and the ACC score was 12.12 ± 2.7, with a mean 2.36-point increase (P < .05). Comparing survivors and nonsurvivors with both scores, significant differences were identified (ABC: P < .04 and ACC: P < .02). Conclusion. During this 13-year period, a low volume of surgery for transposition of the great arteries (TGA) was performed at our institution with a relatively high surgical mortality. Many patients with TGA in Guatemala are either never referred for surgery or referred late. Strategies to improve outcomes for neonates with TGA in Guatemala must include increases in early diagnosis countrywide and prompt referral to our unit. Based on the larger number of neonates with TGA that would be referred to our center, we anticipate that this strategy should substantially improve surgical outcomes and favor overall team-related skills.

Unplanned Robotic-Assisted Conversion-to-Open Colorectal Surgery is Associated with Adverse Outcomes.

PubMed

Lee, Yongjin F; Albright, Jeremy; Akram, Warqaa M; Wu, Juan; Ferraro, Jane; Cleary, Robert K

2018-06-01

Laparoscopic conversion-to-open colorectal surgery is associated with worse outcomes when compared to operations completed without conversion. Consequences of robotic conversion have not yet been determined. The purpose of this study is to compare short-term outcomes of converted robotic colorectal cases with those that are completed without conversion, as well as with cases done by the open approach. The ACS-NSQIP database was queried for patients who underwent robotic completed, robotic converted-to-open, and open colorectal resection between 2012 and 2015. Propensity scores were estimated using gradient-boosted machines and converted to weights. Generalized linear models were fit using propensity score-weighted data. A total of 25,253 patients met inclusion criteria-21,356 (84.5%) open, 3663 (14.5%) robotic completed, and 234 (0.9%) conversions. Conversion rate was 6.0%. Converted cases had significantly higher 30-day mortality rate, higher complication rate, and longer hospital length of stay than completed cases. Converted patients also had significantly higher rates of the following complications: surgical site infections, cardiac complications, deep venous thrombosis, postoperative ileus, postoperative re-intubation, renal failure, and 30-day reoperation. Compared to the open approach, converted patients had significantly more cardiac complications, postoperative reintubation, and longer operating times with no significant difference in 30-day mortality. Unplanned robotic conversion-to-open is associated with worse outcomes than completed cases and outcomes that more closely resemble traditional open colorectal surgery. Patients should be counseled with regard to minimally invasive conversion rates and outcomes. The continued pursuit of technological advancements that decrease the risk for conversion in minimally invasive colorectal surgery is clearly warranted.

Acute Mitral Valve Dysfunction Due to Escape of Prosthetic Mechanical Leaflet and Peripheral Leaftlet Embolization.

PubMed

Calik, Eyup Serhat; Limandal, Husnu Kamil; Arslan, Umit; Tort, Mehmet; Yildiz, Ziya; Bayram, Ednan; Dag, Ozgur; Kaygin, Mehmet Ali; Erkut, Bilgehan

2015-12-14

Leaflet escape of prosthetic valve is rare but potentially life threatening. Early diagnosis is essential on account of avoiding mortality, and emergency surgical correction is compulsory. This complication has previously been reported for both monoleaflet and bileaflet valve models. A 30-year-old man who had undergone mitral valve replacement with a bileaflet valve 8 years prior at another center was admitted with acute-onset with cardiogenic shock as an emergency case. Transthoracic echocardiograms showed acute-starting severe mitral regurgitation associated with prosthetic mitral valve. There was a suspicious finding of a single prosthetic mitral leaflet. But the problem related with the valve wasn't specifically determined. The patient underwent emergent surgery for replacement of the damaged prosthetic valves immediately. There was no tissue impingement and thrombosis, one of the two leaflets was absent, and there were no signs of endocarditis or pannus formation in the prosthetic valve. The missing leaflet could not be found within the cardiac cavity. The abdominal fluoroscopic study and plain radiography were unable to detect the escaped leaflet during surgery. The damaged valve was removed and a replacement 29 mm bileaflet mechanical valve was inserted by right lateral thoracotomy. After post-operative week one, the abdominal computed tomography scan and the ultrasound showed the escaped leaflet in the left femoral artery. Fifteen days after the surgery the escaped leaflet was removed safely from the left femoral artery and the patient made a complete recovery. The escaped leaflet showed a fracture of one of the pivot systems caused by structural failure. Early cardiac surgery should be applied because of life-threatening problems.

Clinical significance of serum cortisol levels following surgery for congenital heart disease.

PubMed

Teagarden, Alicia M; Mastropietro, Christopher W

2017-03-01

Use of hydrocortisone to treat refractory haemodynamic instability in patients recovering from surgery for congenital heart disease is common practice at many centres. We aimed to determine whether there is a relationship between total serum cortisol concentrations and haemodynamic response to this therapy. Material and methods We retrospectively reviewed patients <21 years who underwent cardiac surgery from 2011 to 2013, received hydrocortisone within 72 hours postoperatively, and had total serum cortisol measurements contemporaneous with its administration. Favourable responders were defined as patients in whom, at 24 hours after hydrocortisone initiation, either (1) systolic blood pressure was increased or unchanged and vasoactive-inotrope score was decreased or (2) systolic blood pressure increased by ⩾10% of baseline and vasoactive-inotrope score was unchanged. Variables were compared using t-tests or Mann-Whitney U tests as appropriate. In total, 24 patients were reviewed, with a median age of 1.4 months and range of 0.1-232 months. Among them, 14 (58%) patients responded favourably to hydrocortisone. At 24 hours, the median change in vasoactive-inotrope score was -18% in favourable responders and +31% in those who did not respond favourably, p=0.001. The mean pre-hydrocortisone total serum cortisol in favourable responders was 17.4±10.9 µg/dl compared with 46.1±44.7 µg/dl in those who did not respond favourably, p=0.03. Total serum cortisol obtained before initiation of hydrocortisone was significantly lower in patients who responded favourably to this therapy. Total serum cortisol may therefore be helpful in identifying children recovering from cardiac surgery who may or may not haemodynamically improve with hydrocortisone.

Measurement of total hemoglobin reduces red cell transfusion in hospitalized patients undergoing cardiac surgery: a retrospective database analysis.

PubMed

Craver, Christopher; Belk, Kathy W; Myers, Gerard J

2018-01-01

Historically, perioperative hemoglobin monitoring has relied on calculated saturation, using blood gas devices that measure plasma hematocrit (Hct). Co-oximetry, which measures total hemoglobin (tHb), yields a more comprehensive assessment of hemodilution. The purpose of this study was to examine the association of tHb measurement by co-oximetry and Hct, using conductivity with red blood cell (RBC) transfusion, length of stay (LOS) and inpatient costs in patients having major cardiac surgery. A retrospective study was conducted on patients who underwent coronary artery bypass graft (CABG) and/or valve replacement (VR) procedures from January 2014 to June 2016, using MedAssets discharge data. The patient population was sub-divided by the measurement modality (tHb and Hct), using detailed billing records and Current Procedural Terminology coding. Cost was calculated using hospital-specific cost-to-charge ratios. Multivariable logistic regression was performed to identify significant drivers of RBC transfusion and resource utilization. The study population included 18,169 cardiovascular surgery patients. Hct-monitored patients accounted for 66% of the population and were more likely to have dual CABG and VR procedures (10.4% vs 8.9%, p=0.0069). After controlling for patient and hospital characteristics, as well as patient comorbidities, Hct-monitored patients had significantly higher RBC transfusion risk (OR=1.26, CI 1.15-1.38, p<0.0001), longer LOS (IRR=1.08, p<0.0001) and higher costs (IRR=1.15, p<0.0001) than tHb-monitored patients. RBC transfusions were a significant driver of LOS (IRR=1.25, p<0.0001) and cost (IRR=1.22, p<0.0001). tHb monitoring during cardiovascular surgery could offer a significant reduction in RBC transfusion, length of stay and hospital cost compared to Hct monitoring.

[Frequency and type of pleuropulmonary complications and their predictors during the first thirty days after cardiopulmonary bypass surgery in children].

PubMed

Hernández-López, Jessica Jacqueline; Solano-Gutiérrez, Alejandro; Rosas-Aragón, Flor Teresita; Antúnez-Soto, Airam Gabriela; Flores-Lujano, Janet; Nuñez-Enríquez, Juan Carlos

2017-07-01

To determine the frequency and type of pleuropulmonary complications and their predictors in the first thirty postoperative days of patients undergoing surgery without cardiopulmonary bypass. A retrospective cohort study was carried out between January 2013 and December 2014. It included all patients with congenital heart disease who underwent cardiac surgery using a sternal or thoracic approach, without cardiopulmonary bypass with a registered admission to a Neonatal or Paediatric Intensive Care. The frequency of events of pleuropulmonary complications and logistic regression analysis was performed, and the adjusted odds ratio (OR) and confidence intervals at 95% (95% CI) were calculated. A total of 139 patients were included. The frequency of pleuropulmonary complications was 42.4% (N=59), and the most frequent types were atelectasis (28 events), ventilator-associated pneumonia (24 events), pneumothorax (20 events), with more than one complication per patient occasionally being found. Significant risk factors were cyanogenic congenital heart disease (OR=3.58, 95% CI: 1.10-7.50, P=.001), thoracotomy approach (OR=1.46, 95% CI: 1.18-1.12, P=.008), and an emergency surgical event (OR=3.46, 95% CI: 1.51-7.95, P=.002). The main pleuropulmonary complication was atelectasis, which is consistent with that reported in the international literature. Patients with any of the predictors identified in the present study should be closely monitored in order to prevent, detect and/or treat pleuropulmonary complications in a timely manner after cardiac surgery. Copyright © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. All rights reserved.

The peri-operative management of anti-platelet therapy in elective, non-cardiac surgery.

PubMed

Alcock, Richard F; Naoum, Chris; Aliprandi-Costa, Bernadette; Hillis, Graham S; Brieger, David B

2013-07-31

Cardiovascular complications are important causes of morbidity and mortality in patients undergoing elective non-cardiac surgery, with adverse cardiac outcomes estimated to occur in approximately 4% of all patients. Anti-platelet therapy withdrawal may precede up to 10% of acute cardiovascular syndromes, with withdrawal in the peri-operative setting incompletely appraised. The aims of our study were to determine the proportion of patients undergoing elective non-cardiac surgery currently prescribed anti-platelet therapy, and identify current practice in peri-operative management. In addition, the relationship between management of anti-platelet therapy and peri-operative cardiac risk was assessed. We evaluated consecutive patients attending elective non-cardiac surgery at a major tertiary referral centre. Clinical and biochemical data were collected and analysed on patients currently prescribed anti-platelet therapy. Peri-operative management of anti-platelet therapy was compared with estimated peri-operative cardiac risk. Included were 2950 consecutive patients, with 516 (17%) prescribed anti-platelet therapy, primarily for ischaemic heart disease. Two hundred and eighty nine (56%) patients had all anti-platelet therapy ceased in the peri-operative period, including 49% of patients with ischaemic heart disease and 46% of patients with previous coronary stenting. Peri-operative cardiac risk score did not influence anti-platelet therapy management. Approximately 17% of patients undergoing elective non-cardiac surgery are prescribed anti-platelet therapy, the predominant indication being for ischaemic heart disease. Almost half of all patients with previous coronary stenting had no anti-platelet therapy during the peri-operative period. The decision to cease anti-platelet therapy, which occurred commonly, did not appear to be guided by peri-operative cardiac risk stratification. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Influence of patient-related and surgery-related risk factors on cognitive performance, emotional state, and convalescence after cardiac surgery.

PubMed

Ille, Rottraut; Lahousen, Theresa; Schweiger, Stefan; Hofmann, Peter; Kapfhammer, Hans-Peter

2007-01-01

Cardiac surgery may account for complications such as cognitive impairment, depression, and delay of convalescence. This study investigated the influence of different risk factors on cognitive performance, emotional state, and convalescence. We included 83 patients undergoing cardiac surgery who had no indication of postoperative delirium. Psychometric testing was performed 1 day before and 7 days after surgery. Neuron-specific enolase (NSE) levels were measured 1 day before and 36 h after surgery. Depression score increased after surgery, but patients showed no clinically significant depression. Postoperative cognitive performance correlated with postoperative depression level and preoperative cognitive performance. Forty-three percent of patients showed postoperative decline. Older patients exhibited a higher postoperative increase in NSE concentrations. Patients undergoing coronary artery bypass grafts or combined procedures exhibited more medical risk factors than those undergoing valve surgery alone. The number of bypass grafts was associated with time of hospitalization, and the number of patient-related risk factors correlated with stay in intensive care unit. For elderly patients undergoing cardiac surgery, older age, total preexisting medical risk factors, and surgery duration seem to be the most important factors influencing cognitive outcome and convalescence. Results show that, also for patients without postoperative delirium, medical risk factors and intraoperative parameters can result in delay of convalescence.

Comparison of the effects of candesartan cilexetil and enalapril maleate on right ventricular myocardial remodeling in dogs with experimentally induced pulmonary stenosis.

PubMed

Yamane, Tsuyoshi; Fujii, Yoko; Orito, Kensuke; Osamura, Kaori; Kanai, Takao; Wakao, Yoshito

2008-12-01

To compare the effects of candesartan cilexetil and enalapril maleate on right ventricular myocardial remodeling in dogs with experimentally induced pulmonary stenosis. 24 Beagles. 18 dogs underwent pulmonary arterial banding (PAB) to induce right ventricular pressure overload, and 6 healthy dogs underwent sham operations (thoracotomy only [sham-operated group]). Dogs that underwent PAB were allocated to receive 1 of 3 treatments (6 dogs/group): candesartan (1 mg/kg, PO, q 24 h [PABC group]), enalapril (0.5 mg/kg, PO, q 24 h [PABE group]), or no treatment (PABNT group). Administration of treatments was commenced the day prior to surgery; control dogs received no cardiac medications. Sixty days after surgery, right ventricular wall thickness was assessed echocardiographically and plasma renin activity, angiotensin-converting enzyme activity, and angiotensin I and II concentrations were assessed; all dogs were euthanatized, and collagenous fiber area, cardiomyocyte diameter, and tissue angiotensin-converting enzyme and chymase-like activities in the right ventricle were evaluated. After 60 days of treatment, right ventricular wall thickness, cardiomyocyte diameter, and collagenous fiber area in the PABNT and PABE groups were significantly increased, compared with values in the PABC and sham-operated groups. Chymase-like activity was markedly greater in the PABE group than in other groups. Results indicated that treatment with candesartan but not enalapril effectively prevented myocardial remodeling in dogs with experimentally induced subacute right ventricular pressure overload.

The use of the RenalGuard system in cardiac surgery with cardiopulmonary bypass: a first in man prospective, observational, feasibility pilot study

PubMed Central

Giri, Ramesh; Wrigley, Benmjamin; Hennessy, Anne-Marie; Nicholas, Johann; Nevill, Alan

2017-01-01

Objectives As proof of concept, this prospective, observational study assessed the feasibility and early clinical outcomes of performing on-pump cardiac surgery with the RenalGuard system. Background Acute kidney injury (AKI) is reported in up to 30% of patients undergoing cardiac surgery and is a recognised independent predictor of both morbidity and mortality. Forced diuresis with the RenalGuard system reduces the incidence of AKI during percutaneous coronary intervention procedures but its use in cardiac surgery has not been explored. Methods Ten consecutive patients who were at risk of developing AKI during cardiac surgery were selected. The RenalGuard system was used to facilitate forced diuresis using weight-adjusted intravenous furosemide while maintaining neutral fluid balance by matched intravenous fluid replacement. This regimen was initiated preoperatively in all patients and continued for 6–12 hours postoperatively. Serum creatinine, electrolytes and need for renal replacement were documented in all patients. Results The RenalGuard system functioned successfully in all patients and facilitated high perioperative urine outputs, even when patients were placed on cardiopulmonary bypass (CPB). There were no incidences of significant (A) electrolyte imbalance, (B) changes in haemoglobin levels or (C) pulmonary oedema. No patients developed AKI within 36 hours of surgery despite one patient developing cardiac tamponade 8 hours postoperatively and one patient developing paralytic ileus. One patient, however, was ‘electively’ haemofiltered on day 2 after developing acute right ventricular failure. The median intensive care stay was 1.5 (1, 5) days. Conclusion The RenalGuard system can be used successfully in patients undergoing cardiac surgery with CPB and may reduce the incidence of AKI in at-risk patients. Trial registration NCT02974946; Pre-results. PMID:29071091

The use of the RenalGuard system in cardiac surgery with cardiopulmonary bypass: a first in man prospective, observational, feasibility pilot study.

PubMed

Luckraz, Heyman; Giri, Ramesh; Wrigley, Benmjamin; Hennessy, Anne-Marie; Nicholas, Johann; Nevill, Alan

2017-01-01

As proof of concept, this prospective, observational study assessed the feasibility and early clinical outcomes of performing on-pump cardiac surgery with the RenalGuard system. Acute kidney injury (AKI) is reported in up to 30% of patients undergoing cardiac surgery and is a recognised independent predictor of both morbidity and mortality. Forced diuresis with the RenalGuard system reduces the incidence of AKI during percutaneous coronary intervention procedures but its use in cardiac surgery has not been explored. Ten consecutive patients who were at risk of developing AKI during cardiac surgery were selected. The RenalGuard system was used to facilitate forced diuresis using weight-adjusted intravenous furosemide while maintaining neutral fluid balance by matched intravenous fluid replacement. This regimen was initiated preoperatively in all patients and continued for 6-12 hours postoperatively. Serum creatinine, electrolytes and need for renal replacement were documented in all patients. The RenalGuard system functioned successfully in all patients and facilitated high perioperative urine outputs, even when patients were placed on cardiopulmonary bypass (CPB). There were no incidences of significant (A) electrolyte imbalance, (B) changes in haemoglobin levels or (C) pulmonary oedema. No patients developed AKI within 36 hours of surgery despite one patient developing cardiac tamponade 8 hours postoperatively and one patient developing paralytic ileus. One patient, however, was 'electively' haemofiltered on day 2 after developing acute right ventricular failure. The median intensive care stay was 1.5 (1, 5) days. The RenalGuard system can be used successfully in patients undergoing cardiac surgery with CPB and may reduce the incidence of AKI in at-risk patients. NCT02974946; Pre-results.

Poor preoperative nutritional status is an important predictor of the retardation of rehabilitation after cardiac surgery in elderly cardiac patients.

