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Fang L, Cheng A, Zhu Z, Shao M, Wang G. Effect of Inspiratory Muscle Training on Outcomes After Cardiac Surgery: A Comprehensive Meta-Analysis of Randomized Controlled Trials. J Cardiopulm Rehabil Prev 2024:01273116-990000000-00169. [PMID: 39185909 DOI: 10.1097/hcr.0000000000000890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
PURPOSE Inspiratory muscle training (IMT) has emerged as a potential intervention to improve respiratory outcomes for patients undergoing cardiac surgery. However, the extent of the IMT effects on preoperative and postoperative respiratory metrics remains uncertain. Hence, we designed this study to determine the effects of IMT on various outcomes of patients undergoing cardiac surgery. METHODS We conducted a comprehensive meta-analysis of studies evaluating the impact of preoperative and postoperative IMT on various respiratory variables and postsurgical outcomes. We synthesized data from multiple studies, encompassing diverse patient populations and IMT protocols. The key outcomes included the maximal inspiratory pressure (MIP), forced expiratory volume in 1 sec (FEV1), forced vital capacity (FVC), and others. RESULTS Our meta-analysis results showed that preoperative IMT significantly improved the MIP values with a pooled standard mean difference (SMD) of 0.62. The hospital stay length was also reduced with a SMD of - 0.4. Other variables such as FEV1 and FVC also improved significantly. Postoperative IMT improved the MIP and peak flow rate values, but the evidence was less robust than with preoperative interventions. We observed high heterogeneity across studies for several outcomes and found evidence of publication bias for some postoperative measures. CONCLUSION Both preoperative and postoperative IMT offer benefits for patients undergoing operations, especially by enhancing respiratory muscle strength and potentially reducing hospital stays. However, the presence of heterogeneity and publication bias underscores the need for further standardized research to consolidate these findings and standardize IMT protocols for optimal patient outcomes.
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Affiliation(s)
- Linqi Fang
- Author Affiliations: Cardiorpulmonary Rehabilitation Ward, Zhejiang Rehabilitation Medical Center (The Affiliated Rehabilitation Hospital of Zhejiang Chinese Medical University), Hangzhou, Zhejiang Province, China; and Rehabilitation Medicine Department 2, The Third Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
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Oettinger V, Hilgendorf I, Wolf D, Stachon P, Heidenreich A, Zehender M, Westermann D, Kaier K, von Zur Mühlen C. Transcatheter aortic valve replacement in Germany with need for a surgical bailout. J Cardiol 2024; 84:99-104. [PMID: 38307247 DOI: 10.1016/j.jjcc.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 01/20/2024] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND In transcatheter aortic valve replacement (TAVR), complications may force the need for a surgical bailout, but knowledge is rare about outcomes in Germany. METHODS Using national health records, we investigated all TAVR in German hospitals between 2007 and 2020, focusing on 2018-2020. We extracted data on those interventions with need for a surgical bailout. RESULTS A total of 159,643 TAVR were analyzed, with an overall rate of surgical bailout of 2.30 %, an overall in-hospital mortality of 3.85 %, and in-hospital mortality in case of bailout of 16.51 %. The number of all annual TAVR procedures increased substantially (202 to 22,972), with the rate of surgical bailout declining from 27.23 to 0.61 % and overall mortality from 11.39 to 2.29 %. However, in-hospital mortality after bailout was still high (28.37 % in 2020). The standardized rates of overall mortality and surgical bailout between 2018 and 2020 were significantly lower for balloon-expandable and self-expanding transfemoral TAVR than for transapical TAVR after risk adjustment [transapical/transfemoral balloon-expandable/transfemoral self-expanding TAVR: in-hospital mortality: 5.66 % (95 % CI 4.81 %; 6.52 %)/2.30 % (2.03 %; 2.57 %)/2.32 % (2.07 %; 2.57 %); surgical bailout: 2.33 % (1.68 %; 2.97 %)/0.79 % (0.60 %; 0.98 %)/0.42 % (0.31 %; 0.53 %)]. Coronary artery disease [risk-adjusted OR = 1.50 (1.21; 1.85), p < 0.001] and atrial fibrillation [OR = 1.29 (1.07; 1.57), p = 0.009] were found to be the main risk factors for bailout. CONCLUSIONS Rates of TAVR with need for a surgical bailout and overall in-hospital mortality have declined noticeably over the years in Germany. However, the outcomes are still unfavorable after surgical bailout, as in-hospital mortality is continuously high. We present risk factors for surgical bailout to improve preparation of subsequent measures. It must be a major goal to further reduce the rate of surgical bailouts in the future.
