Coronary artery bypass graft surgery complications: A review for emergency clinicians

Enhancing mortality prediction after coronary artery bypass graft: a machine learning approach utilizing EuroScore

Aim: We developed a machine learning model using EuroScore assumptions and preoperative and intraoperative risk factors to predict mortality after coronary artery bypass graft (CABG). Materials & methods: We retrospectively examined data from 108 CABG patients at King Abdullah University Hospital, classifying them into risk groups via EuroScore and predicting mortality through random forest classification. Results: High-risk patients displayed longer surgical times and significant factors such as age and surgery choice. The median EuroScore was 0.95 (0.5-6.4). The model yielded high AUC scores (0.98, 0.95) indicating strong predictive accuracy. Conclusion: Our findings showed that the machine learning models combined with the EuroScore significantly improve post-CABG mortality prediction. For further validation, larger datasets are needed.

Investigating the potential of catheter-assisted pulsed focused ultrasound ablation for atherosclerotic plaques

BACKGROUND

Atherosclerosis is a condition in which an adhesive substance called plaque accumulates over time inside the arteries. Plaque buildup results in the constriction of arteries, causing a shortage of blood supply to tissues and organs. Removing atherosclerotic plaques controls the development of acute ischemic stroke and heart diseases. It remains imperative for positive patient outcomes.

PURPOSE

This study sought to develop a minimally invasive technique for removing arterial plaques by applying focused ultrasound (FUS) energy on the metal surface of a nitinol catheter wire to induce inertial cavitation. The induced cavitation can deplete plaque mechanically inside the arteries, leading towards improved recanalization of blood vessels.

METHODS

The enhanced cavitation effect induced by combining FUS with a metal catheter was first verified by exposing agar phantom gels with or without a 0.9-mm diameter nitinol wire to an acoustic field produced by a 0.5-MHz FUS transducer. The phenomenon was further confirmed in pork belly fat samples with or without a 3-mm diameter nitinol catheter wire. Cavitation was monitored by detecting the peaks of emitted ultrasound signals from the samples using a passive cavitation detector (PCD). Cavitation threshold values were determined by observing the jump in the peak amplitude of signals received by the PCD when the applied FUS peak negative pressure (PNP) increased. To simulate arterial plaque removal, FUS with or without a catheter was used to remove tissues from pork belly fat samples and the lipid cores of human atherosclerotic plaque samples using 2500-cycle FUS bursts at 10% duty cycle and a burst repetition rate of 20 Hz. Treatment outcomes were quantified by subtracting the weight of samples before treatment from the weight of samples after treatment. All measurements were repeated 5 times (n = 5) unless otherwise indicated, and paired t-tests were used to compare the means of two groups. A p-value of <0.05 will be considered significant.

RESULTS

Our results showed that with a nitinol wire, the cavitation threshold in agar phantoms was reduced to 2.6 MPa from 4.3 MPa PNP when there was no nitinol wire in the focal region of FUS. For pork belly fat samples, cavitation threshold values were 1.0 and 2.0 MPa PNP, with and without a catheter wire, respectively. Pork belly fat tissues and lipid cores of atherosclerotic plaques were depleted at the interface between a catheter and the samples at 2 and 4 MPa FUS PNP, respectively. The results showed that with a catheter wire in the focal region of a 3-min FUS treatment session, 24.7 and 25.6 mg of lipid tissues were removed from pork belly fat and human atherosclerotic samples, respectively. In contrast, the FUS-only group showed no reduction in sample weight. The differences between FUS-only and FUS-plus-catheter groups were statistically significant (p < 0.001 for the treatment on pork belly samples, and p < 0.01 for the treatment on human atherosclerotic samples).

CONCLUSION

This study demonstrated the feasibility of catheter-assisted FUS therapy for removing atherosclerotic plaques.

Outcomes of coronary artery bypass grafting (CABG) in patients with OSA-COPD overlap syndrome versus COPD alone: an analysis of US Nationwide Inpatient Sample

BACKGROUND

Obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) are associated with unfavorable outcomes following coronary artery bypass grafting (CABG). The purpose of this study was to compare in-hospital outcomes of patients with COPD alone versus OSA-COPD overlap after CABG.

METHODS

Data of adults ≥ 18 years old with COPD who received elective CABG between 2005 and 2018 were extracted from the US Nationwide Inpatient Sample (NIS). Patients were divided into two groups: with OSA-COPD overlap and COPD alone. Propensity score matching (PSM) was employed to balance the between-group characteristics. Logistic and linear regression analyses determined the associations between study variables and inpatient outcomes.

RESULTS

After PSM, data of 2,439 patients with OSA-COPD overlap and 9,756 with COPD alone were analyzed. After adjustment, OSA-COPD overlap was associated with a significantly increased risk of overall postoperative complications (adjusted odd ratio [aOR] = 1.12, 95% confidence interval [CI]: 95% CI: 1.01-1.24), respiratory failure/prolonged mechanical ventilation (aOR = 1.27, 95%CI: 1.14-1.41), and non-routine discharge (aOR = 1.16, 95%CI: 1.03-1.29), and AKI (aOR = 1.14, 95% CI: 1.00-1.29). Patients with OSA-COPD overlap had a lower risk of in-hospital mortality (adjusted odd ratio [aOR] = 0.53, 95% CI: 0.35-0.81) than those with COPD only. Pneumonia or postoperative atrial fibrillation (AF) risks were not significantly different between the 2 groups. Stratified analyses revealed that, compared to COPD alone, OSA-COPD overlap was associated with increased respiratory failure/prolonged mechanical ventilation risks among patients ≥ 60 years, and both obese and non-obese subgroups. In addition, OSA-COPD overlap was associated with increased risk of AKI among the older and obese subgroups.

CONCLUSION

In US adults who undergo CABG, compared to COPD alone, those with OSA-COPD are at higher risks of non-routine discharge, AKI, and respiratory failure/prolonged mechanical ventilation, but a lower in-hospital mortality. No increased risk of AF was noted.

Effect of preoperative vitamin D on postoperative atrial fibrillation incidence after coronary artery bypass grafting

BACKGROUND

Post-operative atrial fibrillation (POAF) is associated with adverse long-term cardiovascular events.

OBJECTIVES

This study investigated the effects of a high-dose vitamin D administered preoperatively on the postoperative atrial fibrillation (POAF) incidence in patients with vitamin D deficiency following coronary artery bypass grafting (CABG) surgery.

METHODS

This randomized controlled clinical trial was conducted on 246 CABG patients with vitamin D deficiency. All patients were randomly divided into intervention and control groups including 123 cases for each group. In the intervention group, from 3 days before surgery, they received a daily dose of 150,000 units of vitamin D orally (50,000 units of Vit D tablet three times a day) and the patients in the control group received placebo tablets before surgery. All patients in the intervention group were assessed continuously for the occurrence of POAF during the recovery period.

RESULTS

In terms of gender, age, and BMI there were no significant differences between intervention and control groups. Our findings showed that the use of vitamin D supplements did not cause a significant change in the duration of intubation and hospitalization. The ratio of POAF following CABG surgery in the control and treatment groups was 26% and 11.4%, respectively (odds ratio = 0.36; 95% CI = 0.18-0.72; P = 0.003).

CONCLUSIONS

Our findings revealed that high-dose vitamin D supplementation before CABG surgery significantly reduced the incidence of POAF. Further multicenter randomized trials with larger sample sizes are certainly warranted to confirm our results.

Clinical efficacy of clopidogrel and ticagrelor in patients undergoing off-pump coronary artery bypass grafting: a retrospective cohort study

BACKGROUND

Ticagrelor is reportedly more effective than clopidogrel in preventing atherothrombotic events in patients with percutaneous coronary intervention. However, the optimal antiplatelet therapy strategy after off-pump coronary artery bypass grafting (OPCABG) is yet to be established.

MATERIALS AND METHODS

This study was performed using the prospectively-maintained database at our institution. Patients who underwent OPCABG were divided into the clopidogrel and the ticagrelor groups. Propensity score matching analysis was performed between the two groups. The clinical outcome was the occurrence of major adverse cardiovascular event (MACE), defined as a composite of vascular death, myocardial infarction, or stroke 1 year after surgery.