PubMed

Ogawa, Masato; Izawa, Kazuhiro P; Satomi-Kobayashi, Seimi; Kitamura, Aki; Ono, Rei; Sakai, Yoshitada; Okita, Yutaka

2017-04-01

Preoperative nutritional status and physical function are important predictors of mortality and morbidity after cardiac surgery. However, the influence of nutritional status before cardiac surgery on physical function and the progress of postoperative rehabilitation requires clarification. To determine the effect of preoperative nutritional status on preoperative physical function and progress of rehabilitation after elective cardiac surgery. We enrolled 131 elderly patients with mean age of 73.7 ± 5.8 years undergoing cardiac surgery. We divided them into two groups by nutritional status as measured by the Geriatric Nutritional Risk Index (GNRI): high GNRI group (GNRI ≥ 92, n = 106) and low GNRI group (GNRI < 92, n = 25). Physical function was estimated by handgrip strength, knee extensor muscle strength (KEMS), the Short Physical Performance Battery (SPPB), and 6-minute walk test (6MWT). Progress of postoperative rehabilitation was evaluated by the number of days to independent walking after surgery, length of stay in the ICU, and length of hospital stay. After adjusting for potential confounding factors, preoperative handgrip strength (P = 0.034), KEMS (P = 0.009), SPPB (P < 0.0001), and 6MWT (P = 0.012) were all significantly better in the high GNRI group. Multiple regression analysis revealed that a low GNRI was an independent predictor of the retardation of postoperative rehabilitation. Preoperative nutritional status as assessed by the GNRI could reflect perioperative physical function. Preoperative poor nutritional status may be an independent predictor of the retardation of postoperative rehabilitation in patients undergoing elective cardiac surgery.

Takotsubo cardiomyopathy associated with cardiac arrest following cardiac surgery: new variants of an unusual syndrome.

PubMed

Vernick, William J; Hargrove, W Clark; Augoustides, John G; Horak, Jiri

2010-11-01

Takotsubo cardiomyopathy is increasingly being recognized in the perioperative period. To date, there have been only three previous cases involving cardiac surgery reported and this represents the fourth case. The precise mechanism remains elusive, and there is no definitive management strategy. It appears that the syndromes course in cardiac surgical patients is self-limited. This syndrome must now be considered in the differential diagnosis of postcardiotomy cardiac failure. © 2010 Wiley Periodicals, Inc.

Complementary and Alternative Medicine in Cardiac Surgery: Prevalence and Modality of use.

PubMed

Dalmayrac, Emilie; Quignon, Anne; Baufreton, Christophe

2016-07-01

Complementary and alternative medicines are developing at a growing rate but their use in the hospital setting is little known, ignoring risk or benefit in practice. The objectives of the study were to quantify the prevalence of complementary and alternative medicines used by patients admitted to a cardiac surgery department. Patients and staff at the Cardiac Surgery unit of Angers University Hospital (France) were surveyed regarding their modality of complementary and alternative medicines use, between April 01, 2013, and April 18, 2014, by means of an anonymous questionnaire. Of 154 patients included in the study, 58% used a complementary and alternative medicine at least once in their lifetime, 38% during the preceding year, and 14% between the consultation and surgery. In all, 71% used them as a complement to their conventional medical treatment. Of those who used a complementary and alternative medicine during the year of their surgery procedure, only 29% informed their physicians and paramedical staff about it. Complementary and alternative medicines use among patients admitted to cardiac surgery units is common. Yet there is a real lack of knowledge regarding these health practices among physicians and paramedical staff. Copyright © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

Evaluation of paediatric cardiosurgical model in Croatia by using the Aristotle basic complexity score and the risk adjustment for congenital cardiac surgery-1 method.

PubMed

Dilber, Daniel; Malcic, Ivan

2010-08-01

The Aristotle basic complexity score and the risk adjustment in congenital cardiac surgery-1 method were developed and used to compare outcomes of congenital cardiac surgery. Both methods were used to compare results of procedures performed on our patients in Croatian cardiosurgical centres and results of procedures were taken abroad. The study population consisted of all patients with congenital cardiac disease born to Croatian residents between 1 October, 2002 and 1 October, 2007 undergoing a cardiovascular operation during this period. Of the 556 operations, the Aristotle basic complexity score could be assigned to 553 operations and the risk adjustment in congenital cardiac surgery-1 method to 536 operations. Procedures were performed in two institutions in Croatia and seven institutions abroad. The average complexity for cardiac procedures performed in Croatia was significantly lower. With both systems, along with the increase in complexity, there is also an increase in mortality before discharge and postoperative length of stay. Only after the adjustment for complexity there are marked differences in mortality and occurrence of postoperative complications. Both, the Aristotle basic complexity score and the risk adjustment in congenital cardiac surgery-1 method were predictive of in-hospital mortality as well as prolonged postoperative length to stay, and can be used as a tool in our country to evaluate a cardiosurgical model and recognise potential problems.

The incidence and cost of cardiac surgery adverse events in Australian (Victorian) hospitals 2003-2004.

PubMed

Ehsani, Jonathon Pouya; Duckett, Stephen J; Jackson, Terri

2007-12-01

The aim of this study was to estimate the incidence of adverse events in acute surgical admissions for cardiac disease in admitted episodes in the year 2003-2004 and to estimate the cost of these complications to the Victorian health system. Cardiac surgery adverse events are among the most frequent and significant contributors to the morbidity, mortality and cost associated with hospitalisation. Patient-level costing data set for major Victorian public hospitals in 2003-2004 was analysed for adverse events using C-prefixed markers, denoting complications that arose during the course of hospital treatment for cardiac surgery diagnosis related groups (DRGs). The cost of adverse events was estimated by linear regression modelling, adjusted for age and co-morbidity. A total of 16,766 multi-day cardiac disease cases were identified, of whom 6,181 (36.85%) had at least one adverse event. Patients with adverse events stayed approximately 7 days longer and had four times the case fatality rate than those without. After adjustment for age and co-morbidity, the presence of an adverse event adds AUS$5,751. The sum of the total cost of adverse events for each DRG was AUS$42.855 million, representing 21.6% of total expenditure on cardiac surgery and adding 27.5% in broad terms to the cardiac surgery budget.

Lithotomy versus jack-knife position on haemodynamic parameters assessed by impedance cardiography during anorectal surgery under low dose spinal anaesthesia: a randomized controlled trial.

PubMed

Borodiciene, Jurgita; Gudaityte, Jurate; Macas, Andrius

2015-05-06

Although the prone position providing better exposure for anorectal surgery is required it can cause a reduction of cardiac output and cardiac index. The goal was to compare haemodynamic changes assessed by impedance cardiography during anorectal surgery under low-dose spinal anaesthesia in lithotomy and jack-knife position. The prospective randomized controlled study included 104, ASA I-II adult patients admitted for elective minor anorectal surgery, assigned to be performed in lithotomy (groupL, n = 52) or jack-knife position (groupJ, n = 52). After arrival to operating room the standard monitoring, impedance cardiography device was connected to the patient, and the following variables were recorded: cardiac output, cardiac index, systemic vascular resistance, stroke index at times of arrival to operating room, placement for, start and end of surgery and placement to bed. Spinal block was made in the sitting position with 4 mg of 0.5% hyperbaric bupivacaine and 10 μg of Fentanyl injected over 2 min. Comparison was based on haemodynamic changes between and inside groups over time. Student's t, chi square tests were used for statistical analysis with p < 0.05 regarded as statistically significant. The reduction of cardiac output was statistically significant after placement of the patient into the prone position: from baseline 7.4+/-1.6 to 4.9+/-1.2 after placement for and 4.7+/-1.2 at the start and end of surgery (mean +/-SD l/min). The difference of cardiac output between groups was 2.0 l/min after positioning for and the start of surgery and 1.5 l/min at the end of surgery (p < 0.05). Mean cardiac index reduced from baseline 3.9+/-0.8 to 2.6+/-0.7 and 2.4+/-0.6 (mean+/-SD l/min/m(2)) in groupJ and between groups: by 1.0 l/min/m(2) after placement for, 1.1 at the start and 0.8 at the end of surgery (p < 0.05). Systemic vascular resistance increased from baseline 1080+/-338 to 1483+/-479 after placement for, 1523+/-481 at the start and 1525+/-545 at the end of surgery in groupJ (mean+/-SD dynes/sec/cm(-5), p < 0.05). According to impedance cardiography, jack-knife position after low-dose spinal anaesthesia produces transitory, but statistically significant reduction of cardiac output and cardiac index with increase of systemic vascular resistance, compared to insignificant changes in lithotomy position. Clinical Trials NCT02115178.

Preoperative platelet transfusions to reverse antiplatelet therapy for urgent non-cardiac surgery: an observational cohort study.

PubMed

Baschin, M; Selleng, S; Hummel, A; Diedrich, S; Schroeder, H W; Kohlmann, T; Westphal, A; Greinacher, A; Thiele, T

2018-04-01

Essentials An increasing number of patients requiring surgery receive antiplatelet therapy (APT). We analyzed 181 patients receiving presurgery platelet transfusions to reverse APT. No coronary thrombosis occurred after platelet transfusion. This justifies a prospective trial to test preoperative platelet transfusions to reverse APT. Background Patients receiving antiplatelet therapy (APT) have an increased risk of perioperative bleeding and cardiac adverse events (CAE). Preoperative platelet transfusions may reduce the bleeding risk but may also increase the risk of CAE, particularly coronary thrombosis in patients after recent stent implantation. Objectives To analyze the incidence of perioperative CAE and bleeding in patients undergoing non-cardiac surgery using a standardized management of transfusing two platelet concentrates preoperatively and restart of APT within 24-72 h after surgery. Methods A cohort of consecutive patients on APT treated with two platelet concentrates before non-cardiac surgery between January 2012 and December 2014 was retrospectively identified. Patients were stratified by the risk of major adverse cardiac and cerebrovascular events (MACCE). The primary objective was the incidence of CAE (myocardial infarction, acute heart failure and cardiac troponine T increase). Secondary objectives were incidences of other thromboembolic events, bleedings, transfusions and mortality. Results Among 181 patients, 88 received aspirin, 21 clopidogrel and 72 dual APT. MACCE risk was high in 63, moderate in 103 and low in 15 patients; 67 had cardiac stents. Ten patients (5.5%; 95% CI, 3.0-9.9%) developed a CAE (three myocardial infarctions, four cardiac failures and three troponin T increases). None was caused by coronary thrombosis. Surgery-related bleeding occurred in 22 patients (12.2%; 95% CI, 8.2-17.7%), making 12 re-interventions necessary (6.6%; 95% CI, 3.8-11.2%). Conclusion Preoperative platelet transfusions and early restart of APT allowed urgent surgery and did not cause coronary thromboses, but non-thrombotic CAEs and re-bleeding occurred. Randomized trials are warranted to test platelet transfusion against other management strategies. © 2018 International Society on Thrombosis and Haemostasis.

Assessment of cardiac risk before non-cardiac surgery: brain natriuretic peptide in 1590 patients.

PubMed

Dernellis, J; Panaretou, M

2006-11-01

To evaluate the predictive value of brain natriuretic peptide (BNP) for assessment of cardiac risk before non-cardiac surgery. Consecutively treated patients (947 men, 643 women) whose BNP was measured before non-cardiac surgery were studied. Clinical and ECG variables were evaluated to identify predictors of postoperative cardiac events. Events occurred in 6% of patients: 21 cardiac deaths, 20 non-fatal myocardial infarctions, 41 episodes of pulmonary oedema and 14 patients with ventricular tachycardia. All of these patients had raised plasma BNP concentrations (best cut-off point 189 pg/ml). The only independent predictor of postoperative events was BNP (odds ratio 34.52, 95% confidence interval (CI) 17.08 to 68.62, p < 0.0001). Clinical variables of Goldman's multifactorial index identified 18% of patients in class I, 40% in class II, 24% in class III and 18% in class IV preoperatively; postoperative event rates were 2%, 3%, 7% and 14%, respectively. BNP identified 60% of patients as having zero risk (BNP 0-100 pg/ml), 22% low risk (101-200 pg/ml), 14% intermediate risk (201-300 pg/ml) and 4% high risk (> 300 pg/ml); postoperative event rates were 0%, 5%, 12% and 81%, respectively. In this population of patients evaluated before non-cardiac surgery, BNP is an independent predictor of postoperative cardiac events. BNP > 189 pg/ml identified patients at highest risk.

Relationship between High Red Cell Distribution Width and Systemic Inflammatory Response Syndrome after Extracorporeal Circulation.

PubMed

Seth, Harsh Sateesh; Mishra, Prashant; Khandekar, Jayant V; Raut, Chaitanya; Mohapatra, Chandan Kumar Ray; Ammannaya, Ganesh Kumar K; Saini, Jaskaran Singh; Shah, Vaibhav

2017-01-01

Cardiac surgical operations involving extracorporeal circulation may develop severe inflammatory response. This severe inflammatory response syndrome (SIRS) is usually associated with poor outcome with no predictive marker. Red cell distribution width (RDW) is a routine hematological marker with a role in inflammation. We aim to determine the relationship between RDW and SIRS through our study. A total of 1250 patients who underwent cardiac surgery with extracorporeal circulation were retrospectively analyzed out of which 26 fell into the SIRS criteria and 26 consecutive control patients were taken. RDW, preoperative clinical data, operative time and postoperative data were compared between SIRS and control groups. The demographic profile of the patients was similar. RDW was significantly higher in the SIRS versus control group (15.5±2.0 vs. 13.03±1.90), respectively with P value <0.0001. There was significant mortality in the SIRS group, 20 (76.92%) as compared to 2 (7.6%) in control group with a P value of <0.005. Multiple logistic regression analysis revealed that there was significant association with high RDW and development of SIRS after extracorporeal circulation (OR for RDW levels exceeding 13.5%; 95% CI 1.0-1.2; P<0.05). Increased RDW was significantly associated with increased risk of SIRS after extracorporeal circulation. Thus, RDW can act as a useful tool to predict SIRS in patients undergoing cardiac surgery with extracorporeal circulation. Hence, more aggressive measures can be taken in patients with high RDW to prevent postoperative morbidity and mortality.

Management of sickle cell disease in patients undergoing cardiac surgery.

PubMed

Crawford, Todd C; Carter, Michael V; Patel, Rina K; Suarez-Pierre, Alejandro; Lin, Sophie Z; Magruder, Jonathan Trent; Grimm, Joshua C; Cameron, Duke E; Baumgartner, William A; Mandal, Kaushik

2017-02-01

Sickle cell disease is a life-limiting inherited hemoglobinopathy that poses inherent risk for surgical complications following cardiac operations. In this review, we discuss preoperative considerations, intraoperative decision-making, and postoperative strategies to optimize the care of a patient with sickle cell disease undergoing cardiac surgery. © 2017 Wiley Periodicals, Inc.

Antifibrinolytic agents and desmopressin as hemostatic agents in cardiac surgery.

PubMed

Erstad, B L

2001-09-01

To review the use of systemic hemostatic medications for reducing bleeding and transfusion requirements with cardiac surgery. Articles were obtained through computerized searches involving MEDLINE (from 1966 to September 2000). Additionally, several textbooks containing information on the diagnosis and management of bleeding associated with cardiac surgery were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references. Due to the large number of randomized investigations involving systemic hemostatic medications for reducing bleeding associated with cardiac surgery, the article selection process focused on recent randomized controlled trials, metaanalyses and pharmacoeconomic evaluations. The primary outcomes extracted from the literature were blood loss and associated transfusion requirements, although other outcome measures such as mortality were extracted when available. Although the majority of investigations for reducing cardiac bleeding and transfusion requirements have involved aprotinin, evidence from recent meta-analyses and randomized trials indicates that the synthetic antifibrinolytic agents, aminocaproic acid and tranexamic acid, have similar clinical efficacy. Additionally, aminocaproic acid (and to a lesser extent tranexamic acid) is much less costly. More comparative information of hemostatic agents is needed retative to other outcomes (eg., reoperation rates, myocardial infarction, stroke). There is insufficient evidence to recommend the use of desmopressin for reducing bleeding and transfusion requirements in cardiac surgery, although certain subsets of patients may benefit from its use. Of the medications that have been used to reduce bleeding and transfusion requirements with cardiac surgery, the antifibrinolytic agents have the best evidence supporting their use. Aminocaproic acid is the least costly therapy based on medication costs and transfusion requirements.

Comparison of Outcomes of Pericardiocentesis Versus Surgical Pericardial Window in Patients Requiring Drainage of Pericardial Effusions.

PubMed

Horr, Samuel E; Mentias, Amgad; Houghtaling, Penny L; Toth, Andrew J; Blackstone, Eugene H; Johnston, Douglas R; Klein, Allan L

2017-09-01

Comparative outcomes of patients undergoing pericardiocentesis or pericardial window are limited. Development of pericardial effusion after cardiac surgery is common but no data exist to guide best management. Procedural billing codes and Cleveland Clinic surgical registries were used to identify 1,281 patients who underwent either pericardiocentesis or surgical pericardial window between January 2000 and December 2012. The 656 patients undergoing an intervention for a pericardial effusion secondary to cardiac surgery were also compared. Propensity scoring was used to identify well-matched patients in each group. In the overall cohort, in-hospital mortality was similar between the group undergoing pericardiocentesis and surgical drainage (5.3% vs 4.4%, p = 0.49). Similar outcomes were found in the propensity-matched group (4.9% vs 6.1%, p = 0.55). Re-accumulation was more common after pericardiocentesis (24% vs 10%, p <0.0001) and remained in the matched cohorts (23% vs 9%, p <0.0001). The secondary outcome of hemodynamic instability after the procedure was more common in the pericardial window group in both the unmatched (5.2% vs 2.9%, p = 0.036) and matched cohorts (6.1% vs 2.0%, p = 0.022). In the subgroup of patients with a pericardial effusion secondary to cardiac surgery, there was a lower mortality after pericardiocentesis in the unmatched group (1.5% vs 4.6%, p = 0.024); however, after adjustment, this difference in mortality was no longer present (2.6% vs 4.5%, p = 0.36). In conclusion, both pericardiocentesis and surgical pericardial window are safe and effective treatment strategies for the patient with a pericardial effusion. In our study there were no significant differences in mortality in patients undergoing either procedure. Observed differences in outcomes with regard to recurrence rates, hemodynamic instability, and in those with postcardiac surgery effusions may help to guide the clinician in management of the patient requiring therapeutic or diagnostic drainage of a pericardial effusion. Copyright © 2017 Elsevier Inc. All rights reserved.

Self-reported physical activity and lung function two months after cardiac surgery – a prospective cohort study

PubMed Central

2014-01-01

Background Physical activity has well-established positive health-related effects. Sedentary behaviour has been associated with postoperative complications and mortality after cardiac surgery. Patients undergoing cardiac surgery often suffer from impaired lung function postoperatively. The association between physical activity and lung function in cardiac surgery patients has not previously been reported. Methods Patients undergoing cardiac surgery were followed up two months postoperatively. Physical activity was assessed on a four-category scale (sedentary, moderate activity, moderate regular exercise, and regular activity and exercise), modified from the Swedish National Institute of Public Health’s national survey. Formal lung function testing was performed preoperatively and two months postoperatively. Results The sample included 283 patients (82% male). Two months after surgery, the level of physical activity had increased (p < 0.001) in the whole sample. Patients who remained active or increased their level of physical activity had significantly better recovery of lung function than patients who remained sedentary or had decreased their level of activity postoperatively in terms of vital capacity (94 ± 11% of preoperative value vs. 91 ± 9%; p = 0.03), inspiratory capacity (94 ± 14% vs. 88 ± 19%; p = 0.008), and total lung capacity (96 ± 11% vs. 90 ± 11%; p = 0.01). Conclusions An increased level of physical activity, compared to preoperative level, was reported as early as two months after surgery. Our data shows that there could be a significant association between physical activity and recovery of lung function after cardiac surgery. The relationship between objectively measured physical activity and postoperative pulmonary recovery needs to be further examined to verify these results. PMID:24678691

The Healthy Heart-Mind trial: melatonin for prevention of delirium following cardiac surgery: study protocol for a randomized controlled trial.