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Affiliation(s)
- Vera Oettinger
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Ingo Hilgendorf
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dennis Wolf
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Adrian Heidenreich
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Mühlen
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Di Pietro G, Improta R, De Filippo O, Bruno F, Birtolo LI, Tocci M, Fabris T, Saade W, Colantonio R, Celli P, Sardella G, Esposito G, Tarantini G, Mancone M, D'Ascenzo F. Transcatheter Aortic Valve Replacement in Low Surgical Risk Patients: An Updated Metanalysis of Extended Follow-Up Randomized Controlled Trials. Am J Cardiol 2024; 224:56-64. [PMID: 38729335 DOI: 10.1016/j.amjcard.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/03/2024] [Accepted: 05/01/2024] [Indexed: 05/12/2024]
Abstract
The long-term safety and effectiveness of transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (SAVR) in low surgical risk has not been evaluated in a pooled analysis. An electronic database search was conducted for randomized controlled trials with a maximal 5 years clinical and echocardiographic follow-up including low surgical risk patients who underwent TAVR or SAVR. We calculated odds ratio (OR) and 95% confidence intervals (CIs) using a random-effects model. Subgroups analysis was performed for permanent pacemaker implantation and paravalvular leaks. Three randomized controlled trials were included with a total of 2,611 low surgical risk patients (Society of Thoracic Surgeons score <4%). Compared with SAVR, the TAVR group had similar rates of all-cause mortality (OR 0.94,95% CI 0.65 to 1.37, p = 0.75) and disabling stroke (OR 0.84, 95% CI 0.52 to 1.36, p = 0.48). No significant differences were registered in the TAVR group in terms of major cardiovascular events (OR 0.96, 95% CI 0.67 to 1.38, p = 0.83), myocardial infarction (OR 0.69, 95% CI 0.34 to 1.40, p = 0.31), valve thrombosis (OR 3.11, 95% CI 0.29 to 33.47, p = 0.35), endocarditis (OR 0.71,95% CI 0.35 to 1.48, p = 0.36), aortic valve reintervention (OR 0.93, 95% CI 0.52 to 1.66, p = 0.80), and rehospitalization (OR 0.80, 95% CI 0.52 to 1.02, p = 0.07) compared with SAVR. However, TAVR patients had a higher risk of paravalvular leaks (OR 8.21, 95% CI 4.18 to 16.14, p <0.00001), but lower rates of new-onset atrial fibrillation (OR 0.27,95% CI 0.17 to 0.30, p <0.0001). The rates of permanent pacemaker implantation were comparable from 1 year up to a maximum of 5 years (OR 1.32, 95% CI 0.88 to 1.97, p = 0.18). Lastly, TAVR had a greater effective orifice area (0.10 cm2/m2, 95% CI 0.05 to 0.15, p = 0.0001), but similar transvalvular mean gradients (0.60, 95% CI 3.94 to 2.73, p = 0.72). In conclusion, TAVR patients had similar long-term outcomes compared with SAVR, except for an elevated risk of paravalvular leaks in the TAVR group and increased rates of atrial fibrillation in the SAVR cohort.
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Affiliation(s)
- Gianluca Di Pietro
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy; Department of Medical Science, Division of Cardiology, Molinette Hospital, Turin University, Italy
| | - Riccardo Improta
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy; Department of Medical Science, Division of Cardiology, Molinette Hospital, Turin University, Italy
| | - Ovidio De Filippo
- Department of Medical Science, Division of Cardiology, Molinette Hospital, Turin University, Italy
| | - Francesco Bruno
- Department of Medical Science, Division of Cardiology, Molinette Hospital, Turin University, Italy
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Marco Tocci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Tommaso Fabris
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | - Wael Saade
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Riccardo Colantonio
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Paola Celli
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Rome, Italy
| | - Gennaro Sardella
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Giovanni Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy.