RESULTS

In total, 545 patients completed the entire follow-up assessment. After propensity score matching, 232 patients each were included in the clopidogrel and ticagrelor groups. The primary outcome occurred in 7.8% and 4.3% of patients in the clopidogrel and ticagrelor groups, respectively (P=0.113). CYP2C19 variants (*2, *3, and *17) did not impact the clinical outcomes, regardless of the use of clopidogrel or ticagrelor. The rates of MACE were significantly lower in patients carrying the ABCB1 C3435T CT/TT genotypes in the ticagrelor group than in those carrying the ABCB1 C3435T CC genotype in the clopidogrel group (1.4% vs. 9.1%, adjusted P=0.030), as well as those carrying the ABCB1 C3435T CC genotype in the ticagrelor group (1.4% vs. 8.9%, adjusted P=0.036). The ABCB1 C3435T CC genotype was significantly associated with the incidence of 1-year MACE (HR=1.558, 95% CI 1.109-2.188, P=0.011). Patients who experienced severe perioperative bleeding exhibited a significantly higher incidence of MACE than those who did not experience severe perioperative bleeding (14.0% vs. 4.9%, adjusted P=0.007).

CONCLUSION

There was no significant difference in the 1-year MACE between patients receiving clopidogrel and those receiving ticagrelor after OPCABG. Notably, The ABCB1 C3435T CC genotype was related to a higher risk of MACE.

Death Anxiety in Patients with a History of Coronary Artery Bypass Graft Surgery During the COVID-19 Pandemic: The Role of Spiritual Well-Being and Coping Strategies

Patients who have previously undergone coronary artery bypass surgery (CABG) were prone to death anxiety during the COVID-19 pandemic. It appears that spiritual well-being and appropriate coping strategies may mitigate the harmful effects of death anxiety. Therefore, this study aimed to determine the level of death anxiety in patients with CABG during the COVID-19 pandemic and investigate the relationship between spiritual well-being, coping strategies and death anxiety.This cross-sectional study was conducted on 100 patients with CABG history in Tehran from June 2021 to February 2022. The face-to-face questionnaire, containing questions on demographics, Templer's death anxiety scale, the spiritual well-being questionnaire, and the ways of coping questionnaire was administered to collect data. Statistical analysis was performed using descriptive-analytical statistics, correlation tests, and logistic regression models.Participants' mean age was 55.59 ± 12.78 years. The mean death anxiety score was 10.00 ± 2.16, with 87% of participants reporting high levels and 13% reporting low levels of death anxiety. Based on the results, there was a significant negative correlation between death anxiety and coping strategies, as well as subscales of distancing, seeking social support, accepting responsibility, and planful problem-solving. Logistic regression showed that with the increase in the score of spiritual well-being, the odds of having high levels of death anxiety decreased (p < 0.05). Furthermore, increasing the total score of coping strategies, and the score of self-controlling, seeking social support, accepting responsibility, and planful problem-solving, significantly reduced the odds of high levels of death anxiety (p < 0.05).The study showed that patients with a CABG history experienced high death anxiety during the COVID-19 pandemic. According to the findings, spiritual well-being and coping strategies, especially self-controlling, seeking social support, accepting responsibility, and planful problem-solving, may reduce the odds of severe death anxiety. These should be considered as effective targets for psychological intervention in these patients.

How Long After Coronary Artery Bypass Surgery Can Patients Have Elective Safer Non-Cardiac Surgery?

Objective

To evaluate the complications and mortality after noncardiac surgeries in patients who underwent previous coronary artery bypass grafting (CABG).

Methods

We used insurance data and identified patients aged ≥20 years undergoing noncardiac surgeries between 2010 and 2017 in Taiwan. Based on propensity-score matching, we selected an adequate number of patients with a previous history of CABG (within preoperative 24 months) and those who did not have a CABG history, and both groups had balanced baseline characteristics. The association of CABG with the risk of postoperative complications and mortality was estimated (odds ratio [OR] and 95% confidence interval [CI]) using multiple logistic regression analysis.

Results

The matching procedure generated 2327 matched pairs for analyses. CABG significantly increased the risks of 30-day in-hospital mortality (OR 2.28, 95% CI 1.36-3.84), postoperative pneumonia (OR 1.49, 95% CI 1.12-1.98), sepsis (OR 1.49, 95% CI 1.17-1.89), stroke (OR 1.53, 95% CI 1.17-1.99) and admission to the intensive care unit (OR, 1.75, 95% CI 1.50-2.05). The findings were generally consistent across most of the evaluated subgroups. A noncardiac surgery performed within 1 month after CABG was associated with the highest risk for adverse events, which declined over time.

Conclusion

Prior history of CABG was associated with postoperative pneumonia, sepsis, stroke, and mortality in patients undergoing noncardiac surgeries. Although we raised the possibility regarding deferral of non-critical elective noncardiac surgeries among patients had recent CABG when considering the risks, critical or emergency surgeries were not in the consideration of delay surgery, especially cancer surgery.

The role of lung ultrasound for detecting atelectasis, consolidation, and/or pneumonia in the adult cardiac surgery population: A scoping review of the literature

OBJECTIVES

Postoperative pulmonary complications (PPCs) frequently occur after cardiac surgery and may lead to adverse patient outcomes. Traditional diagnostic tools such as auscultation or chest x-ray have inferior diagnostic accuracy compared to the gold standard (chest computed tomography). Lung ultrasound (LUS) is an emerging area of research combating these issues. However, no review has employed a formal search strategy to examine the role of LUS in identifying the specific PPCs of atelectasis, consolidation, and/or pneumonia or investigated the ability of LUS to predict these complications in this cohort. The objective of this study was to collate and present evidence for the use of LUS in the adult cardiac surgery population to specifically identify atelectasis, consolidation, and/or pneumonia.

REVIEW METHOD USED

A scoping review of the literature was completed using predefined search terms across six databases which identified 1432 articles. One additional article was included from reviewing reference lists. Six articles met the inclusion criteria, providing sufficient data for the final analysis.

DATA SOURCES

Six databases were searched: MEDLINE, Embase, CINAHL, Scopus, CENTRAL, and PEDro. This review was not registered.

REVIEW METHODS

The review followed the PRISMA Extension for Scoping Reviews.

RESULTS

Several LUS methodologies were reported across studies. Overall, LUS outperformed all other included bedside diagnostic tools, with superior diagnostic accuracy in identifying atelectasis, consolidation, and/or pneumonia. Incidences of PPCs tended to increase with each subsequent timepoint after surgery and were better identified with LUS than all other assessments. A change in diagnosis occurred at a rate of 67% with the inclusion of LUS and transthoracic echocardiography in one study. Pre-established assessment scores were improved by substituting chest x-rays with LUS scans.

CONCLUSION

The results of this scoping review support the use of LUS as a diagnostic tool after cardiac surgery; however, they also highlighted a lack of consistent methodologies used. Future research is required to determine the optimal methodology for LUS in diagnosing PPCs in this cohort and to determine whether LUS possesses the ability to predict these complications and guide proactive respiratory supports after extubation.

Predictors of Premature Mortality Following Coronary Artery Bypass Grafting: An Iranian Single-Centre Study

Modifiable risk factors play an important role in the premature mortality among patients undergoing coronary artery bypass grafting (CABG). The aim of this study was to examine the factors that influence the early death of patients who had CABG. We conducted a prospective cohort study and followed 2863 patients after their CABG, and collected data on their characteristics and blood tests. We used the Cox proportional hazards regression model in Stata, version 16, to identify the predictors of early mortality. Out of 2863 patients, 162 died during the follow-up period. The survival rate was 99.2% within the first three days after the surgery, 96.2% from the fourth day to the end of the first year, 94.9% at the end of the second year, and 93.6% at the end of the third year. After adjusting for confounding factors, we found that older age (hazard ratio [HR] 1.05, 95% CI 1.02, 1.08 for one year increase in age), obesity (HR 2.16, 95% CI 1.25, 3.72), ejection fraction < 50% (HR 1.61, 95% CI 1.06, 2.44), number of rehospitalizations (HR 2.63, 95% CI 1.35, 5.12 for two or more readmissions), history of stroke (HR 2.91, 95% CI 1.63, 5.21), living in rural areas (HR 1.58, 95% CI 1.06, 2.34), opium use (HR 2.08, 95% CI 1.40, 3.09), and impaired glomerular filtration rate increased the risk of early death after CABG, while taking a beta-blocker (HR 0.59, 95% CI 0.38, 0.91) reduced the risk. We conclude that modifiable risk factors such as excess body mass, high blood glucose, opium use, and kidney dysfunction should be monitored and managed in patients who had CABG to improve their survival outcomes.

The effect of cardiac rehabilitation on cardiopulmonary function after coronary artery bypass grafting: A systematic review and meta-analysis

We carried out a meta-analysis on the effect of cardiac rehabilitation (CR) on cardiopulmonary function after coronary artery bypass grafting (CABG). Four databases were searched for studies comparing CR with control. A random-effects model was used to pool mean difference (MD). The meta-analysis showed an increase in peak oxygen consumption (peak VO2) (MD = 1.93 mL/kg/min, p = 0.0006), and 6-min walk distance (6MWD) (MD = 59.21 m, p < 0.00001), and a decrease in resting heart rate (resting HR) (MD = 5.68 bpm, p < 0.0001) in the CR group. The subgroup analysis revealed aerobic exercise could further improve resting HR and peak HR, and physical/combination with aerobic exercise could further increase 6MWD. The improvement of peak VO2, workload, resting HR, peak HR, and 6MWD regarding CR performed within one week after CABG is greater than that one week after CABG. CR after CABG can improve the cardiopulmonary function, which is reflected by the improvement of peak VO2, 6MWD, and resting HR.