PubMed

Ford, Andrew H; Flicker, Leon; Passage, Jurgen; Wibrow, Bradley; Anstey, Matthew; Edwards, Mark; Almeida, Osvaldo P

2016-01-28

Delirium is a common occurrence in patients undergoing major cardiac surgery and is associated with a number of adverse consequences for the individual, their family and the health system. Current approaches to the prevention of delirium include identifying those at risk together with various non-pharmacological and pharmacological strategies, although the efficacy of these is often modest. Emerging evidence suggests that melatonin may be biologically implicated in the development of delirium and that melatonin supplementation may be beneficial in reducing the incidence of delirium in medical and surgical patients. We designed this trial to determine whether melatonin reduces the incidence of delirium following cardiac surgery compared with placebo. The Healthy Heart-Mind trial is a randomized, double-blind, placebo-controlled clinical trial of 3 mg melatonin or matching placebo administered on seven consecutive days for the prevention of delirium following cardiac surgery. We will recruit 210 adult participants, aged 50 and older, undergoing elective or semi-elective cardiac surgery with the primary outcome of interest for this study being the difference in the incidence of delirium between the groups within 7 days of surgery. Secondary outcomes of interest include the difference between groups in the severity and duration of delirious episodes, hospital length of stay and referrals to mental health services during admission. In addition, we will assess differences in depressive and anxiety symptoms, as well as cognitive performance, at discharge and 3 months after surgery. The results of this trial will clarify whether melatonin reduces the incidence of delirium following cardiac surgery. The trial is registered with the Australian Clinical Trials Registry, trial number ACTRN12615000819527 (10 August 2015).

Cost-consequence analysis of different active flowable hemostatic matrices in cardiac surgical procedures.

PubMed

Makhija, D; Rock, M; Xiong, Y; Epstein, J D; Arnold, M R; Lattouf, O M; Calcaterra, D

2017-06-01

A recent retrospective comparative effectiveness study found that use of the FLOSEAL Hemostatic Matrix in cardiac surgery was associated with significantly lower risks of complications, blood transfusions, surgical revisions, and shorter length of surgery than use of SURGIFLO Hemostatic Matrix. These outcome improvements in cardiac surgery procedures may translate to economic savings for hospitals and payers. The objective of this study was to estimate the cost-consequence of two flowable hemostatic matrices (FLOSEAL or SURGIFLO) in cardiac surgeries for US hospitals. A cost-consequence model was constructed using clinical outcomes from a previously published retrospective comparative effectiveness study of FLOSEAL vs SURGIFLO in adult cardiac surgeries. The model accounted for the reported differences between these products in length of surgery, rates of major and minor complications, surgical revisions, and blood product transfusions. Costs were derived from Healthcare Cost and Utilization Project's National Inpatient Sample (NIS) 2012 database and converted to 2015 US dollars. Savings were modeled for a hospital performing 245 cardiac surgeries annually, as identified as the average for hospitals in the NIS dataset. One-way sensitivity analysis and probabilistic sensitivity analysis were performed to test model robustness. The results suggest that if FLOSEAL is utilized in a hospital that performs 245 mixed cardiac surgery procedures annually, 11 major complications, 31 minor complications, nine surgical revisions, 79 blood product transfusions, and 260.3 h of cumulative operating time could be avoided. These improved outcomes correspond to a net annualized saving of $1,532,896. Cost savings remained consistent between $1.3m and $1.8m and between $911k and $2.4m, even after accounting for the uncertainty around clinical and cost inputs, in a one-way and probabilistic sensitivity analysis, respectively. Outcome differences associated with FLOSEAL vs SURGIFLO that were previously reported in a comparative effectiveness study may result in substantial cost savings for US hospitals.

Effects of levosimendan on glomerular filtration rate, renal blood flow, and renal oxygenation after cardiac surgery with cardiopulmonary bypass: a randomized placebo-controlled study.

PubMed

Bragadottir, Gudrun; Redfors, Bengt; Ricksten, Sven-Erik

2013-10-01

Acute kidney injury develops in a large proportion of patients after cardiac surgery because of the low cardiac output syndrome. The inodilator levosimendan increases cardiac output after cardiac surgery with cardiopulmonary bypass, but a detailed analysis of its effects on renal perfusion, glomerular filtration, and renal oxygenation in this group of patients is lacking. We therefore evaluated the effects of levosimendan on renal blood flow, glomerular filtration rate, renal oxygen consumption, and renal oxygen demand/supply relationship, i.e., renal oxygen extraction, early after cardiac surgery with cardiopulmonary bypass. Prospective, placebo-controlled, and randomized trial. Cardiothoracic ICU of a tertiary center. Postcardiac surgery patients (n=30). The patients were randomized to receive levosimendan, 0.1 µg/kg/min after a loading dose of 12 µg/kg (n=15), or placebo (n=15). The experimental procedure started 4-6 hours after surgery in the ICU during propofol sedation and mechanical ventilation. Systemic hemodynamic were evaluated by a pulmonary artery thermodilution catheter. Renal blood flow and glomerular filtration rate were measured by the renal vein retrograde thermodilution technique and by renal extraction of Cr-EDTA, respectively. Central venous pressure was kept constant by colloid/crystalloid infusion. Compared to placebo, levosimendan increased cardiac index (22%), stroke volume index (15%), and heart rate (7%) and decreased systemic vascular resistance index (21%), whereas mean arterial pressure was not affected. Levosimendan induced significant increases in renal blood flow (12%, p<0.05) and glomerular filtration rate (21%, p<0.05), decreased renal vascular resistance (18%, p<0.05) but caused no significant changes in filtration fraction, renal oxygen consumption, or renal oxygen extraction, compared to placebo. After cardiac surgery with cardiopulmonary bypass, levosimendan induces a vasodilation, preferentially of preglomerular resistance vessels, increasing both renal blood flow and glomerular filtration rate without jeopardizing renal oxygenation. Due to its pharmacodynamic profile, levosimendan might be an interesting alternative for treatment of postoperative heart failure complicated by acute kidney injury in postcardiac surgery patients.

The Effect of Noncardiac and Genetic Abnormalities on Outcomes Following Neonatal Congenital Heart Surgery.

PubMed

Alsoufi, Bahaaldin; Gillespie, Scott; Mahle, William T; Deshpande, Shriprasad; Kogon, Brian; Maher, Kevin; Kanter, Kirk

2016-01-01

Significant noncardiac and genetic abnormalities (NC and GA) are common in neonates with congenital heart defects. We sought to examine current-era effect of those abnormalities on early and late outcomes following cardiac surgery. The method from 2002-2012, 1538 neonates underwent repair (n = 860, 56%) or palliation (n = 678, 44%) of congenital heart defects. Regression models examined the effect of NC and GA on operative results, resource utilization, and late outcomes. Neonates with NC and GA (n = 312, 20%) had higher incidence of prematurity (21% vs 13%; P < 0.001) and weight ≤2.5kg (24% vs 12%; P < 0.001) than neonates without NC and GA (n = 1226, 80%). Although the incidence of single ventricle was comparable (34% vs 31%; P = 0.37), neonates with NC and GA underwent more palliation (52% vs 42%; P = 0.001) and subsequently had higher percentage of STAT mortality categories (Society of Thoracic Surgeons (STS) and the European Association for Cardio-thoracic Surgery (EACTS) Congenital Heart Surgery Mortality Categories) 4 and 5 procedures (78% vs 66%; P < 0.001). Adjusted logistic regression models that included disparate patient and operative variables showed that the presence of NC and GA was associated with increased unplanned reoperation (odds ratio = 1.7; 95% CI: 1.1-2.7; P = 0.03) and hospital mortality (odds ratio = 2.2; 95% CI: 1.3-3.6; P = 0.002). Adjusted linear regression models showed significant association between NC and GA and increased postoperative mechanical ventilation duration, intensive care unit, and hospital stays (P < 0.001 each). Adjusted hazard analysis showed that the presence of NC and GA was associated with diminished late survival (hazard ratio = 2.4; 95% CI: 1.9-3.1; P < 0.001) and that was evident in all subgroups of patients (P < 0.001 each). Conclusion is neonates with NC and GA commonly have associated risk factors for morbidity and mortality such as prematurity and low weight. After adjusting for those factors, the presence of NC and GA continues to have significant association with increased unplanned reoperation, hospital mortality, and resource utilization after palliative and corrective cardiac surgery. Importantly, the hazard of death in those patients continues beyond the perioperative period for at least 1 year. Our findings show that the presence of NC and GA should be emphasized during parent counseling and decision making; and underscore the need to explore strategies to improve outcomes for this high-risk population that must address perioperative care, outpatient surveillance, and management. Copyright © 2016 Elsevier Inc. All rights reserved.

Plasma exchange to remove HIT antibodies: dissociation between enzyme-immunoassay and platelet activation test reactivities.

PubMed

Warkentin, Theodore E; Sheppard, Jo-Ann I; Chu, F Victor; Kapoor, Anil; Crowther, Mark A; Gangji, Azim

2015-01-01

Repeated therapeutic plasma exchange (TPE) has been advocated to remove heparin-induced thrombocytopenia (HIT) IgG antibodies before cardiac/vascular surgery in patients who have serologically-confirmed acute or subacute HIT; for this situation, a negative platelet activation assay (eg, platelet serotonin-release assay [SRA]) has been recommended as the target serological end point to permit safe surgery. We compared reactivities in the SRA and an anti-PF4/heparin IgG-specific enzyme immunoassay (EIA), testing serial serum samples in a patient with recent (subacute) HIT who underwent serial TPE precardiac surgery, as well as for 15 other serially-diluted HIT sera. We observed that post-TPE/diluted HIT sera-when first testing SRA-negative-continue to test strongly positive by EIA-IgG. This dissociation between the platelet activation assay and a PF4-dependent immunoassay for HIT antibodies indicates that patients with subacute HIT undergoing repeated TPE before heparin reexposure should be tested by serial platelet activation assays even when their EIAs remain strongly positive. © 2015 by The American Society of Hematology.

Adverse Effects and Surgical Complications in Pediatric Patients Undergoing Vagal Nerve Stimulation for Drug-Resistant Epilepsy.

PubMed

Trezza, A; Landi, A; Grioni, D; Pirillo, D; Fiori, L; Giussani, C; Sganzerla, E P

2017-01-01

Vagal nerve stimulation (VNS) is an effective treatment for drug-resistant epilepsy that is not suitable for resective surgery, both in adults and in children. Few reports describe the adverse effects and complications of VNS. The aim of our study was to present a series of 33 pediatric patients who underwent VNS for drug-resistant epilepsy and to discuss the adverse effects and complications through a review of the literature.The adverse effects of VNS are usually transient and are dependent on stimulation of the vagus and its efferent fibers; surgical complications of the procedure may be challenging and patients sometimes require further surgery; generally these complications affect VNS efficacy; in addition, hardware complications also have to be taken into account.In our experience and according to the literature, adverse effects and surgical and hardware complications are uncommon and can usually be managed definitely. Careful selection of patients, particularly from a respiratory and cardiac point of view, has to be done before surgery to limit the incidence of some adverse effects.

A Score for Predicting Acute Kidney Injury After Coronary Artery Bypass Graft Surgery in an Asian Population.

PubMed

Mithiran, Harish; Kunnath Bonney, Glenn; Bose, Saideep; Subramanian, Srinivas; Zhe Yan, Zan Ng; Zong En, Seth Yeak; Papadimas, Evangelos; Chauhan, Ishaan; MacLaren, Graeme; Kofidis, Theodoros

2016-10-01

To develop a scoring system to predict acute kidney injury in Asian patients after coronary artery bypass grafting. A retrospective analysis of data collected in an institutional cardiac database. A tertiary academic hospital in a large metropolitan city. The study comprised 954 patients with coronary artery disease. All patients underwent coronary artery bypass surgery with cardiopulmonary bypass but did not undergo any other concomitant procedures. The main outcome measured was acute kidney injury as defined by the Acute Kidney Injury Network criteria. The following 6 clinical variables were independent predictors of kidney injury: age>60 years, diabetes requiring insulin, estimated glomerular filtration rate<60 mL/min/1.73 m(2), ejection fraction<40%, cardiopulmonary bypass time>140 minutes, and aortic cross-clamp time>100 minutes. These variables were used to develop the Singapore Acute Kidney Injury score. The Singapore Acute Kidney Injury score is a simple way to predict, at the time of admission to the intensive care unit, an Asian patient's risk of developing acute kidney injury after coronary artery bypass surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Functional Aortic Root Parameters and Expression of Aortopathy in Bicuspid Versus Tricuspid Aortic Valve Stenosis.

PubMed

Girdauskas, Evaldas; Rouman, Mina; Disha, Kushtrim; Fey, Beatrix; Dubslaff, Georg; Theis, Bernhard; Petersen, Iver; Gutberlet, Matthias; Borger, Michael A; Kuntze, Thomas

2016-04-19

The correlation between bicuspid aortic valve (BAV) disease and aortopathy is not fully defined. This study aimed to prospectively analyze the correlation between functional parameters of the aortic root and expression of aortopathy in patients undergoing surgery for BAV versus tricuspid aortic valve (TAV) stenosis. From January 1, 2012 through December 31, 2014, 190 consecutive patients (63 ± 8 years, 67% male) underwent aortic valve replacement ± proximal aortic surgery for BAV stenosis (n = 137, BAV group) and TAV stenosis (n = 53, TAV group). All patients underwent pre-operative cardiac magnetic resonance imaging to evaluate morphological/functional parameters of the aortic root. Aortic tissue was sampled during surgery on the basis of the location of eccentric blood flow contact with the aortic wall, as determined by cardiac magnetic resonance (i.e., jet sample and control sample). Aortic wall lesions were graded using a histological sum score (0 to 21). The largest cross-sectional aortic diameters were at the mid-ascending level in both groups and were larger in BAV patients (40.2 ± 7.2 mm vs. 36.6 ± 3.3 mm, respectively, p < 0.001). The histological sum score was 2.9 ± 1.4 in the BAV group versus 3.4 ± 2.6 in the TAV group (p = 0.4). The correlation was linear and comparable between the maximum indexed aortic diameter and the angle between the left ventricular outflow axis and aortic root (left ventricle/aorta angle) in both groups (BAV group: r = 0.6, p < 0.001 vs. TAV group r = 0.45, p = 0.03, z = 1.26, p = 0.2). Logistic regression identified the left ventricle/aorta angle as an indicator of indexed aortic diameter >22 mm/m(2) (odds ratio: 1.2; p < 0.001). Comparable correlation patterns between functional aortic root parameters and expression of aortopathy are found in patients with BAV versus TAV stenosis. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Cardiac, renal, and neurological benefits of preoperative levosimendan administration in patients with right ventricular dysfunction and pulmonary hypertension undergoing cardiac surgery: evaluation with two biomarkers neutrophil gelatinase-associated lipocalin and neuronal enolase.

PubMed

Guerrero-Orriach, José Luis; Ariza-Villanueva, Daniel; Florez-Vela, Ana; Garrido-Sánchez, Lourdes; Moreno-Cortés, María Isabel; Galán-Ortega, Manuel; Ramírez-Fernández, Alicia; Alcaide Torres, Juan; Fernandez, Concepción Santiago; Navarro Arce, Isabel; Melero-Tejedor, José María; Rubio-Navarro, Manuel; Cruz-Mañas, José

2016-01-01

To evaluate if the preoperative administration of levosimendan in patients with right ventricular (RV) dysfunction, pulmonary hypertension, and high perioperative risk would improve cardiac function and would also have a protective effect on renal and neurological functions, assessed using two biomarkers neutrophil gelatinase-associated lipocalin (N-GAL) and neuronal enolase. This is an observational study. Twenty-seven high-risk cardiac patients with RV dysfunction and pulmonary hypertension, scheduled for cardiac valve surgery, were prospectively followed after preoperative administration of levosimendan. Levosimendan was administered preoperatively on the day before surgery. All patients were considered high risk of cardiac and perioperative renal complications. Cardiac function was assessed by echocardiography, renal function by urinary N-GAL levels, and the acute kidney injury scale. Neuronal damage was assessed by neuron-specific enolase levels. After surgery, no significant variations were found in mean and SE levels of N-GAL (14.31 [28.34] ng/mL vs 13.41 [38.24] ng/mL), neuron-specific enolase (5.40 [0.41] ng/mL vs 4.32 [0.61] ng/mL), or mean ± SD creatinine (1.06±0.24 mg/dL vs 1.25±0.37 mg/dL at 48 hours). RV dilatation decreased from 4.23±0.7 mm to 3.45±0.6 mm and pulmonary artery pressure from 58±18 mmHg to 42±19 mmHg at 48 hours. Preoperative administration of levosimendan has shown a protective role against cardiac, renal, and neurological damage in patients with a high risk of multiple organ dysfunctions undergoing cardiac surgery.

Initial Experience and Early Results of Mitral Valve Repair with Cardiocel Pericardial Patch.

PubMed

Tomšič, Anton; Bissessar, Daniella D; van Brakel, Thomas J; Marsan, Nina Ajmone; Klautz, Robert J M; Palmen, Meindert

2018-06-07

To assess the performance of a tissue engineering process-treated bovine pericardium patch (CardioCel) in the setting of reconstructive mitral valve surgery. Between 3/2014 and 4/2016, 30 patients (57.2±14.3 years, 27% female) underwent mitral valve leaflet repair with a CardioCel patch. Perioperative mortality was 7% (2 patients, non-graft-related). In 28 remaining patients, pre-discharge echocardiography demonstrated good repaired valve function. At a mean follow-up of 1.7±0.9 years, 3 additional deaths occurred (2 due to infective endocarditis, 1 non-cardiac related). On follow-up echocardiography [follow-up time 1.7±0.8 years, available for 26/28 (93%) hospital survivors], recurrent regurgitation was seen in 2 patients (both infective endocarditis) and 1 underwent reoperation (no infection at the level of patch repair was observed). In the remaining patients, the most recent echocardiogram demonstrated ≤mild regurgitation and stable gradients. The thickness and echodensity of the implanted patch on follow-up echocardiograms were comparable with postoperative echocardiograms. Initial results of the CardioCel patch in mitral valve repair surgery are satisfactory. The resistance to infection and late degeneration will need to be assessed in the future. Copyright © 2018. Published by Elsevier Inc.

Surgical ablation of atrial fibrillation in patients with a giant left atrium undergoing mitral valve surgery.