TIMP-1 in the prognosis of patients who underwent coronary artery bypass surgery: a 12-year follow-up study

Introduction

Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) have been linked to clinical outcomes in patients with coronary artery disease (CAD). However, the prognostic value of TIMP-1 in patients with CAD who underwent coronary artery bypass grafting (CABG) has not been elucidated. We aimed to investigate the correlations of TIMP-1 with high-sensitivity C-reactive protein (hs-CRP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in the long-term prognosis of consecutive patients who underwent CABG.

Methods

A total of 234 patients (age: 70.4 ± 10.5 years, 84.6% men) with CAD who underwent CABG were prospectively enrolled. Preoperative levels of MMPs, TIMP-1, hs-CRP, and NT-proBNP were recorded. Major adverse cardiovascular events (MACE) were defined as non-fatal myocardial infarction, non-fatal stroke, and cardiovascular death.

Results

During a median follow-up of 12.1 years, 120 deaths were recorded. The deceased were older, had more manifest acute coronary syndrome (ACS), a lower left ventricular ejection fraction (LVEF), and an estimated glomerular filtration rate (eGFR), but significantly higher MMP13, TIMP-1, hs-CRP, and NT-proBNP compared with the survivors. After adjusting for age, sex, manifest ACS, eGFR, LVEF, total cholesterol, and triglycerides, TIMP-1 (hazard ratio and 95% confidence intervals per SD: 1.506, 1.183-1.917), hs-CRP (1.349, 1.183-1.561), and NT-ProBNP (1.707, 1.326-2.199) were all independently associated with all-cause mortality. The mediation analysis revealed that the mortality risks of TIMP-1 were partially mediated by NT-proBNP (62.2%) and hs-CRP (25.3%). The associations of TIMP-1 with MACE were partially mediated by NT-proBNP (54.4%) but not hs-CRP.

Conclusions

TIMP-1 was an independent predictor of long-term outcomes after CABG, with possible roles in subclinical inflammation and postoperative cardiac remodeling.

Risk factors of in-hospital mortality for isolated on-pump coronary artery bypass graft surgery in the northeast of Iran from 2007 to 2016

BACKGROUND AND OBJECTIVE

Coronary artery bypass graft (CABG) surgery is the most common cardiac surgery worldwide. The reported mortality rates for this operation vary greatly. We aimed to determine the risk factors of in-hospital mortality for isolated on-pump CABG surgery.

METHODS

This was a large-scale retrospective cohort study of two heart centers in Golestan province. Patients over the age of 18 from both genders who underwent isolated on-pump CABG procedures from 2007 to 2016 were included. The study outcome was in-hospital mortality, which was determined according to the clinical records of study patients.

RESULTS

A total of 3704 patients were included in the study, and 63% were men. In-hospital mortality occurred in 2.8% (n=103) of the patients. The median (IQR) age of survived and not-survived patients were 59 (53-65) and 62 (55-75) years, respectively. 44% of the mortalities occurred in patients older than 65, while 28% of the survivors were older than 65. Multivariable logistic regression indicated that emergency CABG (OR 4.52, 95% CI, 1.45, 14.02; P = 0.009) and cardiopulmonary bypass time (CPB) (OR 1.004, 95% CI 1.001, 1.008; P = 0.034) were the risk factors of in-hospital mortality. The area under the receiver operating characteristic (ROC) curve (AUC) of the model consisting of operative and preoperative variables was 0.70 (acceptable performance).

CONCLUSION

Our study revealed an acceptable mortality proportion for CABG surgeries conducted in the region. Emergency CABG and CPB time were the main risk factors for in-hospital mortality after CABG.

The Effect of Listening to Holy Quran Recital on Pain and Length of Stay Post-CABG: A Randomized Control Trial

Background

Nearly, 75% of patients post-CABG complain of moderate to severe pain during their hospital stay. Nonpharmacological interventions have been investigated; however, the effect of Holy Quran recital post-CABG is still not well studied, especially in developing Islamic countries.

Objective

To investigate the effect of listening to the Holy Quran recital on pain and length of stay post-CABG.

Methods

This was a randomized control trial on 132 patients recruited from four hospitals in Amman, Jordan. The intervention group listened to the Holy Quran recited for 10 minutes twice daily while the control group received the usual care. Data were analyzed using paired and independent samples t-tests.

Results

Paired t-test testing showed that there was a significant reduction in the pain level, (M [SD], 6.82 [2.27] vs. 4.65 [2.18], t = 23.65, p < 0.001) for the intervention group. In addition, the intervention group had shorter LoS in the ICU and in the hospital compared to the control group, (M [SD], 5.0 [4.02] vs. 6.58 [4.18], t = -2.1, p < 0.05), (M [SD], 10.15 [9.21] vs. 15.01 [13.14], t = -2.6, p < 0.05), respectively.

Conclusions

Listening to the Quran was significantly effective in improving pain intensity among post-CABG patients and shortening their hospital/ICU stay. This trial is registered with NCT05419554.

A Comparison Between Cardiac Telerehabilitation Program and Outpatient Hospital-Based Cardiac Rehabilitation Program for Patients Undergoing Coronary Artery Bypass Graft (CABG) Surgery: A Review

Coronary artery disease (CAD) is a prevalent and possibly fatal cardiovascular ailment, and it is treated surgically by coronary artery bypass grafting (CABG). The coronary arteries, which supply the heart with oxygen and nutrients, are the most commonly affected. Even though CABG is a frequently employed procedure to restore cardiac blood flow, prolonged rehabilitation is necessary for long-term success. For patients with heart disease, cardiac rehabilitation (CR) involves a comprehensive therapeutic approach. It consists of risk mitigation, regular exercise, health education, and efficient stress management. Information and communication technology is used in telerehabilitation (TR), a rehabilitation service that offers a flexible choice that improves self-management. This study examined novel approaches and effective intervention elements while comparing cardiac TR with center-based programs in terms of risk factor management, patient commitment, and satisfaction.

A Case of Saphenous Vein Graft Aneurysm Treated With Percutaneous Coiling

In adults, coronary artery bypass grafting (CABG) is a commonly performed surgery. Oftentimes, saphenous veins from the lower extremity are used as the graft vessels. A rare complication of this procedure is the formation of saphenous vein graft (SVG) aneurysms. We present the case of a 63-year-old male who presented to a referring emergency department with left-sided chest pain after falling off a ladder. The patient's initial chest X-ray revealed a suprahilar mass that was suspicious for being an aneurysm. A computerized tomography coronary angiogram indicated a large aneurysm. The patient was transferred to our facility for specialist evaluation. The patient's history was positive for two CABG procedures and a sternal wound infection, so a repeat sternotomy was not advisable. The SVG aneurysm was treated with percutaneous coiling. The patient tolerated the procedure well and was discharged home the next day.

Advances in drug delivery to atherosclerosis: Investigating the efficiency of different nanomaterials employed for different type of drugs

Atherosclerosis is the build-up of fatty deposits in the arteries, which is the main underlying cause of cardiovascular diseases and the leading cause of global morbidity and mortality. Current pharmaceutical treatment options are unable to effectively treat the plaque in the later stages of the disease. Instead, they are aimed at resolving the risk factors. Nanomaterials and nanoparticle-mediated therapies have become increasingly popular for the treatment of atherosclerosis due to their targeted and controlled release of therapeutics. In this review, we discuss different types of therapeutics used to treat this disease and focus on the different nanomaterial strategies employed for the delivery of these drugs, enabling the effective and efficient resolution of the atherosclerotic plaque. The ideal nanomaterial strategy for each drug type (e.g. statins, nucleic acids, small molecule drugs, peptides) will be comprehensively discussed.

Inflammatory Biomarkers and Blood Physical Property Transformations Following On-Pump Coronary Artery Bypass Graft Surgery

OBJECTIVE

This study aimed to compare the hemorheological and inflammatory changes before and after coronary artery bypass graft (CABG) surgery, as factors such as hypothermia, hemodilution, transfusion, and other variables affect blood viscosity and inflammation during the procedure.

METHODS

A total of 25 patients who underwent CABG surgery were enrolled in this study. Whole blood was collected just before the CABG (D0), 2 days after surgery (D2), and 5 days after surgery (D5). The plasma viscosity (PV) and whole blood viscosity (WBV) were measured at shear rates ranging from 0.1 to 1000 s-1 using a rheometer, and the mean values were compared. Inflammatory markers were also assessed and analyzed in relation to the hemorheological changes.

RESULTS

Compared with the baseline values, the PV significantly increased after 5 days. WBV showed a significant increase on day 2 and after 5 days. The WBV and fibrinogen were significantly correlated on day 2 and day 5 but not before surgery. Inflammatory markers such as CRP, WBC, platelets, and fibrinogen also demonstrated notable changes in relation to the hemorheological alterations.

CONCLUSIONS

This study highlights the crucial finding that hyperviscosity, characterized by elevated PV and WBV, persists for almost one week after on-pump CABG surgery. Understanding the interplay between inflammation and hemorheological properties during the postoperative period is crucial for optimizing patient care. Future research should focus on exploring the underlying mechanisms and potential therapeutic interventions to mitigate the impact of inflammation on blood viscosity and improve patient outcomes following CABG surgery.

New strategy of using double-network hydrogel extravascular stent for preventing venous graft restenosis after coronary artery bypass grafting

OBJECTIVE

Effective therapies for the prevention of vein graft failure, which frequently occurs in coronary artery bypass grafting (CABG) due to intimal hyperplasia (IH), are still lacking. Here, we investigated the effects of the perivenous application of double-network hydrogel on vein grafts in carotid artery bypass grafting in a rabbit model.

METHODS

Healthy New Zealand white rabbits were randomized into the following groups: no graft, graft, or graft + Double-network hydrogel external stent (DNHES). The rabbits' carotid artery was bypassed via the jugular vein. Double-network hydrogel external stent was wrapped around the jugular graft after the anastomoses were completed. Blood flow parameters and tissue histology of the vein grafts were evaluated.

RESULTS

Compared with the untreated vein grafts at 12 weeks after the surgery, the DNHES significantly improved graft flow, attenuated intimal and medial thickening, reduced the anti-proliferating cell nuclear antigen proliferation index of the vein grafts, decreased the mRNA and protein expression of Mitogen-Activated Protein Kinase (MAPK) and Transforming Growth Factor-β (TGF-β), and increased the mRNA and protein expression of endothelial Nitric Oxide Synthase (eNOS).

CONCLUSION

The perivenous application of DNHES exerts beneficial effects on vein grafts, reduces the inflammatory response in carotid artery bypass grafting in a rabbit model, and appears to be a safe and promising strategy to prevent vein graft failure.

Obstruction of the Inferior Vena Cava Following Coronary Artery Bypass Grafting

Obstruction of the inferior vena cava (IVC) following coronary artery bypass grafting (CABG) is a rare complication. We describe a case of IVC outflow obstruction secondary to inferior cavoatrial junction injury during CABG. The diagnostic and management approaches used to care for this patient are discussed. (Level of Difficulty: Intermediate.).

The Role of Vitamin D Supplementation Before Coronary Artery Bypass Grafting in Preventing Postoperative Atrial Fibrillation in Patients With Vitamin D Deficiency or Insufficiency: A Systematic Review and Meta-Analysis

This study aims to evaluate the role of preoperative vitamin D supplementation before coronary artery bypass grafting (CABG) surgery in preventing postoperative atrial fibrillation (POAF) in vitamin D deficient or insufficient patients. Three randomized controlled trials (RCTs) comprising 448 subjects were selected after a detailed search was conducted on PubMed, Cochrane CENTRAL, Scopus, and Embase in December 2022. Analysis was run using RevMan (version 5.4.1; Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). The analysis collected risk ratio (RR) and 95% confidence interval (CI) data from the relevant studies, which were then pooled using a random effects model. A significance level of less than 0.05 (p<0.05) was considered significant. Our analysis showed that compared with the standard of care, preoperative vitamin D supplementation in vitamin D deficient and insufficient patients effectively reduced POAF after CABG surgery (RR=0.6, 95% CI=0.4-0.9, P=0.01). There was no significant difference in the duration of hospitalization between the vitamin D supplementation group compared with the control following CABG (mean difference -0.85, 95% CI -2.13 to 0.43, P = 0.19). This meta-analysis shows that preoperative vitamin D supplementation in vitamin D deficient and insufficient patients undergoing CABG can reduce the rate of POAF. As POAF is associated with many complications, providing vitamin D supplementation to individuals with a vitamin D deficiency undergoing CABG can improve long-term cardiovascular outcomes following surgery.

Cardiac troponin release following coronary artery bypass grafting: mechanisms and clinical implications

The use of biomarkers is undisputed in the diagnosis of primary myocardial infarction (MI), but their value for identifying MI is less well studied in the postoperative phase following coronary artery bypass grafting (CABG). To identify patients with periprocedural MI (PMI), several conflicting definitions of PMI have been proposed, relying either on cardiac troponin (cTn) or the MB isoenzyme of creatine kinase, with or without supporting evidence of ischaemia. However, CABG inherently induces the release of cardiac biomarkers, as reflected by significant cTn concentrations in patients with uncomplicated postoperative courses. Still, the underlying (patho)physiological release mechanisms of cTn are incompletely understood, complicating adequate interpretation of postoperative increases in cTn concentrations. Therefore, the aim of the current review is to present these potential underlying mechanisms of cTn release in general, and following CABG in particular (Graphical Abstract). Based on these mechanisms, dissimilarities in the release of cTnI and cTnT are discussed, with potentially important implications for clinical practice. Consequently, currently proposed cTn biomarker cut-offs by the prevailing definitions of PMI might warrant re-assessment, with differentiation in cut-offs for the separate available assays and surgical strategies. To resolve these issues, future prospective studies are warranted to determine the prognostic influence of biomarker release in general and PMI in particular.

Prognostic significance of neutrophil count on in-hospital mortality in patients with acute type A aortic dissection

Backgrounds

The goal of this study was to assess the impact of neutrophil count, in patients with acute type A aortic dissection (ATAAD).

Methods

This study retrospectively collected data from patients between September 2017 and June 2021. Youden's index was used to determine the optimal cut-off value for the neutrophil count and patients were divided into two subgroups. A restricted cubic spline (RCS) was used to model the relationship between variables and in-hospital mortality. The least absolute shrinkage and selection operator (LASSO) method and multivariate logistic regression analyses were used to investigate the independent prognostic factors for in-hospital mortality in patients with ATAAD.

Results

A total of 467 patients were enrolled in this study. In-hospital mortality was 7.28%. The group with elevated neutrophil counts had significantly higher mortality than the group with decreased neutrophil counts (10.8% vs. 3.2%, P = 0.02). This data shows that elevated neutrophil count was significantly associated with in-hospital mortality (OR 3.07, 95% CI 1.22-7.62, P = 0.02).

Conclusions

Neutrophil count is an independent risk factor for in-hospital mortality in patients with ATAAD. It is an effective inflammatory index, which can be individualized for patients.

Smart Drain for Post-Cardiac Surgery Left Ventricular Volumes Evaluated in Large Animal Models

BACKGROUND

Open heart surgeries for coronary arterial bypass graft and valve replacements are performed on 400,000 Americans each year. Unexplained hypotension during recovery causes morbidity and mortality through cerebral, kidney, and coronary hypoperfusion. An early detection method that distinguishes between hypovolemia and decreased myocardial function before onset of hypotension is desirable. We hypothesized that admittance measured from a modified pericardial drain can detect changes in left ventricular end-systolic, end-diastolic, and stroke volumes.

METHODS

Admittance was measured from 2 modified pericardial drains placed in 7 adult female dogs using an open chest preparation, each with 8 electrodes. The resistive and capacitive components of the measured admittance signal were used to distinguish blood and muscle components. Admittance measurements were taken from 12 electrode configurations in each experiment. Left ventricular preload was reduced by inferior vena cava occlusion. Physiologic response to vena cava occlusion was measured by aortic pressure, aortic flow, left ventricle diameter, left ventricular wall thickness, and electrocardiogram.

RESULTS

Admittance successfully detected a drop in left ventricular end-diastolic volume (P < .001), end-systolic volume (P < .001), and stroke volume (P < .001). Measured left ventricular muscle resistance correlated with crystal-derived left ventricular wall thickness (R2 = 0.96), validating the method's ability to distinguish blood from muscle components.

CONCLUSIONS

Admittance measured from chest tubes can detect changes in left ventricular end-systolic, end-diastolic, and stroke volumes and may therefore have diagnostic value for unexplained hypotension.

Hybrid coronary revascularization (HCR) versus coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD): A meta-analysis of 14 studies comprising 4226 patients

OBJECTIVES

To compare the outcomes of hybrid coronary revascularization (HCR) with traditional coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD).