PubMed

Kim, Ho Jin; Kim, Joon Bum; Jung, Sung-Ho; Choo, Suk Jung; Chung, Cheol Hyun; Lee, Jae Won

2016-08-01

As the efficacy of surgical ablation for atrial fibrillation (AF) is reported to be suboptimal for patients with a giant left atrium (LA), its routine use on this population has remained controversial. We sought to evaluate the clinical outcomes of patients with a giant LA undergoing mitral valve (MV) surgery with/without the maze procedure. We identified 759 patients with a giant LA (>60 mm) and AF undergoing MV surgery from 1999 through 2012. Of these, 400 underwent MV surgery with the maze procedure (maze group), and the remainder (n=359) underwent MV surgery only (no-maze group). To reduce the impact of selection bias, propensity score analyses were performed based on 25 baseline covariates. Early death occurred in five (1.3%) and nine (2.5%) patients in the maze and the no-maze group, respectively (p=0.28). Freedom from AF at 5 years was 68.9% in the maze group and 9.6% in the no-maze group (p<0.001). After adjustment, the maze group showed a significantly lower risk of death (HR, 0.65; 95% CI 0.44 to 0.98; p=0.038), thromboembolic events (HR, 0.23; 95% CI 0.09 to 0.58; p=0.002) and composite adverse outcomes (death, congestive heart failure and valve-related complications; HR, 0.55; 95% CI 0.42 to 0.71; p<0.001) than the no-maze group. In subgroup analyses, MV surgery with the maze procedure resulted in higher survival and event-free survival in most risk subgroups than without the maze procedure. The concomitant maze procedure improved postoperative rhythm status, clinical outcomes and cardiac functions in patients with a giant LA undergoing MV surgery. This study indicates that the patients with a giant LA undergoing MV surgery may benefit from an addition of the maze procedure. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

[The beginnings and the development of heart surgery in Debrecen; the consequence of Professor József Schnitzler's initiative].

PubMed

Péterffy, Arpád

2009-10-04

In the early 1960s, cardiac surgery was founded in Debrecen in the department of thoracic surgery, on Professor József Schnitzler's initiative with the cooperation of the head surgeon Arpád Eisert from Nyíregyháza. During the first 5 years, between 1963-1968, 44 closed cardiac surgical procedures were performed (closure of patent ductus arteriosus, pulmonal and mitral stenosis, pericardectomy). The first open heart surgery was performed by Gábor Kovács visiting professor from Szeged in 1968, after the Pemco heart-lung machine, a donation by Béla Köteles and the Presbyterian Church in Cleveland had arrived. The cardiac surgical activity was led by Professor András Gömöry (1972-1983). During the first 20 years 310 open, 220 closed cardiac surgical, and 612 pacemaker operations were performed. After Professor Schnitzler's retirement in 1983, Arpád Péterffy was appointed the head of the entire department (general and cardio-thoracic surgery). In the last 25 years, 18,000 open, 1500 closed and 8500 pacemaker procedures altogether 32,000 were performed. In 2008 associate professor Tamás Szerafin became the head of the department of cardiac surgery.

Incentive spirometry in major surgeries: a systematic review.

PubMed

Carvalho, Celso R F; Paisani, Denise M; Lunardi, Adriana C

2011-01-01

To conduct a systematic review to evaluate the evidence of the use of incentive spirometry (IS) for the prevention of postoperative pulmonary complications and for the recovery of pulmonary function in patients undergoing abdominal, cardiac and thoracic surgeries. Searches were performed in the following databases: Medline, Embase, Web of Science, PEDro and Scopus to select randomized controlled trials which the IS was used in pre- and/or post-operative in order to prevent postoperative pulmonary complications and/or recover lung function after abdominal, cardiac and thoracic surgery. Two reviewers independently assessed all studies. In addition, the studies quality was assessed using the PEDro scale. Thirty studies were included (14 abdominal, 13 cardiac and 3 thoracic surgery; n=3,370 patients). In the analysis of the methodological quality, studies achieved a PEDro average score of 5.6, 4.7 and 4.8 points in abdominal, cardiac and thoracic surgeries, respectively. Five studies (3 abdominal, 1 cardiac and 1 thoracic surgery) compared the effect of the IS with control group (no intervention) and no difference was detected in the evaluated outcomes. There was no evidence to support the use of incentive spirometry in the management of surgical patients. Despite this, the use of incentive spirometry remains widely used without standardization in clinical practice.

Wearable Cardioverter-Defibrillators following Cardiac Surgery-A Single-Center Experience.

PubMed

Heimeshoff, Jan; Merz, Constanze; Ricklefs, Marcel; Kirchhoff, Felix; Haverich, Axel; Bara, Christoph; Kühn, Christian

2018-06-20

 A wearable cardioverter-defibrillator (WCD) can terminate ventricular fibrillation and ventricular tachycardias via electrical shock and thus give transient protection from sudden cardiac death. We investigated its role after cardiac surgery.  We retrospectively analyzed all patients who were discharged with a WCD from cardiac surgery department. The WCD was prescribed for patients with a left ventricular ejection fraction (LVEF) of ≤35% or an explanted implantable cardioverter-defibrillator (ICD).  A total of 100 patients were included in this study, the majority ( n  = 59) had received coronary artery bypass graft surgery. The median wearing time of a WCD patient was 23.5 hours per day. LVEF was 28.9 ± 8% after surgery and improved in the follow-up to 36.7 ± 11% ( p  < 0.001). Three patients were successfully defibrillated. Ten patients experienced ventricular tachycardias. No inappropriate shocks were given. An ICD was implanted in 25 patients after the WCD wearing period.  Ventricular arrhythmias occurred in 13% of the investigated patients. LVEF improved significantly after 3 months, and thus a permanent ICD implantation was avoided in several cases. Sternotomy did not impair wearing time of the WCD. A WCD can effectively protect patients against ventricular tachyarrhythmias after cardiac surgery. Georg Thieme Verlag KG Stuttgart · New York.

Left atrial concomitant surgical ablation for treatment of atrial fibrillation in cardiac surgery: A meta-analysis of randomized controlled trials

PubMed Central

Wang, Chunguo; Ye, Minhua; Lin, Jiang; Jin, Jiang; Hu, Quanteng; Zhu, Chengchu; Chen, Baofu

2018-01-01

Introduction Surgical ablation is a generally established treatment for patients with atrial fibrillation undergoing concomitant cardiac surgery. Left atrial (LA) lesion set for ablation is a simplified procedure suggested to reduce the surgery time and morbidity after procedure. The present meta-analysis aims to explore the outcomes of left atrial lesion set versus no ablative treatment in patients with AF undergoing cardiac surgery. Methods A literature research was performed in six database from their inception to July 2017, identifying all relevant randomized controlled trials (RCTs) comparing left atrial lesion set versus no ablative treatment in AF patient undergoing cardiac surgery. Data were extracted and analyzed according to predefined clinical endpoints. Results Eleven relevant RCTs were included for analysis in the present study. The prevalence of sinus rhythm in ablation group was significantly higher at discharge, 6-month and 1-year follow-up period. The morbidity including 30 day mortality, late all-cause mortality, reoperation for bleeding, permanent pacemaker implantation and neurological events were of no significant difference between two groups. Conclusions The result of our meta-analysis demonstrates that left atrial lesion set is an effective and safe surgical ablation strategy for AF patients undergoing concomitant cardiac surgery. PMID:29360851

Systematic preoperative coronary angiography and stenting improves postoperative results of carotid endarterectomy in patients with asymptomatic coronary artery disease: a randomised controlled trial.

PubMed

Illuminati, G; Ricco, J-B; Greco, C; Mangieri, E; Calio', F; Ceccanei, G; Pacilè, M A; Schiariti, M; Tanzilli, G; Barillà, F; Paravati, V; Mazzesi, G; Miraldi, F; Tritapepe, L

2010-02-01

To evaluate the usefulness of systematic coronary angiography followed, if needed, by coronary artery angioplasty (percutaneous coronary intervention (PCI)) on the incidence of cardiac ischaemic events after carotid endarterectomy (CEA) in patients without evidence of coronary artery disease (CAD). From January 2005 to December 2008, 426 patients, candidates for CEA, with no history of CAD and with normal cardiac ultrasound and electrocardiography (ECG), were randomised into two groups. In group A (n=216) all the patients had coronary angiography performed before CEA. In group B, all the patients had CEA without previous coronary angiography. In group A, 66 patients presenting significant coronary artery lesions at angiography received PCI before CEA. They subsequently underwent surgery under aspirin (100 mg day(-1)) and clopidogrel (75 mg day(-1)). CEA was performed within a median delay of 4 days after PCI (range: 1-8 days). Risk factors, indications for CEA and surgical techniques were comparable in both groups (p>0.05). The primary combined endpoint of the study was the incidence of postoperative myocardial ischaemic events combined with the incidence of complications of coronary angiography. Secondary endpoints were death and stroke rates after CEA and incidence of cervical haematoma. Postoperative mortality was 0% in group A and 0.9% in group B (p=0.24). One postoperative stroke (0.5%) occurred in group A, and two (0.9%) in group B (p=0.62). No postoperative myocardial event was observed in group A, whereas nine ischaemic events were observed in group B, including one fatal myocardial infarction (p=0.01). Binary logistic regression analysis demonstrated that preoperative coronary angiography was the only independent variable that predicted the occurrence of postoperative coronary ischaemia after CEA. The odds ratio for coronary angiography (group A) indicated that when holding all other variables constant, a patient having preoperative coronary angiography before carotid surgery was 4 times less likely to have a cardiac ischaemic event after carotid surgery. No complications related to coronary angiography were observed and no cervical haematomas occurred in patients undergoing surgery under aspirin and clopidogrel in this study. Systematic preoperative coronary angiography, possibly followed by PCI, significantly reduces the incidence of postoperative myocardial events after CEA in patients without clinical evidence of CAD. Copyright (c) 2009 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

The Influence of Comprehensive Cardiac Rehabilitation on Heart Rate Variability Indices after CABG is More Effective than after PCI.

PubMed

Szmigielska, Katarzyna; Szmigielska-Kapłon, Anna; Jegier, Anna

2018-02-01

The aim of this study was to evaluate the influence of cardiac rehabilitation (CR) on heart rate variability (HRV) indices in men with coronary artery disease (CAD) treated with percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). The study population consisted of 131 male patients with CAD prospectively and consecutively admitted to CR after PCI n = 72, or CABG n = 59. Participants performed cycle ergometer interval training for 45 min three times a week for 8 weeks. At baseline and after 8 weeks, all patients underwent the HRV assessment. HRV indices in CAGB survivals were significantly lower in comparison to PCI patients at baseline. Significant increases were seen for SDNN, rMSSD, and HF in the CABG group and only in HF component in PCI group after 8 weeks of CR. Eight weeks of CR seems to be more effective in CABG patients than patients after PCI.

Is minimally invasive mitral valve repair with artificial chords reproducible and applicable in routine surgery?

PubMed

Panos, Aristotelis; Vlad, Sylvio; Milas, Fotios; Myers, Patrick O

2015-06-01

Traditional resectional techniques and chordal transfer are difficult to apply in video-assisted mitral valve repair. Using artificial chords appears easier in this setting. The purpose of this study was to review the effectiveness and reproducibility of neochordal repair as a routine approach to minimally invasive mitral repair, and to assess the stability of neochord implantation using the figure-of-eight suture without pledgets in this setting. This is a retrospective review of all patients who underwent minimally invasive video-assisted mitral valve repair from 2008 to 2013. The primary endpoints were recurrent mitral regurgitation and reoperation. A total of 426 consecutive patients were included during the study period, with a mean age of 55 ± 18 years. Neochords were used in all patients, and in association with leaflet resection in 47 patients. One patient was not repairable and underwent valve replacement (repair rate, 99.8%). Fifteen patients had Grade I (3.5%) regurgitation, whereas the remainder had none. Patients were fast-tracked, with 25% extubated in the operation theatre and the remainder within 6 h. There were 5 deaths within 30 days (1.2%). Follow-up ranged 3-60 months, during which all of the patients remained with no or trace mitral regurgitation. No de-insertion or rupture of any neochords was found, and no patients required a reoperation. Minimally invasive mitral valve repair using neochords provided a high rate of repair, reproducible results in a routine cardiac surgery setting and stable repair during follow-up. This has become our preferred technique for mitral valve surgery. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Preoperative assessment of lung cancer patients: evaluating guideline compliance (re-audit).

PubMed

Jayia, Parminderjit Kaur; Mishra, Pankaj Kumar; Shah, Raajul R; Panayiotou, Andrew; Yiu, Patrick; Luckraz, Heyman

2015-03-01

Guidelines have been issued for the management of lung cancer patients in the United Kingdom. However, compliance with these national guidelines varies in different thoracic units in the country. We set out to evaluate our thoracic surgery practice and compliance with the national guidelines. An initial audit in 2011 showed deficiencies in practice, thus another audit was conducted to check for improvements in guideline compliance. A retrospective study was carried out over a 12-month period from January 2013 to January 2014 and included all patients who underwent radical surgical resection for lung cancer. Data were collected from computerized records. Sixty-eight patients had radical surgery for lung cancer between January 2013 and January 2014. Four patients were excluded from the analysis due to incomplete records. Our results showed improvements in our practice compared to our initial audit. More patients underwent surgery within 4 weeks of computed tomography and positron-emission tomography scanning. An improvement was noticed in carbon monoxide transfer factor measurements. Areas for improvement include measurement of carbon monoxide transfer factor in all patients, a cardiology referral in patients at risk of cardiac complications, and the use of a global risk stratification model such as Thoracoscore. Guideline-directed service delivery provision for lung cancer patients leads to improved outcomes. Our results show improvement in our practice compared to our initial audit. We aim to liaise with other thoracic surgery units to get feedback about their practice and any audits regarding adherence to the British Thoracic Society and National Institute for Health and Care Excellence guidelines. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Physical Therapy Management for Adult Patients Undergoing Cardiac Surgery: A Canadian Practice Survey

PubMed Central

Anderson, Cathy M.; Jackson, Jennifer; Lucy, S. Deborah; Prendergast, Monique; Sinclair, Susanne

2010-01-01

ABSTRACT Purpose: To determine current Canadian physical therapy practice for adult patients requiring routine care following cardiac surgery. Methods: A telephone survey was conducted of a selected sample (n=18) of Canadian hospitals performing cardiac surgery to determine cardiorespiratory care, mobility, exercises, and education provided to patients undergoing cardiac surgery. Results: An average of 21 cardiac surgeries per week (range: 6–42) were performed, with an average length of stay of 6.4 days (range: 4.0–10.6). Patients were seen preoperatively at 7 of 18 sites and on postoperative day 1 (POD-1) at 16 of 18 sites. On POD-1, 16 sites performed deep breathing and coughing, 7 used incentive spirometers, 13 did upper-extremity exercises, and 12 did lower-extremity exercises. Nine sites provided cardiorespiratory treatment on POD-3. On POD-1, patients were dangled at 17 sites and mobilized out of bed at 13. By POD-3, patients ambulated 50–120 m per session 2–5 times per day. Sternal precautions were variable, but the lifting limit was reported as ranging between 5 lb and 10 lb. Conclusions: Canadian physical therapists reported the provision of cardiorespiratory treatment after POD-1. According to current available evidence, this level of care may be unnecessary for uncomplicated patients following cardiac surgery. In addition, some sites provide cardiorespiratory treatment techniques that are not supported by evidence in the literature. Further research is required. PMID:21629599

Impact of Milrinone Administration in Adult Cardiac Surgery Patients: Updated Meta-Analysis.

PubMed

Ushio, Masahiro; Egi, Moritoki; Wakabayashi, Junji; Nishimura, Taichi; Miyatake, Yuji; Obata, Norihiko; Mizobuchi, Satoshi

2016-12-01

To determine the effects of milrinone on short-term mortality in cardiac surgery patients with focus on the presence or absence of heterogeneity of the effect. A systematic review and meta-analysis. Five hundred thirty-seven adult cardiac surgery patients from 12 RCTs. Milrinone administration. The authors conducted a systematic Medline and Pubmed search to assess the effect of milrinone on short-term mortality in adult cardiac surgery patients. Subanalysis was performed according to the timing for commencement of milrinone administration and the type of comparators. The primary outcome was any short-term mortality. Overall analysis showed no difference in mortality rates in patients who received milrinone and patients who received comparators (odds ratio = 1.25, 95% CI 0.45-3.51, p = 0.67). In subanalysis for the timing to commence milrinone administration and the type of comparators, odds ratio for mortality varied from 0.19 (placebo as control drug, start of administration after cardiopulmonary bypass) to 2.58 (levosimendan as control drug, start of administration after cardiopulmonary bypass). Among RCTs to assess the effect of milrinone administration in adult cardiac surgery patients, there are wide variations of the odds ratios of administration of milrinone for short-term mortality according to the comparators and the timing of administration. This fact may suggest that a simple pooling meta-analysis is not applicable for assessing the risk and benefit of milrinone administration in an adult cardiac surgery cohort. Copyright © 2016 Elsevier Inc. All rights reserved.

Inhalation of diesel exhaust does not exacerbate cardiac hypertrophy or heart failure in two mouse models of cardiac hypertrophy

PubMed Central

2013-01-01

Background Strong associations have been observed between exposure to fine ambient particulate matter (PM2.5) and adverse cardiovascular outcomes. In particular, exposure to traffic related PM2.5 has been associated with increases in left ventricular hypertrophy, a strong risk factor for cardiovascular mortality. As much of traffic related PM2.5 is derived from diesel exhaust (DE), we investigated the effects of chronic DE exposure on cardiac hypertrophy and heart failure in the adult mouse by exposing mice to DE combined with either of two mouse models of cardiac hypertrophy: angiotensin II infusion or pressure overload induced by transverse aortic banding. Methods Wild type male C57BL/6 J mice were either infused with angiotensin II (800 ng/kg/min) via osmotic minipump implanted subcutaneously for 1 month, or underwent transverse aortic banding (27 gauge needle 1 week for observing acute reactions, 26 gauge needle 3 months or 6 months for observing chronic reactions). Vehicle (saline) infusion or sham surgery was used as a control. Shortly after surgery, mice were transferred to our exposure facility and randomly assigned to either diesel exhaust (300 or 400 μg/m3) or filtered air exposures. After reaching the end of designated time points, echocardiography was performed to measure heart structure and function. Gravimetric analysis was used to measure the ventricular weight to body weight ratio. We also measured heart rate by telemetry using implanted ambulatory ECG monitors. Results Both angiotensin II and transverse aortic banding promoted cardiac hypertrophy compared to vehicle or sham controls. Transverse aortic banding for six months also promoted heart failure in addition to cardiac hypertrophy. In all cases, DE failed to exacerbate the development of hypertrophy or heart failure when compared to filtered air controls. Prolonged DE exposure also led to a decrease in average heart rate. Conclusions Up to 6-months of DE exposure had no effect on cardiac hypertrophy and heart function induced by angiotensin II stimulation or pressure overload in adult C57BL/6 J mice. This study highlights the potential importance of particle constituents of ambient PM2.5 to elicit cardiotoxic effects. Further investigations on particle constituents and cardiotoxicity are warranted. PMID:24093778

Effect of diastolic dysfunction on postoperative outcomes after cardiovascular surgery: A systematic review and meta-analysis.