BACKGROUND

HCR has emerged as an alternative to CABG in patients with MVCAD. Through minimally invasive surgical techniques, HCR carries the potential for faster recovery postoperatively, fewer complications, and lower utilization of resources.

METHODS

Systematic search of electronic databases was conducted up to December 2021 and studies comparing HCR with CABG in the treatment of MVCAD were included in this meta-analysis. Primary outcomes of interest were incidence of 5-year mortality and major adverse cardiac and cerebral event (MACCE).

RESULTS

Fourteen studies (12 observational studies and 2 randomized controlled trials) comprising 4226 patients were included. The rates of 5-year mortality (odds ratios [OR]: 1.55; 95% confidence interval [CI]: 0.92-2.62; I²  = 83.0%) and long-term MACCE (OR: 0.97; 95% CI: 0.47-2.01; I²  = 74.7%) were comparable between HCR and CABG groups. HCR was associated with a significantly lower likelihood of perioperative blood transfusion (OR: 0.36; 95% CI: 0.25-0.51; I²  = 55.9%), shorter mean hospital stay (weighted mean difference: -2.04; 95% CI: -2.60 to -1.47; I²  = 54%), and risk of postoperative acute kidney injury (OR: 0.45; 95% CI: 0.23-0.88; p = 0.02). CABG demonstrated a lower likelihood of requiring long-term repeat revascularization (OR: 1.51; 95% CI: 1.03-2.20; I²  = 18%) over a follow-up duration of 29.14 ± 21.75 months.

CONCLUSION

This meta-analysis suggests that HCR is feasible and safe for the treatment of MVCAD. However, benefits of HCR should be carefully weighed against the increased long-term risk of repeat-revascularization when selecting patients, and further studies evaluating differences in long-term mortality between HCR and CABG are required.

The role of optimism in manifesting recovery outcomes after coronary artery bypass graft surgery: A systematic review

OBJECTIVE

Coronary artery bypass graft (CABG) is a major surgery conducted in coronary heart disease management. Postoperative recovery is a crucial process for patients undergoing CABG. This systematic review evaluates current evidence regarding the association between trait optimism and recovery outcomes in patients following coronary artery bypass graft surgery.

METHODS

This review followed the Preferred Reporting Items of Systematic Review and Meta-Analysis (PRISMA) 2020 Guideline. The inclusion criteria focused on observational study that examined study participants aged ≥18 years old undergoing elective CABG and measurement of trait optimism with validated methods (i.e. LOT, LOT-R) and at least one recovery outcome. Studies in non-English languages and duplicates were excluded. A systematic literature search was carried out on PubMed, Scopus, and Web of Science electronic databases. Search results were screened based on the eligibility criteria. The Newcastle-Ottawa Scale was used to assess the quality of each included study.

RESULTS

The search yielded a total of 1853 articles, in which 7 articles fulfilled the eligibility criteria and were subsequently included in the analysis. Measurement of trait optimism was conducted on 1276 patients who underwent a non-emergency/elective CABG. Optimism was significantly associated with several categories of recovery, including reduced rehospitalization rate, complications, pain, and physical symptoms along with improved quality of life, rate of return to normal life, and psychological status.

CONCLUSION

Our review showed that trait optimism was associated with recovery outcomes following CABG surgery. However, the heterogeneity of recovery outcomes may hamper the clinical benefit of trait optimism in CABG. (PROSPERO CRD42022301882).

Assessment of the Anti-Thrombogenic Activity of Polyurethane Starch Composites

The increasing morbidity and mortality of patients due to post-surgery complications of coronary artery bypass grafts (CABPG) are related to blood–material interactions. Thus, the characterization of the thrombogenicity of the biomaterial for cardiovascular devices is of particular interest. This research evaluated the anti-thrombogenic activity of polyurethanes–starch composites. We previously synthesized polyurethane matrices that were obtained from polycaprolactone diol (PCL), polyethylene glycol (PEG), pentaerythritol (PE), and isophorone diisocyanate (IPDI). In addition, potato starch (AL-N) and zwitterionic starch (AL-Z) were added as fillers. The anti-thrombogenic property was characterized by the clot formation time, platelet adhesion, protein absorption, TAT complex levels, and hemolysis. Additionally, we evaluated the cell viability of the endothelial and smooth muscle cells. Statically significant differences among the polyurethane matrices (P1, P2, and P3) were found for protein absorption and the blood clotting time without fillers. The polyurethanes composites with AL-Z presented an improvement in the anti-thrombogenic property. On the other hand, the composites with AL-Z reduced the viability of the endothelial cells and did not significantly affect the AoSCM (except for P1, which increased). These results classify these biomaterials as inert; therefore, they can be used for cardiovascular applications.

Risk factors for post sternotomy wound complications across the patient journey: A systematised review of the literature

BACKGROUND

Around 36,000 cardiac operations are undertaken in the United Kingdom annually, with most procedures undertaken via median sternotomy. Wound complications occur in up to 8% of operations, with an associated mortality rate of around 47% in late or undetected cases.

OBJECTIVE

To undertake a systematised literature review to identify pre-operative, peri-operative and post-operative risk factors associated with sternal wound complications.

METHODS

Healthcare databases were searched for articles written in the English language and published between 2013 and 2021. Inclusion criteria were quantitative studies involving patients undergoing median sternotomy for cardiac surgery; sternal complications and risk factors.

RESULTS

1360 papers were identified, with 25 included in this review. Patient-related factors included: high BMI; diabetes; comorbidities; gender; age; presenting for surgery in a critical state; predictive risk scores; vascular disease; severe anaemia; medication such as steroids or α-blockers; and previous sternotomy. Peri-operative risk increased with specific types and combinations of surgical procedures. Sternal reopening was also associated with increased risk of sternal wound infection. Post-operative risk factors included a complicated recovery; the need for blood transfusions; respiratory complications; renal failure; non-diabetic hyperglycaemia; sternal asymmetry and sepsis.

CONCLUSION

Pre, peri and post-operative risk factors increase the risk of sternal wound complications in cardiac surgery. Generic risk assessment tools are primarily designed to provide mortality risk scores, with their ability to predict risk of wound infection questionable. Tools that incorporate factors throughout the operative journey are required to identify patients at risk of surgical wound infection.

Implants with Sensing Capabilities

Because of the aging human population and increased numbers of surgical procedures being performed, there is a growing number of biomedical devices being implanted each year. Although the benefits of implants are significant, there are risks to having foreign materials in the body that may lead to complications that may remain undetectable until a time at which the damage done becomes irreversible. To address this challenge, advances in implantable sensors may enable early detection of even minor changes in the implants or the surrounding tissues and provide early cues for intervention. Therefore, integrating sensors with implants will enable real-time monitoring and lead to improvements in implant function. Sensor integration has been mostly applied to cardiovascular, neural, and orthopedic implants, and advances in combined implant-sensor devices have been significant, yet there are needs still to be addressed. Sensor-integrating implants are still in their infancy; however, some have already made it to the clinic. With an interdisciplinary approach, these sensor-integrating devices will become more efficient, providing clear paths to clinical translation in the future.

A Novel Polysaccharide From Chuanminshen violaceum and Its Protective Effect Against Myocardial Injury

We isolated and purified a novel polysaccharide from the root of Chuanminshen violaceum, namely, Chuanminshen violaceumis polysaccharide (CVP) and confirmed its structure and molecular weight. Furthermore, in vivo experiment, CVP’s protective effect against myocardial ischemia-reperfusion (I/R) injury in mice was evidenced by significantly reducing I/R-induced myocardial infarction (MI) size, decreasing the secretion of heart damage biomarkers, and improving cardiac function. Then, the myocardial anoxia/reoxygenation (A/R) injury model was established to mimic reperfusion injury. Noticeably, ferroptosis was the major death manner for A/R-damaged H9c2 cells. Meanwhile, CVP significantly inhibited ferroptosis by decreasing intracellular Fe²⁺ level, enhancing GPX4 expression, and suppressing lipid peroxidation to confront A/R injury. In conclusion, CVP, with a clear structure, ameliorated I/R injury by inhibiting ferroptosis.

Abandon Informed Consent in Favor of Probability-Based, Shared Decision-Making Following the Wishes of a Reasonable Person

Legally and ethically physicians must provide information to patients so they may make an informed decision about invasive procedures. The problem is who decides what information to provide. Is it the reasonable patient or the reasonable physician? Individual patients and individual physicians may differ from the norm on what is reasonable. This problem may be solved by shared decision-making in which the preferences of the patient and the probability-based knowledge of the physician are used to co-produce an optimal choice. Currently, patients are seldom prepared to engage in shared decision-making, and vestiges of meaningless “informed consent” are common. The present case study illustrates how “reasonable person” survey data may be used by a patient to engage in probability-based, shared decision-making with a surgeon planning to perform a laminectomy. Recommendations include probability-based, shared decision-making training for patients and physicians and improved documentation to facilitate learning.

Polygenic Risk Scores for Predicting Adverse Outcomes After Coronary Revascularization

Coronary procedures predispose patients to adverse events. To improve our understanding of the genetic factors underlying postoperative prognosis, we studied the association of polygenic risk scores (PRSs) with postprocedural complications in coronary patients who underwent revascularization. The study sample comprised 8,296, 6,132, and 13,082 patients who underwent percutaneous coronary intervention, coronary artery bypass grafting, or any revascularization, respectively. We genotyped all subjects and identified adverse events during follow-up of up to 30 years by record linkage with nationwide healthcare registers. We computed PRSs for each postoperative adverse outcome (atrial fibrillation [AF], myocardial infarction, stroke, and bleeding complications) for all participants. Cox proportional hazards models were used to examine the association between PRSs and outcomes. A 1-SD increase in AF-PRS was associated with greater risk of postoperative AF with hazard ratios of 1.22 (95% confidence interval [CI] 1.16 to 1.28), 1.15 (95% CI 1.10 to 1.20) and 1.18 (95% CI 1.14 to 1.22) after percutaneous coronary intervention, coronary artery bypass grafting, and any revascularization, respectively. In contrast, the association of each PRSs with other postoperative complications was nonexistent to marginal. Inclusion of the AF-PRS in a model with a clinical risk score resulted in significant model improvement (increase in model c-statistic 0.0059 to 0.0098 depending on procedure; p <0.0002 for all). In conclusion, our results demonstrate that PRS can be used for AF risk-prediction in patients who underwent revascularization. The AF-PRS could potentially be used to improve AF prevention and outcomes in patients who underwent revascularization.

Platelet-Leucocyte Aggregates as Novel Biomarkers in Cardiovascular Diseases

Simple Summary

Cardiovascular diseases are the most common cause of death worldwide. Hence, novel biomarkers are urgently needed to improve diagnosis and treatment. Platelet–leucocyte aggregates are conglomerates of platelets and leucocytes and are widely investigated as biomarkers in cardiovascular diseases. Platelet–leucocytes aggregates are present in health, but increase in patients with cardiovascular risk factors and acute or stable coronary syndromes, making them a potential diagnostic marker. Moreover, platelet–leucocyte aggregates predict outcomes after surgery or percutaneous treatment and could be used to monitor antiplatelet therapy. Emerging data about the participation of platelet–leucocyte aggregates in cardiovascular diseases pathogenesis make them an attractive target for novel therapies. Furthermore, simple detection with conventional flow cytometry provides accurate and reproducible results, although requires specific sample handling. The main task for the future is to determine the standardized protocol to measure blood concentrations of platelet–leucocyte aggregates and subsequently establish their normal range in health and disease.

Abstract

Platelet–leucocyte aggregates (PLA) are a formation of leucocytes and platelets bound by specific receptors. They arise in the condition of sheer stress, thrombosis, immune reaction, vessel injury, and the activation of leukocytes or platelets. PLA participate in cardiovascular diseases (CVD). Increased levels of PLA were revealed in acute and chronic coronary syndromes, carotid stenosis cardiovascular risk factors. Due to accessible, available, replicable, quick, and low-cost quantifying using flow cytometry, PLA constitute an ideal biomarker for clinical practice. PLA are promising in early diagnosing and estimating prognosis in patients with acute or chronic coronary syndromes treated by percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). PLA were also a reliable marker of platelet activity for monitoring antiplatelet therapy. PLA consist also targets potential therapies in CVD. All of the above potential clinical applications require further studies to validate methods of assay and proof clinical benefits.

The effect of preoperative chest physiotherapy on oxygenation and lung function in cardiac surgery patients: a randomized controlled study

BACKGROUND

Postoperative pulmonary complications in patients who undergo open heart surgery are serious life-threatening conditions. Few studies have investigated the potentially beneficial effects of preoperative physiotherapy in patients undergoing cardiac surgery.

OBJECTIVES

Assess the effects of preoperative chest physiotherapy on oxygenation and lung function in patients undergoing open heart surgery.

DESIGN

Randomized, controlled.

SETTING

University hospital.

PATIENTS AND METHODS

Patients with planned open heart surgery were randomly allocated into an intervention group of patients who underwent a preoperative home chest physiotherapy program for one week in addition to the traditional postoperative program and a control group who underwent only the traditional postoperative program. Lung function was assessed daily from the day before surgery until the seventh postoperative day.

MAIN OUTCOME MEASURES

Differences in measures of respiratory function and oxygen saturation. Length of postoperative hospital stay was a secondary outcome.

SAMPLE SIZE

100 patients (46 in intervention group, 54 in control group).

RESULTS

Postoperative improvements in lung function and oxygen saturation in the intervention group were statistically significant compared with the control group. The intervention group also had a statistically significant shorter hospital stay (P<.01).

CONCLUSION

Preoperative chest physiotherapy is effective in improving respiratory function following open heart surgery.

LIMITATIONS

Relatively small number of patients.

CONFLICT OF INTEREST

None.

REGISTRATION

ClinicalTrials.gov (NCT04665024).

Acute respiratory distress syndrome following coronary artery bypass grafting successfully treated with venovenous extracorporeal membrane oxygenation

Introduction. Acute respiratory distress syndrome (ARDS) is one of the most serious complications during the postoperative period in cardiac surgery. Venovenous extracorporeal membrane oxygenation (VV-ECMO) has proven to be a valuable therapy in ARDS when standard therapy is insufficient. Our aim is to present a case of severe ARDS which was succesfully treated by VV-ECMO. Case outline. A 54-year-old male patient was urgently admitted to our hospital due to anterior wall myocardal infarction. Urgent coronarography was performed, which found severe three-vessel coronary disease. Triple coronary artery bypass grafting (CABG) was performed. After surgery, due to prolonged respiratory insufficiency, the patient was diagnosed with ARDS and VV-ECMO was placed. Nine days later, normal values of gase exchange were achieved and the patient was succesfully weaned from VV-ECMO. Conclusion. We showed that when conventional therapy for ARDS is not effective, use of ECMO should be considered.

Frailty as a Predictor of Postoperative Outcomes in Invasive Cardiac Surgery: A Systematic Review of Literature

OBJECTIVES

Frailty is a syndrome characterized by increased vulnerability and reduced ability to maintain homeostasis after stressful events that results in an increased risk for poor outcomes. Frailty screening could potentially be valuable in cardiac surgery risk assessment. The purpose of this review is to evaluate the current literature linking multicomponent frailty assessment and invasive cardiac surgery outcomes.

METHODS

We searched PubMed, EMBASE, and CINAHL; 1887 articles met the search criteria, and each was independently reviewed by 2 reviewers.

RESULTS

The 19 eligible studies assessed 52 291 subjects using 17 different frailty measurements. The most commonly used instruments were the Fried Frailty Phenotype and the Clinical Frailty Scale. Between 9% and 61% of participants were found to be frail in each study. All 19 studies included mortality as an outcome, 12 included surgical complications, 12 included hospital length of stay, 3 included quality of life, and 2 included functional status. Nine found statistically significant differences in survival between frail and nonfrail patients, 6 of 12 found that frail patients had a longer length of stay, 4 of 12 found that frail patients were more likely to experience major complications, and 2 of 2 found that frail patients were more likely to have a decrease in functional status.

CONCLUSION

Although some studies lacked power, the majority confirmed that frail patients are more likely to experience poor outcomes. Further research is needed to determine which frailty measure provides the best predictive validity and to identify interventions to mitigate the risks that major cardiac surgery poses to frail patients.

Targeting angiogenesis in myocardial infarction: Novel therapeutics (Review)

Acute myocardial infarction (AMI) remains the main cause of mortality worldwide. Despite surgery and medical treatment, the non-regeneration of dead cardiomyocytes and the limited contractile ability of scar tissue can lead to heart failure. Therefore, restoring blood flow in the infarcted area is important for the repair of myocardial injury. The objective of the present review was to summarize the factors influencing angiogenesis after AMI, and to describe the application of angiogenesis for cardiac repair. Collectively, this review may be helpful for relevant studies and to provide insight into future therapeutic applications in clinical practice.