PubMed

Kaw, Roop; Hernandez, Adrian V; Pasupuleti, Vinay; Deshpande, Abhishek; Nagarajan, Vijaiganesh; Bueno, Hector; Coleman, Craig I; Ioannidis, John P A; Bhatt, Deepak L; Blackstone, Eugene H

2016-10-01

The objective of this study was to investigate the effect of preoperative diastolic dysfunction on postoperative mortality and morbidity after cardiovascular surgery. We systematically searched for articles that assessed the prognostic role of diastolic dysfunction on cardiovascular surgery in PubMed, Cochrane Library, Web of Science, Embase, and Scopus until February 2016. Twelve studies (n = 8224) met our inclusion criteria. Because of the scarcity of outcome events, fixed-effects meta-analysis was performed via the Mantel-Haenszel method. Preoperative diagnosis of diastolic dysfunction was associated with greater postoperative mortality (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.54-3.71; P < .0001), major adverse cardiac events (OR, 2.07; 95% CI, 1.55-2.78; P ≤ .0001), and prolonged mechanical ventilation (OR, 2.08; 95% CI, 1.04-4.16; P = .04) compared with patients without diastolic dysfunction among patients who underwent cardiovascular surgery. The odds of postoperative myocardial infarction (OR, 1.29; 95% CI, 0.82-2.05; P = .28) and atrial fibrillation (OR, 2.67; 95% CI, 0.49-14.43; P = .25) did not significantly differ between the 2 groups. Severity of preoperative diastolic dysfunction was associated with increased postoperative mortality (OR, 21.22; 95% CI, 3.74-120.33; P = .0006) for Grade 3 diastolic dysfunction compared with patients with normal diastolic function. Inclusion of left ventricular ejection fraction (LVEF) <40% accompanying diastolic dysfunction did not further impact postoperative mortality (P = .27; I(2) = 18%) compared with patients with normal LVEF and diastolic dysfunction. Presence of preoperative diastolic dysfunction was associated with greater postoperative mortality and major adverse cardiac events, regardless of LVEF. Mortality was significantly greater in grade III diastolic dysfunction. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Impaired olfaction and risk of delirium or cognitive decline after cardiac surgery.

PubMed

Brown, Charles H; Morrissey, Candice; Ono, Masahiro; Yenokyan, Gayane; Selnes, Ola A; Walston, Jeremy; Max, Laura; LaFlam, Andrew; Neufeld, Karin; Gottesman, Rebecca F; Hogue, Charles W

2015-01-01

To determine the prevalence of impaired olfaction in individuals presenting for cardiac surgery and the independent association between impaired olfaction and postoperative delirium and cognitive decline. Nested prospective cohort study. Academic hospital. Individuals undergoing coronary artery bypass, valve surgery, or both (n = 165). Olfaction was measured using the Brief Smell Identification Test, with impaired olfaction defined as an olfactory score below the fifth percentile of normative data. Delirium was assessed using a validated chart review method. Cognitive performance was assessed using a neuropsychological testing battery at baseline and 4 to 6 weeks after surgery. Impaired olfaction was identified in 54 of 165 participants (33%) before surgery. Impaired olfaction was associated with greater adjusted risk of postoperative delirium (relative risk = 1.90, 95% confidence interval = 1.17-3.09, P = .009). There was no association between impaired olfaction and change in composite cognitive score in the overall study population. Impaired olfaction is prevalent in individuals undergoing cardiac surgery and is associated with greater adjusted risk of postoperative delirium but not cognitive decline. Impaired olfaction may identify unrecognized vulnerability to postoperative delirium in individuals undergoing cardiac surgery. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.

Patient perceptions of experience with cardiac rehabilitation after isolated heart valve surgery.

PubMed

Hansen, Tina B; Berg, Selina K; Sibilitz, Kirstine L; Zwisler, Ann D; Norekvål, Tone M; Lee, Anne; Buus, Niels

2018-01-01

Little evidence exists on whether cardiac rehabilitation is effective for patients after heart valve surgery. Yet, accepted recommendations for patients with ischaemic heart disease continue to support it. To date, no studies have determined what heart valve surgery patients prefer in a cardiac rehabilitation programme, and none have analysed their experiences with it. The purpose of this qualitative analysis was to gain insight into patients' experiences in cardiac rehabilitation, the CopenHeart VR trial. This trial specifically assesses patients undergoing isolated heart valve surgery. Semi-structured interviews were conducted with nine patients recruited from the intervention arm of the trial. The intervention consisted of a physical training programme and a psycho-educational intervention. Participants were interviewed three times: 2-3 weeks, 3-4 months and 8-9 months after surgery between April 2013 and October 2014. Data were analysed using qualitative thematic analysis. Participants had diverse needs and preferences. Two overall themes emerged: cardiac rehabilitation played an important role in (i) reducing insecurity and (ii) helping participants to take active personal responsibility for their health. Despite these benefits, participants experienced existential and psychological challenges and musculoskeletal problems. Participants also sought additional advice from healthcare professionals both inside and outside the healthcare system. Even though the cardiac rehabilitation programme reduced insecurity and helped participants take active personal responsibility for their health, they experienced existential, psychological and physical challenges during recovery. The cardiac rehabilitation programme had several limitations, having implications for designing future programmes.

Novel Zero-Heat-Flux Deep Body Temperature Measurement in Lower Extremity Vascular and Cardiac Surgery.

PubMed

Mäkinen, Marja-Tellervo; Pesonen, Anne; Jousela, Irma; Päivärinta, Janne; Poikajärvi, Satu; Albäck, Anders; Salminen, Ulla-Stina; Pesonen, Eero

2016-08-01

The aim of this study was to compare deep body temperature obtained using a novel noninvasive continuous zero-heat-flux temperature measurement system with core temperatures obtained using conventional methods. A prospective, observational study. Operating room of a university hospital. The study comprised 15 patients undergoing vascular surgery of the lower extremities and 15 patients undergoing cardiac surgery with cardiopulmonary bypass. Zero-heat-flux thermometry on the forehead and standard core temperature measurements. Body temperature was measured using a new thermometry system (SpotOn; 3M, St. Paul, MN) on the forehead and with conventional methods in the esophagus during vascular surgery (n = 15), and in the nasopharynx and pulmonary artery during cardiac surgery (n = 15). The agreement between SpotOn and the conventional methods was assessed using the Bland-Altman random-effects approach for repeated measures. The mean difference between SpotOn and the esophageal temperature during vascular surgery was+0.08°C (95% limit of agreement -0.25 to+0.40°C). During cardiac surgery, during off CPB, the mean difference between SpotOn and the pulmonary arterial temperature was -0.05°C (95% limits of agreement -0.56 to+0.47°C). Throughout cardiac surgery (on and off CPB), the mean difference between SpotOn and the nasopharyngeal temperature was -0.12°C (95% limits of agreement -0.94 to+0.71°C). Poor agreement between the SpotOn and nasopharyngeal temperatures was detected in hypothermia below approximately 32°C. According to this preliminary study, the deep body temperature measured using the zero-heat-flux system was in good agreement with standard core temperatures during lower extremity vascular and cardiac surgery. However, agreement was questionable during hypothermia below 32°C. Copyright © 2016 Elsevier Inc. All rights reserved.

Diagnostic value of chest ultrasound after cardiac surgery: a comparison with chest X-ray and auscultation.

PubMed

Vezzani, Antonella; Manca, Tullio; Brusasco, Claudia; Santori, Gregorio; Valentino, Massimo; Nicolini, Francesco; Molardi, Alberto; Gherli, Tiziano; Corradi, Francesco

2014-12-01

Chest auscultation and chest x-ray commonly are used to detect postoperative abnormalities and complications in patients admitted to intensive care after cardiac surgery. The aim of the study was to evaluate whether chest ultrasound represents an effective alternative to bedside chest x-ray to identify early postoperative abnormalities. Diagnostic accuracy of chest auscultation and chest ultrasound were compared in identifying individual abnormalities detected by chest x-ray, considered the reference method. Cardiac surgery intensive care unit. One hundred fifty-one consecutive adult patients undergoing cardiac surgery. All patients included were studied by chest auscultation, ultrasound, and x-ray upon admission to intensive care after cardiac surgery. Six lung pathologic changes and endotracheal tube malposition were found. There was a highly significant correlation between abnormalities detected by chest ultrasound and x-ray (k = 0.90), but a poor correlation between chest auscultation and x-ray abnormalities (k = 0.15). Chest auscultation may help identify endotracheal tube misplacement and tension pneumothorax but it may miss most major abnormalities. Chest ultrasound represents a valid alternative to chest x-ray to detect most postoperative abnormalities and misplacements. Copyright © 2014 Elsevier Inc. All rights reserved.

Analysis of Complaints from Patients During Mechanical Ventilation After Cardiac Surgery: A Retrospective Study.

PubMed

Wang, Yi; Li, Hua; Zou, Honglin; Li, Yaxiong

2015-08-01

This study analyzed major complaints from patients during mechanical ventilation after cardiac surgery and identified the most common complaints to reduce adverse psychologic responses. Retrospective. A single tertiary university hospital. Patients with heart disease who were on mechanical ventilation after cardiac surgery (N = 800). The major complaints of the patients during mechanical ventilation after cardiac surgery were analyzed. Patients' comfort was evaluated using a visual analog scale, and the factors affecting comfort were analyzed. The average visual analog scale score in all patients was 5.8±2.0, and most patients presented moderate discomfort. The factors affecting comfort included dry mouth, thirst, tracheal intubation, aspiration of sputum, communication barriers, limited mobility, fear/anxiety, patient-ventilator dyssynchrony, and poor environmental conditions. Of these factors, 8 were independent predictors of the visual analog scale score. Patients considered mechanical ventilation to be the worst part of their hospitalization. The study identified 8 independent factors causing discomfort in patients during mechanical ventilation after cardiac surgery. Clinicians should take appropriate measures and implement nursing interventions to reduce suffering, physical and psychologic trauma, and adverse psychologic responses and to promote recovery. Copyright © 2015 Elsevier Inc. All rights reserved.

Prevalence, implication, and determinants of worsening renal function after surgery for congenital heart disease.

PubMed

Saiki, Hirofumi; Kuwata, Seiko; Kurishima, Clara; Iwamoto, Yoichi; Ishido, Hirotaka; Masutani, Satoshi; Senzaki, Hideaki

2016-08-01

Accumulating data in adults indicate the prognostic importance of worsening renal function (WRF) during treatment of acute heart failure. Venous congestion appears to play a dominant role in WRF; however, data regarding WRF in children with congenital heart disease (CHD) are limited. The present study was conducted to elucidate the prevalence and characteristics of WRF after surgery for CHD in children. We also tested our hypothesis that, similar to adult heart failure, venous congestion is an important determinant of WRF independent of cardiac output in this population. Fifty-five consecutive pediatric patients who underwent cardiovascular surgery for CHD were studied (median age 0.7 years; range 3 days to 17 years). The degree of WRF was assessed by the difference between the maximum levels of postoperative serum creatinine (Cr) and preoperative serum Cr. There was a high prevalence of WRF in the present cohort: an increase in Cr level was observed in 47 patients (85 %) and a Cr increase ≥0.3 mg/dL was seen in 23 (42 %). Importantly, WRF was significantly associated with a worse clinical outcome of a longer stay in the intensive care unit and hospital (both p < 0.05), even after controlling for age and operative factors. In addition, multivariate regression analysis revealed that central venous pressure, rather than cardiac output, was an independent determinant of WRF. Postoperative management to relieve venous congestion may help ameliorate or prevent WRF and thereby improve outcomes in patients with CHD.

Cardiac registers: the adult cardiac surgery register.

PubMed

Bridgewater, Ben

2010-09-01

AIMS OF THE SCTS ADULT CARDIAC SURGERY DATABASE: To measure the quality of care of adult cardiac surgery in GB and Ireland and provide information for quality improvement and research. Feedback of structured data to hospitals, publication of named hospital and surgeon mortality data, publication of benchmarked activity and risk adjusted clinical outcomes through intermittent comprehensive database reports, annual screening of all hospital and individual surgeon risk adjusted mortality rates by the professional society. All NHS hospitals in England, Scotland and Wales with input from some private providers and hospitals in Ireland. 1994-ongoing. Consecutive patients, unconsented. Current number of records: 400000. Adult cardiac surgery operations excluding cardiac transplantation and ventricular assist devices. 129 fields covering demographic factors, pre-operative risk factors, operative details and post-operative in-hospital outcomes. Entry onto local software systems by direct key board entry or subsequent transcription from paper records, with subsequent electronic upload to the central cardiac audit database. Non-financial incentives at hospital level. Local validation processes exist in the hospitals. There is currently no external data validation process. All cause mortality is obtained through linkage with Office for National Statistics. No other linkages exist at present. Available for research and audit by application to the SCTS database committee at http://www.scts.org.

The 2017 Seventh World Congress of Paediatric Cardiology and Cardiac Surgery: "The Olympics of our Profession".

PubMed

Cohen, Mitchell I; Jacobs, Jeffrey P; Cicek, Sertac

2017-12-01

The 1st World Congress of Paediatric Cardiology was held in London, United Kingdom, in 1980, organised by Dr Jane Somerville and Prof. Fergus Macartney. The idea was that of Jane Somerville, who worked with enormous energy and enthusiasm to bring together paediatric cardiologists and surgeons from around the world. The 2nd World Congress of Paediatric Cardiology took place in New York in 1985, organised by Bill Rashkind, Mary Ellen Engle, and Eugene Doyle. The 3rd World Congress of Paediatric Cardiology was held in Bangkok, Thailand, in 1989, organised by Chompol Vongraprateep. Although cardiac surgeons were heavily involved in these early meetings, a separate World Congress of Paediatric Cardiac Surgery was held in Bergamo, Italy, in 1988, organised by Lucio Parenzan. Thereafter, it was recognised that surgeons and cardiologists working on the same problems and driven by a desire to help children would really rather meet together. A momentous decision was taken to initiate a Joint World Congress of Paediatric Cardiology and Cardiac Surgery. A steering committee was established with membership comprising the main organisers of the four separate previous Congresses and additional members were recruited in an effort to achieve numerical equality of cardiologists and surgeons and a broad geographical representation. The historic 1st "World Congress of Paediatric Cardiology and Cardiac Surgery" took place in Paris in June, 1993, organised by Jean Kachaner. The next was to be held in Japan, but the catastrophic Kobe earthquake in 1995 forced relocation to Hawaii in 1997. Then followed Toronto, Canada, 2001, organised by Bill Williams and Lee Benson; Buenos Aires, Argentina, 2005, organised by Horatio Capelli and Guillermo Kreutzer; Cairns, Australia, 2009, organised by Jim Wilkinson; Cape Town, South Africa, 2013, organised by Christopher Hugo-Hamman; and Barcelona, Spain, 2017, organised by Sertac Cicek. With stops in Europe (1993), Asia-Pacific (1997), North America (2001), South America (2005), Australia (2009), Africa (2013), and Europe again (2017), in 2021, The World Congress of Paediatric Cardiology and Cardiac Surgery will be held for the first time in the continental United States. 1 The 8th World Congress of Paediatric Cardiology and Cardiac Surgery will be held in Washington DC, United States of America, 19-24 September, 2021, and will be organised by Jeffrey P. Jacobs and Gil Wernovsky. Mitchell I. Cohen served as the Scientific Program Co-Chair for the 2017 World Congress of Paediatric Cardiology and Cardiac Surgery, and he will again serve as the Scientific Program Co-Chair for the 2021 World Congress of Paediatric Cardiology and Cardiac Surgery along with Kathyrn Dodds RN, MSN, CRNP. Information about the upcoming 8th World Congress of Paediatric Cardiology and Cardiac Surgery can be found at www.WCPCCS2021.org.

Long-term neurodevelopmental outcome and exercise capacity after corrective surgery for tetralogy of Fallot or ventricular septal defect in infancy.

PubMed

Hövels-Gürich, Hedwig H; Konrad, Kerstin; Skorzenski, Daniela; Nacken, Claudia; Minkenberg, Ralf; Messmer, Bruno J; Seghaye, Marie-Christine

2006-03-01

The purpose of this prospective study was to assess whether neurodevelopmental status and exercise capacity of children 5 to 10 years after corrective surgery for tetralogy of Fallot or ventricular septal defect in infancy was different compared with normal children and influenced by the preoperative condition of hypoxemia or cardiac insufficiency. Forty unselected children, 20 with tetralogy of Fallot and hypoxemia and 20 with ventricular septal defect and cardiac insufficiency, operated on with combined deep hypothermic circulatory arrest and low flow cardiopulmonary bypass at a mean age of 0.7 +/- 0.3 years (mean +/- SD), underwent, at mean age 7.4 +/- 1.6 years, standardized evaluation of neurologic status, gross motor function, intelligence, academic achievement, language, and exercise capacity. Results were compared between the groups and related to preoperative, perioperative, and postoperative status and management. Rate of mild neurologic dysfunction was increased compared with normal children, but not different between the groups. Exercise capacity and socioeconomic status were not different compared with normal children and between the groups. Compared with the normal population, motor function, formal intelligence, academic achievement, and expressive and receptive language were significantly reduced (p < 0.01 to p < 0.001) in the whole group and in the subgroups, except for normal intelligence in ventricular septal defect patients. Motor dysfunction was significantly higher in the Fallot group compared with the ventricular septal defect group (p < 0.01) and correlated with neurologic dysfunction, lower intelligence, and reduced expressive language (p < 0.05 each). Reduced New York Heart Association functional class was correlated with lower exercise capacity and longer duration of cardiopulmonary bypass (p < 0.05 each). Reduced socioeconomic status significantly influenced dysfunction in formal intelligence (p < 0.01) and academic achievement (p < 0.05). Preoperative risk factors such as prenatal hypoxia, perinatal asphyxia, and preterm birth, factors of perioperative management such as cardiac arrest, lowest nasopharyngeal temperature, and age at surgery, and postoperative risk factors as postoperative cardiocirculatory insufficiency and duration of mechanical ventilation were not different between the groups and had no influence on outcome. Degree of hypoxemia in Fallot patients and degree of cardiac insufficiency in ventricular septal defect patients did not influence the outcome within the subgroups. Children with preoperative hypoxemia in infancy are at higher risk for motor dysfunction than children with cardiac insufficiency. Corrective surgery in infancy for tetralogy of Fallot or ventricular septal defect with combined circulatory arrest and low flow bypass is associated with reduced neurodevelopmental outcome, but not with reduced exercise capacity in childhood. In our experience, the general risk of long-term neurodevelopmental impairment is related to unfavorable effects of the global perioperative management. Socioeconomic status influences cognitive capabilities.

Myocardial scar location as detected by cardiac magnetic resonance is associated with the outcome in heart failure patients undergoing surgical ventricular reconstruction.