Diagnostic and Prognostic Value of miRNAs after Coronary Artery Bypass Grafting: A Review

MiRNAs are noncoding, 21-24 nucleotide-long RNA particles that control over 60% of genes. MiRNAs affect gene expression through binding to the 3'-untranslated region of messenger RNA (mRNA), thus inhibiting mRNA translation or inducing mRNA degradation. MiRNAs have been associated with various cardiovascular diseases, including heart failure, hypertension, left ventricular hypertrophy, or ischemic heart disease. In addition, miRNA expression alters during coronary artery bypass grafting (CABG) surgery, which could be used to predict perioperative outcomes. CABG is an operation in which complex coronary arteries stenosis is treated by bypassing atherosclerotic lesions with venous or arterial grafts. Despite a very low perioperative mortality rate and excellent long-term survival, CABG is associated with postoperative complications, including reperfusion injury, graft failure, atrial fibrillation and perioperative myocardial infarction. So far, no reliable diagnostic and prognostic tools to predict prognosis after CABG have been developed. Changes in the perioperative miRNA expression levels could improve the diagnosis of post-CABG myocardial infarction and atrial fibrillation and could be used to stratify risk after CABG. Herein, we describe the expression changes of different subtypes of miRNAs during CABG and review the diagnostic and prognostic utility of miRNAs in patients undergoing CABG.

Hemodynamics Challenges for the Navigation of Medical Microbots for the Treatment of CVDs

Microbots have been considered powerful tools in minimally invasive medicine. In the last few years, the topic has been highly studied by researchers across the globe to further develop the capabilities of microbots in medicine. One of many applications of these devices is performing surgical procedures inside the human circulatory system. It is expected that these microdevices traveling along the microvascular system can remove clots, deliver drugs, or even look for specific cells or regions to diagnose and treat. Although many studies have been published about this subject, the experimental influence of microbot morphology in hemodynamics of specific sites of the human circulatory system is yet to be explored. There are numerical studies already considering some of human physiological conditions, however, experimental validation is vital and demands further investigations. The roles of specific hemodynamic variables, the non-Newtonian behavior of blood and its particulate nature at small scales, the flow disturbances caused by the heart cycle, and the anatomy of certain arteries (i.e., bifurcations and tortuosity of vessels of some regions) in the determination of the dynamic performance of microbots are of paramount importance. This paper presents a critical analysis of the state-of-the-art literature related to pulsatile blood flow around microbots.

The Effect of Pulmonary Rehabilitation on Respiratory Functions, and the Quality of Life, following Coronary Artery Bypass Grafting: A Randomised Controlled Study

Objective

Examining the effects of a pulmonary rehabilitation (PR) program applied to patients undergoing coronary artery bypass grafting (CABG) surgery with open heart technique on respiratory functions, functional capacity, and quality of life (QoL).

Design

This randomised controlled study applied the Consolidated Standards of Reporting Trials statement.

Methods

The study was conducted with two groups: the intervention group (n = 25) and the control group (n = 25). The control group received standard care after coronary artery bypass grafting. On the contrary, the experimental group participated in a PR program created by the researchers in addition to standard care. After coronary artery bypass grafting, the respiratory functions (on the 4th day of clinical care) and QoL (at the 6^th week) of both groups were evaluated. The primary outcome measure was the respiratory function (forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC). The secondary outcome measure of this study was the QoL.

Results

When the average pulmonary function test values of the patients were examined, the mean FVC and FEV1 values of the patients in the intervention group on the 4th day of clinical care were significantly higher with a medium level size effect than the control group (p = 0.027; effect size (d) = 0.643; p < 0.024; effect size (d) = 0.658, respectively). At the postoperative 6th week measurement of QoL, a decrease was observed in all subdimensions of the scale, albeit less in the intervention group (p < 0.05). There was a decrease in both the mental and physical component summary of QoL (p < 0.05).

Conclusion

The results of this study revealed that pulmonary rehabilitation applied to patients who have undergone coronary artery bypass graft recover their functional capacity faster.

Perioperative risk factors for new-onset postoperative atrial fibrillation after coronary artery bypass grafting: a systematic review

Background

Postoperative atrial fibrillation (POAF) is the most common cardiac dysrhythmia to occur after coronary artery bypass grafting (CABG). However, the risk factors for new-onset POAF after CABG during the perioperative period have yet to be clearly defined. Accordingly, the aim of our systematic review was to evaluate the perioperative predictors of new-onset POAF after isolated CABG.

Method

Our review methods adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. We searched seven electronic databases (PubMed, Embase, CINAHL, PsycArticles, Cochrane, Web of Science, and SCOPUS) to identify all relevant English articles published up to January 2020. Identified studies were screened independently by two researchers for selection, according to predefined criteria. The Newcastle–Ottawa Scale was used to evaluate the quality of studies retained.

Results

After screening, nine studies were retained for analysis, including 4798 patients, of whom 1555 (32.4%) experienced new-onset POAF after CABG. The incidence rate of new-onset POAF ranged between 17.3% and 47.4%. The following risk factors were identified: old age (p < 0.001), a high preoperative serum creatinine level (p = 0.001), a low preoperative hemoglobin level (p = 0.007), a low left ventricle ejection fraction in Asian patients (p = 0.001), essential hypertension (p < 0.001), chronic obstructive pulmonary disease (p = 0.010), renal failure (p = 0.009), cardiopulmonary bypass use (p = 0.002), perfusion time (p = 0.017), postoperative use of inotropes (p < 0.001), postoperative renal failure (p = 0.001), and re-operation (p = 0.005). All studies included in the analysis were of good quality.

Conclusions

The risk factors identified in our review could be used to improve monitoring of at-risk patients for early detection and treatment of new-onset POAF after CABG, reducing the risk of other complications and negative clinical outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02224-x.

The Effect of Rhythmic Breathing on the Severity of Sternotomy Pain after Coronary Artery Bypass Graft Surgery: A Randomized Controlled Clinical Trial

Background

Moderate-to-severe pain is reported in up to 75% of the patients in the first 48 hours after cardiac surgery. Evidence suggests that distraction is an effective nursing intervention for controlling short-term and transient pain. Distraction can be achieved by various techniques, including progressive muscle relaxation, meditation, and rhythmic breathing (RB). The present research aimed at evaluating the impacts of RB on the severity of sternotomy pain after Coronary Artery Bypass Graft (CABG).

Methods

This randomized, controlled clinical trial was conducted on 60 patients after CABG surgery at the open-heart surgery Intensive Care Unit (ICU) of Kowsar Hospital, affiliated to Semnan University of Medical Sciences in Semnan, Iran. The patients were selected through convenience sampling and randomly assigned to two groups, including (1) intervention or RB and (2) control groups. RB was performed in the intervention group every 12 hours (9 a.m. and 9 p.m.) for three consecutive days after the surgery. The control group received only routine care for pain control (opioid analgesics) with no additional interventions. The severity of pain was measured every day in both groups of patients before and after the interventions using the Visual Analog Scale (VAS).

Results

The mean postintervention pain scores were significantly different from the mean preintervention scores in the intervention group (p < 0.05). The changes in the mean pain score in the intervention group were also significantly different from the corresponding changes in the controls (p < 0.05).

Conclusion

Based on the results, the severity of pain after the intervention was significantly lower in the RB group compared to the control. RB was found to be an effective technique for reducing the patients' pain and is therefore recommended as a post-CABG pain control technique. Iranian Registry of Clinical Trials: this trial is clinically registered with IRCT20120109008665N7, registered 3 September 2018.

Prognostic Indicators of Delayed Surgical Recovery in Patients Undergoing Cardiac Surgery

PURPOSE

The purpose of this study was to analyze the prognostic capacity of the clinical indicators of a delayed surgical recovery nursing diagnosis throughout the hospital stay of patients having cardiac surgery.

DESIGN

A prospective cohort design was adopted. A sample of inpatients undergoing elective cardiac surgery was followed during the immediate preoperative period and hospitalization. This research was conducted in the southeast region of Brazil at a national reference institution that treats highly complex diseases and performs cardiac surgeries. Data were collected from July 2017 to July 2018.

METHODS

At the end of 1 year of data collection, 181 patients were followed in this study. The Kaplan-Meier method was used to calculate the survival time related to delayed surgical recovery. In addition, an extended Cox model of time-dependent covariates was adjusted to identify the clinical signs that influenced the change in the nursing diagnosis status.

RESULTS

A delayed surgical recovery nursing diagnosis was present in 23.2% of the sample studied. With an expected length of stay of 8 to 10 days, most new cases of delayed surgical recovery were observed on the 10th postoperative day, and the survival rate after this day was decreased until the 29th postoperative day, when the nursing diagnosis no longer appeared. Interrupted healing of the surgical area, loss of appetite, and atrial flutter were indicators related to an increased risk for delayed surgical recovery.

CONCLUSIONS

Timely recognition of selected clinical indicators demonstrates a promising prognostic capacity for delayed surgical recovery.

CLINICAL RELEVANCE

Accurate identification of prognostic factors allows nurses to identify early signs of postoperative complications. Consequently, the professional can develop an individualized plan of care, aiming at the satisfactory clinical recovery of the patient.

Hospital Case Volume, Health Care Providers, and Mortality in Patients Undergoing Coronary Artery Bypass Grafting: a Nationwide Cohort Study in South Korea

Our South Korean population-based cohort study showed that a higher annual hospital case volume was associated with a lower 90-day mortality after isolated coronary artery bypass grafting (CABG). Additionally, a higher overall specialty physician volume was independently associated with a lower 90-day mortality. We reported cut-off values of ≥65 and ≥18 for the annual case volume of CABG and the total number of overall specialty doctors per 100 hospital beds, respectively, for achieving better outcomes after CABG.

Background and Objectives

Surgical quality is evaluated by measuring the annual hospital case volume; a higher case volume is associated with better survival after various surgeries. We aimed to investigate if the annual hospital case volume and the health care providers were associated with a 90-day mortality after coronary artery bypass grafting (CABG).

Methods

For this population-based cohort study, we used data from a National Health Insurance Service database in South Korea. We included all adult patients diagnosed with ischemic heart disease who underwent isolated CABG between January 2012 and December 2017. Data on the annual surgical volume for CABG in each hospital where the patients received CABG and the total number of health care providers (including physicians [trainees and specialists] from all department of the hospitals, nurses, and pharmacists) were collected.

Results

The final analysis included 15,790 adult patients; of these, 1,039 (6.6%) died within 90 days. The annual CABG volume was divided into 4 groups (Q1: ≤33, Q2: 34–86, Q3: 87–223, and Q4: ≥224). Multivariable Cox regression analysis revealed that the 90-day mortality rates in the Q4, Q3, Q2 groups were 75%, 32%, and 31% lower than that in the Q1 group, respectively. Additionally, an increase in the ratio of the total number of specialist physicians to 100 hospital beds was associated with a 4% decrease in the 90-day mortality after CABG.

Conclusion

Both, a higher annual hospital case volume and overall specialist physician volume were associated with better 90-day mortality rates after isolated CABG.

Machine learning prediction models for prognosis of critically ill patients after open-heart surgery

We aimed to build up multiple machine learning models to predict 30-days mortality, and 3 complications including septic shock, thrombocytopenia, and liver dysfunction after open-heart surgery. Patients who underwent coronary artery bypass surgery, aortic valve replacement, or other heart-related surgeries between 2001 and 2012 were extracted from MIMIC-III databases. Extreme gradient boosting, random forest, artificial neural network, and logistic regression were employed to build models by utilizing fivefold cross-validation and grid search. Receiver operating characteristic curve, area under curve (AUC), decision curve analysis, test accuracy, F1 score, precision, and recall were applied to access the performance. Among 6844 patients enrolled in this study, 215 patients (3.1%) died within 30 days after surgery, part of patients appeared liver dysfunction (248; 3.6%), septic shock (32; 0.5%), and thrombocytopenia (202; 2.9%). XGBoost, selected to be our final model, achieved the best performance with highest AUC and F1 score. AUC and F1 score of XGBoost for 4 outcomes: 0.88 and 0.58 for 30-days mortality, 0.98 and 0.70 for septic shock, 0.88 and 0.55 for thrombocytopenia, 0.89 and 0.40 for liver dysfunction. We developed a promising model, presented as software, to realize monitoring for patients in ICU and to improve prognosis.

Anticoagulation and antiplatelet therapy post coronary artery bypass surgery

BACKGROUND

Coronary artery bypass grafting (CABG) is the gold standard treatment for patients with multivessel coronary heart disease. Although its use has proven long-term survival benefits, there is a relative degree of graft failure which increases morbidity and mortality rates.

DISCUSSION

This review discusses clinical outcomes following antiplatelet and anticoagulant therapy after CABG. There is wide variation of evidence about the use of clopidogrel or ticagrelor to aspirin postoperatively in relation to improving graft patency rates or clinical outcomes over the use of aspirin alone. These dual therapies may have significant protective effects in patients undergoing off-pump CABG. Recent studies suggest that superior outcomes may be attained by combining prasugrel with aspirin. Further research is needed to evaluate this, as well as compare the effectiveness of different dual antiplatelet regimens. There is weak evidence for post-CABG anticoagulation, with warfarin and rivaroxaban providing no protection against graft failure but decreasing long-term major adverse cardiac events. Anticoagulation seems to be indicated only in post-CABG patients at high risk of future ischemic events.

CONCLUSION

The use of dual anti-platelet therapy post coronary artery bypass surgery needs further research. Potentially, selective patient groups will benefit more from the addition of thienopyridine antiplatelets or anticoagulants to aspirin after CABG.

Profilin 1 and Mitochondria-Partners in the Pathogenesis of Coronary Artery Disease?

Atherosclerosis remains a large health and economic burden. Even though it has been studied for more than a century, its complex pathophysiology has not been elucidated. The relatively well-established contributors include: chronic inflammation in response to oxidized cholesterol, reactive oxygen species-induced damage and apoptosis. Recently, profilin 1, a regulator of actin dynamics emerged as a potential new player in the field. Profilin is abundant in stable atherosclerotic plaques and in thrombi extracted from infarct-related arteries in patients with acute myocardial infarction. The exact role of profilin in atherosclerosis and its complications, as well as its mechanisms of action, remain unknown. Here, we summarize several pathways in which profilin may act through mitochondria in a number of processes implicated in atherosclerosis.

Effects of intravenous and transdermal photobiomodulation on the postoperative complications of coronary artery bypass grafting surgery: a randomized, controlled clinical trial

Although coronary artery bypass graft (CABG) surgery is one of the most worldwide commonly performed cardiac surgeries to enhance myocardial perfusion in high-grade myocardial occlusion, it remains a high-risk procedure. Photobiomodulation (PBM) is one of the methods which have been shown to have positive effects on the healing process after CABG and postoperative complications. The aim of this study was to evaluate the efficacy of PBM in patients who underwent a coronary artery bypass graft (CABG). Ths study was conducted with 192 volunteers who electively submitted to CABG. The volunteers were randomly allocated into two groups: laser-treated (transdermal: 980 nm, 200 mW, continuous, average energy fluency of 6 J/cm² and intravenous: 405 nm, 1.5 mW, continuous for 30 min) and standard treatment and control group (standard treatment only). Intravenous laser was illuminated the day before the surgery, immediately after transferring the patient to CCU post-operation and IV laser in addition to transdermal laser was applied every day after surgery for 6 days. A total of 170 out of 192 participants completed the study, 82 (48.2%) in the PBM group and 88 (51.8%) in the control group. Level of LDH and CPK was significantly lower in the PBM group (P < 0.05) in the 4th day postoperatively. The PBM group also showed significantly lower post-surgery complications, including pericardial effusion, ejection fraction, pathologic ST changes, pathologic Q, rehospitalization, heart failure, and mediastinitis (P < 0.05). Likewise, the VAS pain score after surgery was significantly lower in patients in the laser group (P < 0.05). PBM seems a promising, safe, cost-benefit therapeutic modality to reduce postoperative complications of CABG. Trial registration number: IRCT2016052926069N4 .

The effect of opium addiction on short-term postoperative outcomes after coronary artery bypass graft surgery: A prospective observational cohort study

Introduction

Opium addiction has been recently suggested as a potential risk factor for the occurrence of perioperative complications in patients undergoing coronary artery bypass graft (CABG) surgery. The aim of this study was to evaluate whether opium addiction can potentially affect patients' short-term postoperative outcomes after CABG surgery.

Material and methods

In a prospective observational cohort study, all consecutive patients who were scheduled for first-time isolated elective on pump CABG surgery were screened during the study period for opium addiction. The study was carried out between September 2015 and November 2016 at Mazandaran Heart Center, Sari, Iran. A total number of 228 patients [110 opium addicted (OA) and 118 non-addicted (NA)] were screened and included. All patients were evaluate, in terms of short-term postoperative outcomes, until hospital discharge or death.

Results

In the OA patients, the mean amount of estimated postoperative bleeding was significantly more than NA patients (535 ± 304.75 ml vs. 463.56 ± 209.77; P = 0.04). Mean ventilation time were significantly longer in the OA patients than in the NA (9.9 days vs. 8.66 days, P = 0.02). The mean duration of postoperative hospital stay was two days longer in the OA (10.83 days vs. 8.34 days, P < 0.001). Also, the mean use of packed cell during surgery and incidence of postoperative atrial fibrillation were higher in the OA patients than NA (P = 0.005).

Conclusion

The results of our study provide strong evidence that the opium addiction should be considered as a risk factors for developing perioperative complications, including higher mean postoperative bleeding, need for intraoperative packed red blood cell transfusion, ventilation time and length of hospital stay, in patients undergoing CABG surgery.