PubMed

Castelvecchio, Serenella; Careri, Giulia; Ambrogi, Federico; Camporeale, Antonia; Menicanti, Lorenzo; Secchi, Francesco; Lombardi, Massimo

2018-01-01

Post-infarction myocardial scar causes adverse left ventricular remodelling and negatively affects the prognosis. We sought to investigate whether scar extent and location obtained by cardiac magnetic resonance may affect the reverse remodelling and survival of heart failure patients undergoing surgical ventricular reconstruction. From January 2011 to December 2015, 151 consecutive patients with previous myocardial infarction and left ventricular remodelling underwent surgical ventricular reconstruction at our Institution, of which 88 (58%) patients had a preoperative protocol-standardized late gadolinium enhancement (LGE)-cardiac magnetic resonance examination during the week before surgery. We excluded 40 patients with devices (26%), 15 patients with irregular heart rhythm (permanent atrial fibrillation, 10% not included in the device group) or mixed contraindications (severe claustrophobia or presence of material magnetic resonance not compatible). Among the 145 survivors, 11 patients received an implantable cardioverter defibrillator after surgery (mostly for persistent low ejection fraction) and were excluded as well, yielding a total of 59 patients (48 men, aged 65 ± 9 years) who repeated a protocol-standardized LGE-cardiac magnetic resonance examination even 6 months postoperatively and therefore represent the study population. Patients were grouped according to the presence of LGE in the antero-basal left ventricular segments (Group A) or the absence of LGE in the same segments (Group B). The postoperative left ventricular end-systolic volume index was considered the primary end-point. After surgery, left ventricular end-systolic volume index and end-diastolic volume index significantly decreased (P < 0.001, for both), while diastolic sphericity index and ejection fraction significantly increased (P = 0.015 and P < 0.001, respectively). The presence of LGE in the antero-basal left ventricular segments (10 patients, Group A) was the only independent predictor of outcome (P = 0.02) at multivariate analysis, being the postoperative left ventricular end-systolic volume index significantly higher compared to that of patients of Group B (49 patients) (78 ± 26 ml/m2 vs 55 ± 20 ml/m2, P = 0.003). Furthermore, patients with a postoperative left ventricular end-systolic volume index >60 ml/m2 showed a higher risk of cardiac events (hazard ratio = 3.67, P = 0.02). In patients undergoing surgical ventricular reconstruction, LGE scar location affects the left ventricular reverse remodelling, which in turn might limit the survival benefit. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Bradycardia as an early warning sign for cardiac arrest during routine laparoscopic surgery.

PubMed

Yong, Jonathan; Hibbert, Peter; Runciman, William B; Coventry, Brendon J

2015-12-01

The aim of this study was to identify clinical patterns of occurrence, management and outcomes surrounding cardiac arrest during laparoscopic surgery using the Australian Incident Monitoring Study (AIMS) database to guide possible prevention and treatment. The AIMS database includes incident reports from participating clinicians from secondary and tertiary healthcare centres across Australia and New Zealand. The AIMS database holds over 11 000 peri- and intraoperative incidents. The primary outcome was to characterize the pattern of events surrounding cardiac arrest. The secondary outcome was to identify successful management strategies in the possible prevention and treatment of cardiac arrest during laparoscopic surgery. Fourteen cases of cardiac arrest during laparoscopic surgery were identified. The majority of cases occurred in 'fit and healthy' patients during elective gynaecological and general surgical procedures. Twelve cases of cardiac arrest were directly associated with pneumoperitoneum with bradycardia preceding cardiac arrest in 75% of these. Management included deflation of pneumoperitoneum, atropine administration and cardiopulmonary resuscitation with circulatory restoration in all cases. The results imply vagal mechanisms associated with peritoneal distension as the predominant contributor to bradycardia and subsequent cardiac arrest during laparoscopy. Bradycardia during gas insufflation is not necessarily a benign event and appears to be a critical early warning sign for possible impending and unexpected cardiac arrest. Immediate deflation of pneumoperitoneum and atropine administration are effective measures that may alleviate bradycardia and possibly avert progression to cardiac arrest. © The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

Surgeon length of service and risk-adjusted outcomes: linked observational analysis of the UK National Adult Cardiac Surgery Audit Registry and General Medical Council Register.

PubMed

Hickey, Graeme L; Grant, Stuart W; Freemantle, Nick; Cunningham, David; Munsch, Christopher M; Livesey, Steven A; Roxburgh, James; Buchan, Iain; Bridgewater, Ben

2014-09-01

To explore the relationship between in-hospital mortality following adult cardiac surgery and the time since primary clinical qualification for the responsible consultant cardiac surgeon (a proxy for experience). Retrospective analysis of prospectively collected national registry data over a 10-year period using mixed-effects multiple logistic regression modelling. Surgeon experience was defined as the time between the date of surgery and award of primary clinical qualification. UK National Health Service hospitals performing cardiac surgery between January 2003 and December 2012. All patients undergoing coronary artery bypass grafts and/or valve surgery under the care of a consultant cardiac surgeon. All-cause in-hospital mortality. A total of 292,973 operations performed by 273 consultant surgeons (with lengths of service from 11.2 to 42.0 years) were included. Crude mortality increased approximately linearly until 33 years service, before decreasing. After adjusting for case-mix and year of surgery, there remained a statistically significant (p=0.002) association between length of service and in-hospital mortality (odds ratio 1.013; 95% CI 1.005-1.021 for each year of 'experience'). Consultant cardiac surgeons take on increasingly complex surgery as they gain experience. With this progression, the incidence of adverse outcomes is expected to increase, as is demonstrated in this study. After adjusting for case-mix using the EuroSCORE, we observed an increased risk of mortality in patients operated on by longer serving surgeons. This finding may reflect under-adjustment for risk, unmeasured confounding or a real association. Further research into outcomes over the time course of surgeon's careers is required. © The Royal Society of Medicine.

Coronary Artery-Bypass-Graft Surgery Increases the Plasma Concentration of Exosomes Carrying a Cargo of Cardiac MicroRNAs: An Example of Exosome Trafficking Out of the Human Heart with Potential for Cardiac Biomarker Discovery.

PubMed

Emanueli, Costanza; Shearn, Andrew I U; Laftah, Abas; Fiorentino, Francesca; Reeves, Barnaby C; Beltrami, Cristina; Mumford, Andrew; Clayton, Aled; Gurney, Mark; Shantikumar, Saran; Angelini, Gianni D

2016-01-01

Exosome nanoparticles carry a composite cargo, including microRNAs (miRs). Cultured cardiovascular cells release miR-containing exosomes. The exosomal trafficking of miRNAs from the heart is largely unexplored. Working on clinical samples from coronary-artery by-pass graft (CABG) surgery, we investigated if: 1) exosomes containing cardiac miRs and hence putatively released by cardiac cells increase in the circulation after surgery; 2) circulating exosomes and exosomal cardiac miRs correlate with cardiac troponin (cTn), the current "gold standard" surrogate biomarker of myocardial damage. The concentration of exosome-sized nanoparticles was determined in serial plasma samples. Cardiac-expressed (miR-1, miR-24, miR-133a/b, miR-208a/b, miR-210), non-cardiovascular (miR-122) and quality control miRs were measured in whole plasma and in plasma exosomes. Linear regression analyses were employed to establish the extent to which the circulating individual miRs, exosomes and exosomal cardiac miR correlated with cTn-I. Cardiac-expressed miRs and the nanoparticle number increased in the plasma on completion of surgery for up to 48 hours. The exosomal concentration of cardiac miRs also increased after CABG. Cardiac miRs in the whole plasma did not correlate significantly with cTn-I. By contrast cTn-I was positively correlated with the plasma exosome level and the exosomal cardiac miRs. The plasma concentrations of exosomes and their cargo of cardiac miRs increased in patients undergoing CABG and were positively correlated with hs-cTnI. These data provide evidence that CABG induces the trafficking of exosomes from the heart to the peripheral circulation. Future studies are necessary to investigate the potential of circulating exosomes as clinical biomarkers in cardiac patients.

Coronary Artery-Bypass-Graft Surgery Increases the Plasma Concentration of Exosomes Carrying a Cargo of Cardiac MicroRNAs: An Example of Exosome Trafficking Out of the Human Heart with Potential for Cardiac Biomarker Discovery

PubMed Central

Emanueli, Costanza; Fiorentino, Francesca; Reeves, Barnaby C.; Beltrami, Cristina; Mumford, Andrew; Clayton, Aled; Gurney, Mark; Shantikumar, Saran; Angelini, Gianni D.

2016-01-01

Introduction Exosome nanoparticles carry a composite cargo, including microRNAs (miRs). Cultured cardiovascular cells release miR-containing exosomes. The exosomal trafficking of miRNAs from the heart is largely unexplored. Working on clinical samples from coronary-artery by-pass graft (CABG) surgery, we investigated if: 1) exosomes containing cardiac miRs and hence putatively released by cardiac cells increase in the circulation after surgery; 2) circulating exosomes and exosomal cardiac miRs correlate with cardiac troponin (cTn), the current “gold standard” surrogate biomarker of myocardial damage. Methods and Results The concentration of exosome-sized nanoparticles was determined in serial plasma samples. Cardiac-expressed (miR-1, miR-24, miR-133a/b, miR-208a/b, miR-210), non-cardiovascular (miR-122) and quality control miRs were measured in whole plasma and in plasma exosomes. Linear regression analyses were employed to establish the extent to which the circulating individual miRs, exosomes and exosomal cardiac miR correlated with cTn-I. Cardiac-expressed miRs and the nanoparticle number increased in the plasma on completion of surgery for up to 48 hours. The exosomal concentration of cardiac miRs also increased after CABG. Cardiac miRs in the whole plasma did not correlate significantly with cTn-I. By contrast cTn-I was positively correlated with the plasma exosome level and the exosomal cardiac miRs. Conclusions The plasma concentrations of exosomes and their cargo of cardiac miRs increased in patients undergoing CABG and were positively correlated with hs-cTnI. These data provide evidence that CABG induces the trafficking of exosomes from the heart to the peripheral circulation. Future studies are necessary to investigate the potential of circulating exosomes as clinical biomarkers in cardiac patients. PMID:27128471

Global Health Estimate of Invasive Mycobacterium chimaera Infections Associated with Heater-Cooler Devices in Cardiac Surgery.

PubMed

Sommerstein, Rami; Hasse, Barbara; Marschall, Jonas; Sax, Hugo; Genoni, Michele; Schlegel, Matthias; Widmer, Andreas F

2018-03-01

Investigations of a worldwide epidemic of invasive Mycobacterium chimaera associated with heater-cooler devices in cardiac surgery have been hampered by low clinical awareness and challenging diagnoses. Using data from Switzerland, we estimated the burden of invasive M. chimaera to be 156-282 cases/year in 10 major cardiac valve replacement market countries.

Serum cortisol concentration with exploratory cut-off values do not predict the effects of hydrocortisone administration in children with low cardiac output after cardiac surgery.

PubMed

Verweij, E J; Hogenbirk, Karin; Roest, Arno A W; van Brempt, Ronald; Hazekamp, Mark G; de Jonge, Evert

2012-10-01

Low cardiac output syndrome is common after paediatric cardiac surgery. Previous studies suggested that hydrocortisone administration may improve haemodynamic stability in case of resistant low cardiac output syndrome in critically ill children. This study was set up to test the hypothesis that the effects of hydrocortisone on haemodynamics in children with low cardiac output syndrome depend on the presence of (relative) adrenal insufficiency. A retrospective study was done on paediatric patients who received hydrocortisone when diagnosed with resistant low cardiac output syndrome after paediatric cardiac surgery in the period from 1 November 2005 to 31 December 2008. We studied the difference in effects of treatment with hydrocortisone administration between patients with adrenal insufficiency defined as an exploratory cut-off value of total cortisol of <100 nmol/l and patients with a serum total cortisol of ≥ 100 nmol/l. A total of 62 of patients were enrolled, meeting the inclusion criteria for low cardiac output syndrome. Thirty-two patients were assigned to Group 1 (<100 nmol/l) and 30 were assigned to Group 2 (≥ 100 nmol/l). Haemodynamics improved after hydrocortisone administration, with an increase in blood pressure, a decrease in administered vasopressors and inotropic drugs, an increase in urine production and a decrease in plasma lactate concentrations. The effects of treatment with hydrocortisone in children with low cardiac output after cardiac surgery was similar in patients with a low baseline serum cortisol concentration and those with normal baseline cortisol levels. A cortisol value using an exploratory cut-off value of 100 nmol/l for adrenal insufficiency should not be used as a criterion to treat these patients with hydrocortisone.

Dilemma in clinical diagnosis of right ventricular masses.

PubMed

Sušić, Livija; Baraban, Vedrana; Vincelj, Josip; Maričić, Lana; Ćatić, Jasmina; Blažeković, Robert; Manojlović, Spomenka

2017-07-08

Detection of an intracardiac mass always represents a clinical challenge. We present a 61-year-old female patient with symptoms of New York Heart Association class III. Two-dimensional transthoracic echocardiography revealed a hypoechogenic mass in the cavity of the dilated right ventricle (RV). Cardiac MRI described a pathologic structure of the RV free wall with pedunculated tumor in its cavity. Three months later, on a repeated echocardiography, there were three individual masses. The patient underwent surgery and the pathohistologic report demonstrated thrombotic masses. During the postoperative period, after reviewing all medical records, the conclusion was arrhythmogenic RV cardiomyopathy. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:362-369, 2017. © 2016 Wiley Periodicals, Inc.

Reoperative Cardiac Surgery - Part II.

PubMed

Tribble, Curtis G

2018-04-10

The preparation for a reoperative cardiac surgical case was covered in Part I of this two part review [Tribble 2018]. Part II will cover primarily intraoperative strategies and techniques.  As noted in Part I, there has been surprisingly little written about the strategies and techniques of reoperative cardiac surgery. Thus, the goal of this two-part review is to collect and collate some of the lessons, abjurations, and tenets related to reoperative cardiac surgery that may be valuable to cardiac surgeons, especially those in training or early in their careers.Some time-honored admonitions that can apply to all complex operations, often enunciated by "old salts," bear repeating:•  Everything matters. Nothing is neutral.•  Some say that a "life or death" decision is made, on average, every 10 seconds during cardiac surgery. •  If something can go wrong, presume that it will.•  If it seems absolutely impossible for something to go wrong, it will anyway, at least some of the time.•  When something does go wrong, it generally does so all at once.•  If what you are doing is working, keep on doing it. If it ain't working, do something else.

Short-term supervised inpatient physiotherapy exercise protocol improves cardiac autonomic function after coronary artery bypass graft surgery--a randomised controlled trial.

PubMed

Mendes, Renata Gonçalves; Simões, Rodrigo Polaquini; De Souza Melo Costa, Fernando; Pantoni, Camila Bianca Falasco; Di Thommazo, Luciana; Luzzi, Sérgio; Catai, Aparecida Maria; Arena, Ross; Borghi-Silva, Audrey

2010-01-01

Coronary artery bypass grafting (CABG) is accompanied by severe impairment of cardiac autonomous regulation (CAR). This study aimed to determine whether a short-term physiotherapy exercise protocol post-CABG, during inpatient cardiac rehabilitation (CR), might improve CAR. Seventy-four patients eligible for CABG were recruited and randomised into physiotherapy exercise group (EG) or physiotherapy usual care group (UCG). EG patients underwent a short-term supervised inpatient physiotherapy exercise protocol consisting of an early mobilisation with progressive exercises plus usual care (respiratory exercises). UCG only received respiratory exercises. Forty-seven patients (24 EG and 23 UGC) completed the study. Outcome measures of CAR included linear and non-linear measures of heart rate variability (HRV) assessed before discharge. By hospital discharge, EG presented significantly higher parasympathetic HRV values [rMSSD, high frequency (HF), SD1)], global power (STD RR, SD2), non-linear HRV indexes [detrended fluctuation analysis (DFA)alpha1, DFAalpha2, approximate entropy (ApEn)] and mean RR compared to UCG (p<0.05). Conversely, higher values of mean HR, low frequency (LF) (sympathetic activity) and the LF/HF (global sympatho-vagal balance) were found in the UCG. A short-term supervised physiotherapy exercise protocol during inpatient CR improves CAR at the time of discharge. Thus, exercise-based inpatient CR might be an effective non-pharmacological tool to improve autonomic cardiac tone in patient's post-CABG.

Chest physiotherapy and breathing exercises for cardiac surgery patients in Sweden--a national survey of practice.

PubMed

Westerdahl, E; Olsén, M Fagevik

2011-06-01

Various chest physiotherapy techniques are recommended after cardiac surgery around the world. There is limited published data on what breathing exercises actually are recommended to patients after surgery in Europe. The aim of this national survey was to establish the current practice of chest physiotherapy and breathing exercises for adult patients following cardiac surgery in Sweden. A postal questionnaire was sent to a total population sample of 33 Swedish physiotherapists working at the departments of cardiothoracic surgery in December 2007 and January 2008. In total, 29 replies (88%) were received. Seven male and twenty two female physiotherapists completed the questionnaire. All physiotherapists instructed, on a regular basis, the cardiac surgery patients to perform post-operative breathing exercises. Positive expiratory pressure (PEP) breathing was routinely used as the first choice for treatment by 22 (83%) of the physiotherapists. Expiratory pressures used varied between 2 and 20 cm H2O. Recommended frequency and duration of the exercises varied from 4 to 30 breaths hourly during the daytime in the first post-operative days. All physiotherapists provided coughing support to the patients. Recommendations to continue breathing exercises after discharge varied from not at all up to 3 months after surgery. Breathing exercises are regularly prescribed during the initial post-operative days after cardiac surgery in Sweden. Hourly deep breathing exercises performed with or without a PEP device were reported to be first choice treatments during the hospital stay. Instructions concerning how long patients should continue the exercises after discharge varied notably.

Associated with Health Care-Associated Infections in Cardiac Surgery

PubMed Central

Greco, Giampaolo; Shi, Wei; Michler, Robert E.; Meltzer, David O.; Ailawadi, Gorav; Hohmann, Samuel F.; Thourani, Vinod; Argenziano, Michael; Alexander, John; Sankovic, Kathy; Gupta, Lopa; Blackstone, Eugene H.; Acker, Michael A.; Russo, Mark J.; Lee, Albert; Burks, Sandra G.; Gelijns, Annetine C.; Bagiella, Emilia; Moskowitz, Alan J.; Gardner, Timothy J.

2014-01-01

BACKGROUND Health care-associated infections (HAIs) are the most common noncardiac complications after cardiac surgery and are associated with increased morbidity and mortality. Current information about their economic burden is limited. OBJECTIVES To determine the cost associated with major types of HAIs during the first 2 months after cardiac surgery. METHODS Prospectively collected data from a multicenter observational study of the Cardiothoracic Surgery Clinical Trials Network, in which patients were monitored for infections for 65 days after surgery, were merged with related financial data, routinely collected by the University HealthSystem Consortium. Incremental length of stay (LOS) and cost associated with HAIs were estimated using generalized linear models, adjusting for patient demographics, clinical history, baseline laboratory values, and surgery type. RESULTS Among 4,320 cardiac surgery patients, mean age of 64 ± 13 years, 119 (2.8%) experienced a major HAI during the index hospitalization. The most common HAIs were pneumonia (48%), sepsis (20%) and C. Difficile colitis (18%). On average, the estimated incremental cost associated with a major HAI was nearly $38,000, of which 47% was related to intensive care unit services. The incremental LOS was 14 days. Overall, there were 849 readmissions, among these, 8.7% were attributed to major HAIs. The cost of readmissions due to major HAI was on average nearly three times as much as readmissions not related to HAI. CONCLUSIONS Hospital cost, length of stay, and readmissions are strongly associated with HAIs. These associations suggest the potential for large reductions in costs if HAIs following cardiac surgery can be reduced. PMID:25572505

Evidence of Impaired Neurocognitive Functioning in School-Age Children Awaiting Cardiac Surgery

ERIC Educational Resources Information Center

van der Rijken, Rachel; Hulstijn-Dirkmaat, Gerdine; Kraaimaat, Floris; Nabuurs-Kohrman, Lida; Daniels, Otto; Maassen, Ben

2010-01-01

Aim: Children with congenital heart disease (CHD) are at risk of developing neurocognitive problems. However, as these problems are usually identified after cardiac surgery, it is unclear whether they resulted from the surgery or whether they pre-existed and hence might be explained by complications and events associated with the heart disease…

Reduction of cardiac and pulmonary complication probabilities after breathing adapted radiotherapy for breast cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Korreman, Stine S.; Pedersen, Anders N.; Aarup, Lasse Rye

Purpose: Substantial reductions of cardio-pulmonary radiation doses can be achieved using voluntary deep inspiration breath-hold (DIBH) or free breathing inspiration gating (IG) in radiotherapy after conserving surgery for breast cancer. The purpose of this study is to evaluate the radiobiological implications of such dosimetric benefits. Methods and Materials: Patients from previously reported studies were pooled for a total of 33 patients. All patients underwent DIBH and free breathing (FB) scans, and 17 patients underwent an additional IG scan. Tangential conformal treatment plans covering the remaining breast, internal mammary, and periclavicular nodes were optimized for each scan, prescription dose 48 Gy.more » Normal tissue complication probabilities were calculated using the relative seriality model for the heart, and the model proposed by Burman et al. for the lung. Results: Previous computed tomography studies showed that both voluntary DIBH and IG provided reduction of the lung V{sub 5} (relative volume receiving more than 50% of prescription dose) on the order of 30-40%, and a 80-90% reduction of the heart V{sub 5} for left-sided cancers. Corresponding pneumonitis probability of 28.1% (range, 0.7-95.6%) for FB could be reduced to 2.6% (range, 0.1-40.1%) for IG, and 4.3% (range, 0.1-59%) for DIBH. The cardiac mortality probability could be reduced from 4.8% (range, 0.1-23.4%) in FB to 0.5% (range, 0.1-2.6%) for IG and 0.1% (range, 0-3.0%) for DIBH. Conclusions: Remarkable potential is shown for simple voluntary DIBH and free breathing IG to reduce the risk of both cardiac mortality and pneumonitis for the common technique of adjuvant tangential breast irradiation.« less

Risk of Acute Kidney Injury in Patients Randomized to a Restrictive Versus Liberal Approach to Red Blood Cell Transfusion in Cardiac Surgery: A Substudy Protocol of the Transfusion Requirements in Cardiac Surgery III Noninferiority Trial.

PubMed

Garg, Amit X; Shehata, Nadine; McGuinness, Shay; Whitlock, Richard; Fergusson, Dean; Wald, Ron; Parikh, Chirag; Bagshaw, Sean M; Khanykin, Boris; Gregory, Alex; Syed, Summer; Hare, Gregory M T; Cuerden, Meaghan S; Thorpe, Kevin E; Hall, Judith; Verma, Subodh; Roshanov, Pavel S; Sontrop, Jessica M; Mazer, C David

2018-01-01

When safe to do so, avoiding blood transfusions in cardiac surgery can avoid the risk of transfusion-related infections and other complications while protecting a scarce resource and reducing costs. This protocol describes a kidney substudy of the Transfusion Requirements in Cardiac Surgery III (TRICS-III) trial, a multinational noninferiority randomized controlled trial to determine whether the risk of major clinical outcomes in patients undergoing planned cardiac surgery with cardiopulmonary bypass is no greater with a restrictive versus liberal approach to red blood cell transfusion. The objective of this substudy is to determine whether the risk of acute kidney injury is no greater with a restrictive versus liberal approach to red blood cell transfusion, and whether this holds true in patients with and without preexisting chronic kidney disease. Multinational noninferiority randomized controlled trial conducted in 73 centers in 19 countries (2014-2017). Patients (~4800) undergoing planned cardiac surgery with cardiopulmonary bypass. The primary outcome of this substudy is perioperative acute kidney injury, defined as an acute rise in serum creatinine from the preoperative value (obtained in the 30-day period before surgery), where an acute rise is defined as ≥26.5 μmol/L in the first 48 hours after surgery or ≥50% in the first 7 days after surgery. We will report the absolute risk difference in acute kidney injury and the 95% confidence interval. We will repeat the primary analysis using alternative definitions of acute kidney injury, including staging definitions, and will examine effect modification by preexisting chronic kidney disease (defined as a preoperative estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m 2 ). It is not possible to blind patients or providers to the intervention; however, objective measures will be used to assess outcomes, and outcome assessors will be blinded to the intervention assignment. Substudy results will be reported by the year 2018. This substudy will provide generalizable estimates of the risk of acute kidney injury of a restrictive versus liberal approach to red blood cell transfusion in the presence of anemia during cardiac surgery done with cardiopulmonary bypass. www.clinicaltrials.gov; clinical trial registration number NCT 02042898.

[Sense of Coherence Scale according to Antonovsky as a possible predictor for return to work for cardiac surgery intensive care patients].

PubMed

Benstoem, C; Wübker, R; Lüngen, M; Breuer, T; Marx, G; Autschbach, R; Goetzenich, A; Schnoering, H

2018-05-14

For cardiac surgery patients who were employed prior to surgery, the return to their professional life is of special importance. In addition to medical reasons, such as pre-existing conditions, the success of the operation or postoperative course and patient-intrinsic reasons, which can be assessed with the Sense of Coherence (SOC) scale by Antonovsky, may also play a role in the question of a possible return into working life. In this study 278 patients (invasive coronary artery bypass graft surgery and/or surgery on heart valves, age < 60 years, employed) were questioned postoperatively via post with the SOC questionnaire. The SOC questionnaire was used in addition to questions about return to work. The cohort was stratified according to the time of return to work. Subsequently, the point of maximum sensitivity and specificity was determined for the total SOC score and the prediction power was considered. Of the 278 patients, 61 questionnaires (22%) were considered as eligible and included in the analysis. Of these, 47 participants had returned to work after undergoing cardiac surgery and 14 participants had not. We observed significant differences in SOC values between both groups (146.07 ± 29.76 versus 124.29 ± 28.8, p = 0.020). Patients that returned to work within the first 6 months after surgery showed even higher SOC scores (148.56 ± 28.98, p = 0.034). Patients with an SOC score < 130 are at greater risk not to return to their professional life after cardiac surgery. The SOC is an easily obtainable score that reliably predicts the probability of return to work after cardiac surgery.

Mycobacterium chimaera infection following cardiac surgery in the United Kingdom: clinical features and outcome of the first 30 cases.

PubMed

Scriven, James E; Scobie, Antonia; Verlander, Neville Q; Houston, Angela; Collyns, Tim; Cajic, Vjeran; Kon, Onn Min; Mitchell, Tamara; Rahama, Omar; Robinson, Amy; Withama, Shirmila; Wilson, Peter; Maxwell, David; Agranoff, Daniel; Davies, Eleri; Llewelyn, Meirion; Soo, Shiu-Shing; Sahota, Amandip; Cooper, Mike; Hunter, Michael; Tomlins, Jennifer; Tiberi, Simon; Kendall, Simon; Dedicoat, Martin; Alexander, Eliza; Fenech, Teresa; Zambon, Maria; Lamagni, Theresa; Smith, E Grace; Chand, Meera

2018-05-24

Mycobacterium chimaera infection following cardiac surgery, due to contaminated cardiopulmonary bypass heater-cooler units, has been reported worldwide. However, the spectrum of clinical disease remains poorly understood. To address this, we report the clinical and laboratory features, treatment and outcome of the first 30 UK cases. Case note review was performed for cases identified retrospectively through outbreak investigations and prospectively through on-going surveillance. Case definition was Mycobacterium chimaera detected in any clinical specimen, history of cardiothoracic surgery with cardiopulmonary bypass, and compatible clinical presentation. Thirty patients were identified (28 with prosthetic material) exhibiting a spectrum of disease including prosthetic valve endocarditis (14/30), sternal wound infection (2/30), aortic graft infection (4/30), and disseminated (non-cardiac) disease (10/30). Patients presented a median of 14 months post surgery (maximum 5 years) most commonly complaining of fever and weight loss. Investigations frequently revealed lymphopenia, thrombocytopenia, liver cholestasis and non-necrotising granulomatous inflammation. Diagnostic sensitivity for a single mycobacterial blood culture was 68% but increased if multiple samples were sent. 27 patients started macrolide-based combination treatment and 14 had further surgery. To date, 18 patients have died (60%) a median of 30 months (IQR 20-39) after initial surgery. Survival analysis identified younger age, mitral valve surgery, mechanical valve replacement, higher serum sodium concentration and lower CRP as factors associated with better survival. Mycobacterium chimaera infection following cardiac surgery is associated with a wide spectrum of disease. The diagnosis should be considered in all patients who develop an unexplained illness following cardiac surgery. Copyright © 2018. Published by Elsevier Ltd.

Cardiac rehabilitation increases physical capacity but not mental health after heart valve surgery: a randomised clinical trial.

PubMed

Sibilitz, Kirstine L; Berg, Selina K; Rasmussen, Trine B; Risom, Signe Stelling; Thygesen, Lau C; Tang, Lars; Hansen, Tina B; Johansen, Pernille Palm; Gluud, Christian; Lindschou, Jane; Schmid, Jean Paul; Hassager, Christian; Køber, Lars; Taylor, Rod S; Zwisler, Ann-Dorthe

2016-12-15

The evidence for cardiac rehabilitation after valve surgery remains sparse. Current recommendations are therefore based on patients with ischaemic heart disease. The aim of this randomised clinical trial was to assess the effects of cardiac rehabilitation versus usual care after heart valve surgery. The trial was an investigator-initiated, randomised superiority trial (The CopenHeart VR trial, VR; valve replacement or repair). We randomised 147 patients after heart valve surgery 1:1 to 12 weeks of cardiac rehabilitation consisting of physical exercise and monthly psycho-educational consultations (intervention) versus usual care without structured physical exercise or psycho-educational consultations (control). Primary outcome was physical capacity measured by VO 2 peak and secondary outcome was self-reported mental health measured by Short Form-36. 76% were men, mean age 62 years, with aortic (62%), mitral (36%) or tricuspid/pulmonary valve surgery (2%). Cardiac rehabilitation compared with control had a beneficial effect on VO 2 peak at 4 months (24.8 mL/kg/min vs 22.5 mL/kg/min, p=0.045) but did not affect Short Form-36 Mental Component Scale at 6 months (53.7 vs 55.2 points, p=0.40) or the exploratory physical and mental outcomes. Cardiac rehabilitation increased the occurrence of self-reported non-serious adverse events (11/72 vs 3/75, p=0.02). Cardiac rehabilitation after heart valve surgery significantly improves VO 2 peak at 4 months but has no effect on mental health and other measures of exercise capacity and self-reported outcomes. Further research is needed to justify cardiac rehabilitation in this patient group. NCT01558765, Results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Association between intraoperative hypotension and 30-day mortality, major adverse cardiac events, and acute kidney injury after non-cardiac surgery: A meta-analysis of cohort studies.

PubMed

Gu, Wan-Jie; Hou, Bai-Ling; Kwong, Joey S W; Tian, Xin; Qian, Yue; Cui, Yin; Hao, Jing; Li, Ju-Chen; Ma, Zheng-Liang; Gu, Xiao-Ping

2018-05-01

The association between intraoperative hypotension (IOH) and postoperative outcomes is not fully understood. We performed a meta-analysis to determine whether IOH is associated with increased risk of 30-day mortality, major adverse cardiac events (MACEs) and acute kidney injury (AKI) after non-cardiac surgery. We searched PubMed and Embase through May 2016 to identify cohort studies that investigated the association between IOH and risk of 30-day mortality, MACEs, or AKI in adult patients after non-cardiac surgery. Ascertainment of IOH and assessment of outcomes were defined by the individual study. Considering the level of clinical heterogeneity, adjusted odds ratios (ORs) with 95% confidence interval (CIs) were pooled using a random-effects model. This meta-analysis is registered on PROSPERO (CRD42016049405). We included 14 cohort studies that were heterogeneous in terms of definition of IOH. IOH alone was associated with increased risk of 30-day mortality (OR 1.29 [95% CI, 1.19-1.41]), MACEs (OR 1.59 [95% CI, 1.23-2.05]), especially myocardial injury (OR 1.67 [95% CI, 1.31-2.13]), and AKI (OR 1.39 [95% CI, 1.09-1.77]). Triple low (IOH coincident with low bispectral index and low minimum alveolar concentration) also predicts increased risk of 30-day mortality (OR 1.32 [95% CI, 1.03-1.68]). IOH alone significantly increases the risk of postoperative 30-day mortality, MACEs, especially myocardial injury, and AKI in adult patients after non-cardiac surgery. Triple low also predicts increased risk of 30-day mortality after non-cardiac surgery. These findings provide evidence that IOH should be recognized as an independent risk factor for postoperative adverse outcomes after non-cardiac surgery. Copyright © 2018 Elsevier B.V. All rights reserved.

Neurologic sequelae of cardiac surgery in children.

PubMed

Ferry, P C

1987-03-01

Major advances in surgical and cardiopulmonary bypass technology have occurred in the past 30 years. Total correction of previously inoperable congenital cardiac defects is being performed with increasing frequency and in children at progressively younger ages. While the majority of children undergoing cardiac surgery survive without incident, increasing concern is being raised about neurologic sequelae seen in some survivors. Complications such as embolization, hypoxia, inadequate cerebral perfusion, and biochemical disturbances may all lead to brain damage following cardiac surgery. Acute postoperative neurologic problems include seizures, impaired levels of consciousness, focal motor deficits, and movement disorders. Long-term sequelae include language and learning disorders, mental retardation, seizures, and cerebral palsy. Intraoperative cerebral monitoring techniques are as yet imperfect, but their use in combination with meticulous intraoperative and postoperative care currently provides the best means of reducing neurologic morbidity. Future studies should explore other methods of preserving neurologic integrity in children undergoing open heart surgery.

A strategy for management of intraoperative Addisonian crisis during coronary artery bypass grafting.

PubMed

D'Silva, Celma; Watson, Dale; Ngaage, Dumbor

2012-04-01

Patients with Addison's disease undergoing cardiac surgery are at risk of developing a crisis. There is no consensus on the preoperative and intraoperative management of this group of patients undergoing cardiac surgery so the recommendations for non-cardiac patients are often used. The consensus statement from the international task force of the American College of Critical Care medicine recommends 100 mg of intravenous hydrocortisone for patients with adrenal insufficiency in septic shock, but in patients undergoing surgery, especially with extracorporeal circulation, the dosage may even be higher. We report our management of a patient with well-controlled adrenal insufficiency for 30 years who developed intraoperative Addisonian crisis despite the recommended preoperative corticosteroid supplementation. The importance of adequate corticosteroid supplementation for cardiac surgery patients, adapting the surgical strategy to allow for optimal management of potential complications and close monitoring with heightened awareness are discussed.

"Just-In-Time" Simulation Training Using 3-D Printed Cardiac Models After Congenital Cardiac Surgery.

PubMed

Olivieri, Laura J; Su, Lillian; Hynes, Conor F; Krieger, Axel; Alfares, Fahad A; Ramakrishnan, Karthik; Zurakowski, David; Marshall, M Blair; Kim, Peter C W; Jonas, Richard A; Nath, Dilip S

2016-03-01

High-fidelity simulation using patient-specific three-dimensional (3D) models may be effective in facilitating pediatric cardiac intensive care unit (PCICU) provider training for clinical management of congenital cardiac surgery patients. The 3D-printed heart models were rendered from preoperative cross-sectional cardiac imaging for 10 patients undergoing congenital cardiac surgery. Immediately following surgical repair, a congenital cardiac surgeon and an intensive care physician conducted a simulation training session regarding postoperative care utilizing the patient-specific 3D model for the PCICU team. After the simulation, Likert-type 0 to 10 scale questionnaire assessed participant perception of impact of the training session. Seventy clinicians participated in training sessions, including 22 physicians, 38 nurses, and 10 ancillary care providers. Average response to whether 3D models were more helpful than standard hand off was 8.4 of 10. Questions regarding enhancement of understanding and clinical ability received average responses of 9.0 or greater, and 90% of participants scored 8 of 10 or higher. Nurses scored significantly higher than other clinicians on self-reported familiarity with the surgery (7.1 vs. 5.8; P = .04), clinical management ability (8.6 vs. 7.7; P = .02), and ability enhancement (9.5 vs. 8.7; P = .02). Compared to physicians, nurses and ancillary providers were more likely to consider 3D models more helpful than standard hand off (8.7 vs. 7.7; P = .05). Higher case complexity predicted greater enhancement of understanding of surgery (P = .04). The 3D heart models can be used to enhance congenital cardiac critical care via simulation training of multidisciplinary intensive care teams. Benefit may be dependent on provider type and case complexity. © The Author(s) 2016.

Levosimendan versus milrinone in neonates and infants after corrective open-heart surgery: a pilot study.

PubMed

Lechner, Evelyn; Hofer, Anna; Leitner-Peneder, Gabriele; Freynschlag, Roland; Mair, Rudolf; Weinzettel, Robert; Rehak, Peter; Gombotz, Hans

2012-09-01

Low cardiac output syndrome commonly complicates the postoperative course after open-heart surgery in children. To prevent low cardiac output syndrome, prophylactic administration of milrinone after cardiopulmonary bypass is commonly used in small children. The aim of this study was to compare the effect of prophylactically administered levosimendan and milrinone on cardiac index in neonates and infants after corrective open-heart surgery. Prospective, single-center, double-blind, randomized pilot study. Tertiary care center, postoperative pediatric cardiac intensive care unit. After written informed consent, 40 infants undergoing corrective open-heart surgery were included. At weaning from cardiopulmonary bypass, either a 24-hr infusion of 0.1 μg/kg/min levosimendan or of 0.5 μg/kg/min milrinone were administered. Cardiac output was evaluated at 2, 6, 9, 12, 18, 24, and 48 hrs after cardiopulmonary bypass using a transesophageal Doppler technique (Cardio-QP, Deltex Medical, Chichester, UK). Cardiac index was calculated from cardiac output and the patients' respective body surface area. Intention-to-treat data of 39 patients (19 in the levosimendan and 20 in the milrinone group) were analyzed using analysis of variance for repeated measurements for statistics. Analysis of variance revealed for both, cardiac index and cardiac output, similar results with no significant differences of the factors group and time. A significant interaction for cardiac output (p = .005) and cardiac index (p = .007) was found, which indicates different time courses of cardiac index in the two groups. Both drugs were well tolerated; no death or serious adverse event occurred. In our small study, postoperative cardiac index over time was similar in patients with prophylactically administered levosimendan and patients with prophylactically given milrinone. We observed an increase in cardiac output and cardiac index over time in the levosimendan group, whereas cardiac output and cardiac index remained stable in the milrinone group. This pilot study has primarily served to obtain experience using the new drug levosimendan in neonates and infants and to initiate further multicenter trials in pediatric patients.

Hybrid options for treating cardiac disease.

PubMed

Umakanthan, Ramanan; Leacche, Marzia; Zhao, David X; Gallion, Anna H; Mishra, Prabodh C; Byrne, John G

2011-01-01

The options for treating heart disease have greatly expanded during the course of the last 2 1/2 decades with the advent of hybrid technology. The hybrid option for treating cardiac disease implies using the technology of both interventional cardiology and cardiac surgery to treat cardiac disease. This rapidly developing technology has given rise to new and creative techniques to treat cardiac disease involving coronary artery disease, coronary artery disease and cardiac valve disease, and atrial fibrillation. It has also led to the establishment of new procedural suites called hybrid operating rooms that facilitate the integration of technologies of interventional cardiology catheterization laboratories with those of cardiac surgery operating rooms. The development of hybrid options for treating cardiac disease has also greatly augmented teamwork and collaboration between interventional cardiologists and cardiac surgeons. Copyright © 2011 Elsevier Inc. All rights reserved.

Is the Preoperative Administration of Amiodarone or Metoprolol More Effective in Reducing Atrial Fibrillation: After Coronary Bypass Surgery?

PubMed

Onk, Oruc Alper; Erkut, Bilgehan

2015-10-01

This study examined the influence of preoperative administration of amiodarone and metoprolol in preventing postoperative atrial fibrillation (AF) after coronary artery bypass grafting (CABG) surgery.The study comprised 251 patients who underwent CABG surgery at our hospital between January 2012 and May 2014. The patients were randomly divided into 2 groups: amiodarone therapy group (n = 122 patients) and metoprolol therapy group (n = 129 patients).In the amiodarone group, the patients received amiodarone tablet orally 1 week before coronary bypass surgery and during the postoperative period. In the metoprolol group, the patients received metoprolol tablet orally 1 week before surgery and during the postoperative period. The AF development rate was retrospectively evaluated between the first 3 days and 4 weeks after surgery.AF developed in 14 patients in the amiodarone group and 16 patients in the metoprolol group 4 weeks after the operation (P = 0.612).No significant difference was observed between the groups in terms of intensive care unit and hospital stay. Furthermore, hospital charges were similar in both groups (P = 0.741).The results of the logistic regression analysis showed age, left ventricular ejection fraction, left atrial diameter, and aortic cross-clamping time to be predictors for postoperative AF.This study demonstrates that amiodarone and metoprolol have similar effects in prevention of AF after cardiac surgery. However, larger-scale studies need to be conducted to substantiate these findings.

Early and late outcomes of 1000 minimally invasive aortic valve operations.

PubMed

Tabata, Minoru; Umakanthan, Ramanan; Cohn, Lawrence H; Bolman, Ralph Morton; Shekar, Prem S; Chen, Frederick Y; Couper, Gregory S; Aranki, Sary F

2008-04-01

Minimal access cardiac valve surgery is increasingly utilized. We report our 11-year experience with minimally invasive aortic valve surgery. From 07/96 to 12/06, 1005 patients underwent minimally invasive aortic valve surgery. Early and late outcomes were analyzed. Median patient age was 68 years (range: 24-95), 179 patients (18%) were 80 years or older, 130 patients (13%) had reoperative aortic valve surgery, 86 (8.4%) had aortic root replacement, 62 (6.1%) had concomitant ascending aortic replacement, and 26 (2.6%) had percutaneous coronary intervention on the day of surgery (hybrid procedure). Operative mortality was 1.9% (19/1005). The incidences of deep sternal wound infection, pneumonia and reoperation for bleeding were 0.5% (5/1005), 1.3% (13/1005) and 2.4% (25/1005), respectively. Median length of stay was 6 days and 733 patients (72%) were discharged home. Actuarial survival was 91% at 5 years and 88% at 10 years. In the subgroup of the elderly (> or =80 years), operative mortality was 1.7% (3/179), median length of stay was 8 days and 66 patients (37%) were discharged home. Actuarial survival at 5 years was 84%. There was a significant decreasing trend in cardiopulmonary bypass time, the incidence of bleeding, and operative mortality over time. Minimal access approaches in aortic valve surgery are safe and feasible with excellent outcomes. Aortic root replacement, ascending aortic replacement, and reoperative surgery can be performed with these approaches. These procedures are particularly well-tolerated in the elderly.

Is delayed surgery related to worse outcomes in native left-sided endocarditis?

PubMed

Tepsuwan, Thitipong; Rimsukcharoenchai, Chartaroon; Tantraworasin, Apichat; Woragidpoonpol, Surin; Schuarattanapong, Suphachai; Nawarawong, Weerachai

2016-05-01

Timing of surgery in the management of infective endocarditis is controversial, and there is still no definite conclusion on how early the surgery should be performed. This study focuses on the outcomes of surgery during the active period of infective endocarditis in consideration of the duration after diagnosis. One hundred and thirty-four patients with active native valve infective endocarditis who underwent surgery from January 2006 to December 2013 were reviewed retrospectively. They were divided in 2 groups based on timing of surgery: early group (first week after diagnosis, n = 37) and delayed group (2 to 6 weeks after diagnosis, n = 97). Compared to the delayed group, the early group had significantly more patients in New York Heart Association class IV (81% vs. 43.3%), more mechanically ventilated (54.1% vs. 18.6%), more on inotropic support (62.2% vs. 38.1%), and hence a worse EuroSCORE II (14.8% vs. 8.8%). Operative mortality was comparable (5.4% vs. 10.3%) and 7-year survival was similar (77.4% vs. 74.6%). On multivariable regression analysis, delayed surgery did not impact on short- and long-term outcomes. Preoperative cardiac arrest and infection with Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, or Kingella were risk factors for higher operative mortality. Predictors of poor 7-year survival were diabetes mellitus and acute renal failure. Delayed surgery is not associated with worse outcomes. Both early and delayed approaches are safe and provide acceptable results. Timing of surgery should be tailored to each patient's clinical status, not based on duration of endocarditis alone. © The Author(s) 2016.

Respiratory muscle strength is not decreased in patients undergoing cardiac surgery.

PubMed

Urell, Charlotte; Emtner, Margareta; Hedenstrom, Hans; Westerdahl, Elisabeth

2016-03-31

Postoperative pulmonary impairments are significant complications after cardiac surgery. Decreased respiratory muscle strength could be one reason for impaired lung function in the postoperative period. The primary aim of this study was to describe respiratory muscle strength before and two months after cardiac surgery. A secondary aim was to describe possible associations between respiratory muscle strength and lung function. In this prospective observational study 36 adult cardiac surgery patients (67 ± 10 years) were studied. Respiratory muscle strength and lung function were measured before and two months after surgery. Pre- and postoperative respiratory muscle strength was in accordance with predicted values; MIP was 78 ± 24 cmH2O preoperatively and 73 ± 22 cmH2O at two months follow-up (p = 0.19). MEP was 122 ± 33 cmH2O preoperatively and 115 ± 38 cmH2O at two months follow-up (p = 0.18). Preoperative lung function was in accordance with predicted values, but was significantly decreased postoperatively. At two-months follow-up there was a moderate correlation between MIP and FEV1 (r = 0.43, p = 0.009). Respiratory muscle strength was not impaired, either before or two months after cardiac surgery. The reason for postoperative lung function alteration is not yet known. Interventions aimed at restore an optimal postoperative lung function should focus on other interventions then respiratory muscle strength training.

Preexisting depressive symptoms are associated with long-term cognitive decline in patients after cardiac surgery.

PubMed

Patron, Elisabetta; Messerotti Benvenuti, Simone; Zanatta, Paolo; Polesel, Elvio; Palomba, Daniela

2013-01-01

To examine whether preoperative psychological dysfunctions rather than intraoperative factors may differentially predict short- and long-term postoperative cognitive decline (POCD) in patients after cardiac surgery. Forty-two patients completed a psychological evaluation, including the Trail Making Test Part A and B (TMT-A/B), the memory with 10/30-s interference, the phonemic verbal fluency and the Center for Epidemiological Studies of Depression (CES-D) scale for cognitive functions and depressive symptoms, respectively, before surgery, at discharge and at 18-month follow-up. Ten (24%) and 11 (26%) patients showed POCD at discharge and at 18-month follow-up, respectively. The duration of cardiopulmonary bypass significantly predicted short-term POCD [odds ratio (OR)=1.04, P<.05], whereas preoperative psychological factors were unrelated to cognitive decline at discharge. Conversely, long-term cognitive decline after cardiac surgery was significantly predicted by preoperative scores in the CES-D (OR=1.26, P<.03) but not by intraoperative variables (all Ps >.23). Our findings showed that preexisting depressive symptoms rather than perioperative risk factors are associated with cognitive decline 18 months after cardiac surgery. This study suggests that a preoperative psychological evaluation of depressive symptoms is essential to anticipate which patients are likely to show long-term cognitive decline after cardiac surgery. Copyright © 2013 Elsevier Inc. All rights reserved.

The role of three-dimensional visualization in robotics-assisted cardiac surgery

NASA Astrophysics Data System (ADS)

Currie, Maria; Trejos, Ana Luisa; Rayman, Reiza; Chu, Michael W. A.; Patel, Rajni; Peters, Terry; Kiaii, Bob

2012-02-01

Objectives: The purpose of this study was to determine the effect of three-dimensional (3D) versus two-dimensional (2D) visualization on the amount of force applied to mitral valve tissue during robotics-assisted mitral valve annuloplasty, and the time to perform the procedure in an ex vivo animal model. In addition, we examined whether these effects are consistent between novices and experts in robotics-assisted cardiac surgery. Methods: A cardiac surgery test-bed was constructed to measure forces applied by the da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA) during mitral valve annuloplasty. Both experts and novices completed roboticsassisted mitral valve annuloplasty with 2D and 3D visualization. Results: The mean time for both experts and novices to suture the mitral valve annulus and to tie sutures using 3D visualization was significantly less than that required to suture the mitral valve annulus and to tie sutures using 2D vision (p∠0.01). However, there was no significant difference in the maximum force applied by novices to the mitral valve during suturing (p = 0.3) and suture tying (p = 0.6) using either 2D or 3D visualization. Conclusion: This finding suggests that 3D visualization does not fully compensate for the absence of haptic feedback in robotics-assisted cardiac surgery. Keywords: Robotics-assisted surgery, visualization, cardiac surgery

Nurse practitioners in postoperative cardiac surgery: are they effective?

PubMed

Goldie, Catherine L; Prodan-Bhalla, Natasha; Mackay, Martha

2012-01-01

High demand for acute care nurse practitioners (ACNPs) in Canadian postoperative cardiac surgery settings has outpaced methodologically rigorous research to support the role. To compare the effectiveness of ACNP-led care to hospitalist-led care in a postoperative cardiac surgery unit in a Canadian, university-affiliated, tertiary care hospital. Patients scheduled for urgent or elective coronary artery bypass and/or valvular surgery were randomly assigned to either ACNP-led (n=22) or hospitalist-led (n=81) postoperative care. Both ACNPs and hospitalists worked in collaboration with a cardiac surgeon. Outcome variables included length of hospital stay, hospital readmission rate, postoperative complications, adherence to follow-up appointments, attendance at cardiac rehabilitation and both patient and health care team satisfaction. Baseline demographic characteristics were similar between groups except more patients in the ACNP-led group had had surgery on an urgent basis (p < or = 0.01), and had undergone more complicated surgical procedures (p < or =0.01). After discharge, more patients in the hospitalist-led group had visited their family doctor within a week (p < or =0.02) and measures of satisfaction relating to teaching, answering questions, listening and pain management were higher in the ACNP-led group. Although challenges in recruitment yielded a lower than anticipated sample size, this study contributes to our knowledge of the ACNP role in postoperative cardiac surgery. Our findings provide support for the ACNP role in this setting as patients who received care from an ACNP had similar outcomes to hospitalist-led care and reported greater satisfaction in some measures of care.

Ischemic Optic Neuropathy in Cardiac Surgery: Incidence and Risk Factors in the United States from the National Inpatient Sample 1998 to 2013.

PubMed

Rubin, Daniel S; Matsumoto, Monica M; Moss, Heather E; Joslin, Charlotte E; Tung, Avery; Roth, Steven

2017-05-01

Ischemic optic neuropathy is the most common form of perioperative visual loss, with highest incidence in cardiac and spinal fusion surgery. To date, potential risk factors have been identified in cardiac surgery by only small, single-institution studies. To determine the preoperative risk factors for ischemic optic neuropathy, the authors used the National Inpatient Sample, a database of inpatient discharges for nonfederal hospitals in the United States. Adults aged 18 yr or older admitted for coronary artery bypass grafting, heart valve repair or replacement surgery, or left ventricular assist device insertion in National Inpatient Sample from 1998 to 2013 were included. Risk of ischemic optic neuropathy was evaluated by multivariable logistic regression. A total of 5,559,395 discharges met inclusion criteria with 794 (0.014%) cases of ischemic optic neuropathy. The average yearly incidence was 1.43 of 10,000 cardiac procedures, with no change during the study period (P = 0.57). Conditions increasing risk were carotid artery stenosis (odds ratio, 2.70), stroke (odds ratio, 3.43), diabetic retinopathy (odds ratio, 3.83), hypertensive retinopathy (odds ratio, 30.09), macular degeneration (odds ratio, 4.50), glaucoma (odds ratio, 2.68), and cataract (odds ratio, 5.62). Female sex (odds ratio, 0.59) and uncomplicated diabetes mellitus type 2 (odds ratio, 0.51) decreased risk. The incidence of ischemic optic neuropathy in cardiac surgery did not change during the study period. Development of ischemic optic neuropathy after cardiac surgery is associated with carotid artery stenosis, stroke, and degenerative eye conditions.

Can cardiac surgery cause hypopituitarism?

PubMed

Francis, Flverly; Burger, Ines; Poll, Eva Maria; Reineke, Andrea; Strasburger, Christian J; Dohmen, Guido; Gilsbach, Joachim M; Kreitschmann-Andermahr, Ilonka

2012-03-01

Apoplexy of pituitary adenomas with subsequent hypopituitarism is a rare but well recognized complication following cardiac surgery. The nature of cardiac on-pump surgery provides a risk of damage to the pituitary because the vascular supply of the pituitary is not included in the cerebral autoregulation. Thus, pituitary tissue may exhibit an increased susceptibility to hypoperfusion, ischemia or intraoperative embolism. After on-pump procedures, patients often present with physical and psychosocial impairments which resemble symptoms of hypopituitarism. Therefore, we analyzed whether on-pump cardiac surgery may cause pituitary dysfunction also in the absence of pre-existing pituitary disease. Twenty-five patients were examined 3-12 months after on-pump cardiac surgery. Basal hormone levels for all four anterior pituitary hormone axes were measured and a short synacthen test and a growth hormone releasing hormone plus arginine (GHRH-ARG)-test were performed. Quality of life (QoL), depression, subjective distress for a specific life event, sleep quality and fatigue were assessed by means of self-rating questionnaires. Hormonal alterations were only slight and no signs of anterior hypopituitarism were found except for an insufficient growth hormone rise in two overweight patients in the GHRH-ARG-test. Psychosocial impairment was pronounced, including symptoms of moderate to severe depression in 9, reduced mental QoL in 8, dysfunctional coping in 6 and pronounced sleep disturbances in 16 patients. Hormone levels did not correlate with psychosocial impairment. On-pump cardiac surgery did not cause relevant hypopituitarism in our sample of patients and does not serve to explain the psychosocial symptoms of these patients.

Increased recombinant activated factor VII use and need for surgical reexploration following a switch from aprotinin to epsilon-aminocaproic acid in infant cardiac surgery.

PubMed

Scott, John P; Costigan, Daniel J; Hoffman, George M; Simpson, Pippa M; Dasgupta, Mahua; Punzalan, Rowena; Berens, Richard J; Tweddell, James S; Stuth, Eckehard A E

2014-05-01

To evaluate whether conversion from aprotinin to epsilon-aminocaproic acid (EACA) during infant cardiac surgery was associated with increased perioperative bleeding. Structured retrospective chart review. University-affiliated large congenital cardiac surgery program. Records from 145 infants (age < 1 yr) receiving aprotinin as antifibrinolytic therapy for cardiac surgery between 6/1/2006 and 12/31/2006 were compared with a cohort of infants receiving EACA for cardiac surgery between 6/1/2008 and 12/31/2008. Sixty-eight infants received aprotinin and 77 infants received EACA. Measured indicators of perioperative bleeding included transfusion volumes, recombinant activated clotting factor VIIa (rFVIIa) administration, need for reexploration, and perioperative chest tube output. EACA treated patients received significantly more rFVIIa for uncontrolled bleeding (19/77 [25%] vs 3/68 [4%]; P < 0.001) and required surgical reexploration more frequently (21/77 [27%] vs 7/68 [10%]; P = 0.01]. Median (25th-75th percentiles) intraoperative platelet transfusion requirements were also increased after the switch to EACA (28 mL [0-58 mL] vs 0 mL [0 mL - 34.5 mL]), but this difference did not reach statistical significance (P = 0.06). Bleeding in infant cardiac surgery increased following the change in antifibrinolytic therapy from aprotinin to EACA. Given the potential for major harm, especially thrombotic complications, from rFVIIa use, prospective studies examining the safety of postcardiopulmonary bypass rFVIIa administration in infants are necessary before the routine off-label use may be recommended. Copyright © 2014 Elsevier Inc. All rights reserved.

Bar-code medication administration system for anesthetics: effects on documentation and billing.

PubMed

Nolen, Agatha L; Rodes, W Dyer

2008-04-01

The effects of using a new bar-code medication administration (BCMA) system for anesthetics to automate documentation of drug administration by anesthesiologists were studied. From October 1, 2004, to September 15, 2005, all medications administered to patients undergoing cardiac surgery were documented with a BCMA system at a large acute care facility. Drug claims data for 12 targeted anesthetics in diagnosis-related groups (DRGs) 104-111 were analyzed to determine the quantity of drugs charged and the revenue generated. Those data were compared with claims data for a historical case-control group (October 1, 2003, to September 15, 2004, for the same DRGs) for which medication use was documented manually. From October 1, 2005, to October 1, 2006, anesthesiologists for cardiac surgeries either voluntarily used the automated system or completed anesthesia records manually. A total of 870 cardiac surgery cases for which the BCMA system was used were evaluated. There were 961 cardiac surgery cases in the historical control group. The BCMA system increased the quantity of drugs documented per case by 21.7% and drug revenue captured per case by 18.8%. The time needed by operating-room pharmacy staff to process an anesthesia record for billing decreased by eight minutes per case. After two years, anesthesiologists voluntarily used the new technology on 100% of cardiac surgery patients. Implementation of a BCMA system for anesthetic use in cardiac surgery increased the quantity of drugs charged by 21.7% per case and drug revenue per case by 18.8%. Anesthesiologists continued to use the automated system on a voluntary basis after conclusion of the initial study.