| | - Fabrizio D'Ascenzo
- Department of Medical Science, Division of Cardiology, Molinette Hospital, Turin University, Italy
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Gregory AJ, Kent WDT, Adams C, Arora RC. Closing the care gap: combining enhanced recovery with minimally invasive valve surgery. Curr Opin Cardiol 2024; 39:380-387. [PMID: 38606679 DOI: 10.1097/hco.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
PURPOSE OF REVIEW Patients with advanced age and frailty require interventions for structural heart disease at an increasing rate. These patients typically experience higher rates of postoperative morbidity, mortality and prolonged hospital length of stay, loss of independence as well as associated increased costs to the healthcare system. Therefore, it is becoming critically important to raise awareness and develop strategies to improve clinical outcomes in the contemporary, high-risk patient population undergoing cardiacprocedures. RECENT FINDINGS Percutaneous options for structural heart disease have dramatically improved the therapeutic options for some older, frail, high-risk patients; however, others may still require cardiac surgery. Minimally invasive techniques can reduce some of the physiologic burden experienced by patients undergoing surgery and improve recovery. Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) is a comprehensive, interdisciplinary, evidence-based approach to perioperative care. It has been shown to improve recovery and patient satisfaction while reducing complications and length of stay. SUMMARY Combining minimally invasive cardiac surgery with enhanced recovery protocols may result in improved patient outcomes for a patient population at high risk of morbidity and mortality following cardiac surgery.
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Affiliation(s)
- Alexander J Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - William D T Kent
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Corey Adams
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Rakesh C Arora
- Harrington Heart and Vascular Institute - University Hospitals, Cleveland, Ohio, USA
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Kahn RA, Egorova N, Ouyang Y, Rhee AJ, Larese J. Practitioner dashboard feedback improves glycemic but not temperature compliance during cardiac surgery: A single center retrospective analysis. J Clin Anesth 2024; 97:111526. [PMID: 38897090 DOI: 10.1016/j.jclinane.2024.111526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 06/06/2024] [Accepted: 06/08/2024] [Indexed: 06/21/2024]
Abstract
STUDY OBJECTIVE To determine the association of practitioner dashboard feedback of intraoperative glycemic and temperature control on maintenance of normoglycemia and normothermia. DESIGN Retrospective review. SETTING Single tertiary care institution. PATIENTS Patients over the age of 18 undergoing cardiac surgery from February 17, 2021 through February 16, 2023. During the study interval, 15 anesthesiologists providing care during 2255 procedures were analyzed: 1114 prior to the individual faculty dashboard distribution and 1141 after commencement of dashboard distribution. INTERVENTIONS On February 17, 2022, anesthesia faculty members began receiving monthly individualized dashboards indicating their personal intraoperative glycemic and temperature compliance rates. MEASUREMENTS Baseline patient demographic characteristics, surgical and cardiopulmonary bypass times, perioperative temperature and glucose concentrations, and the incidence of sternal wound infections. Glycemic compliance was defined as final serum glucose between 80 and 180 mg/dL. Temperature compliance was defined as an average temperature during the final 30 min of the surgical procedure between 35 and 37.3 °C inclusive. MAIN RESULTS Dashboard distribution was associated with a significant decrease in the average glucose concentration (median location shift by -6 mg% (95% confidence interval (CI) -8, -4), p < 0.001) from 157 mg/dL to 152 mg/dL and final glucose concentration (median location shift by -17 mg/dL (95% CI -19, -14, p < 0.001) from 161 mg/dL to 145 mg/dL. The intervention was associated with an improvement in glycemic compliance from 71.4% to 87.1% (odds ratio (OR): 2.71(95% CI 2.19, 3.37, p < 0.001)). There were no significant differences in final temperature (36.3 °C [Q1, Q3: 36.0, 36.6] vs. 36.3 °C [Q1, Q3: 36.0, 36.7] (p = 0.232)) with the intervention nor were there any statistically significant differences in temperature compliance (93.9% vs. 92.9%, OR: 0.79 (95% CI 0.55-1.14, p = 0.25). There were no statistically significant changes in the incidence of superficial, deep, or any wound infections with the intervention. CONCLUSIONS Individualized practitioner dashboard distribution may be an effective tool to increase intraoperative glycemic control.
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Affiliation(s)
- Ronald A Kahn
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, United States of America.
| | - Natalia Egorova
- Center for Biostatistics, Department of Population Health Science and Policy, The Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, United States of America
| | - Yuxia Ouyang
- Center for Biostatistics, Department of Population Health Science and Policy, The Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, United States of America
| | - Amanda J Rhee
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, United States of America
| | - Joseph Larese
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, United States of America
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Liao KM, Lu HY, Chen CY, Kuo LT, Tang BR. The impact of comorbidities on prolonged mechanical ventilation in patients with chronic obstructive pulmonary disease. BMC Pulm Med 2024; 24:257. [PMID: 38796444 PMCID: PMC11128105 DOI: 10.1186/s12890-024-03068-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 05/20/2024] [Indexed: 05/28/2024] Open
Abstract
BACKGROUND In patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure, approximately 10% of them are considered to be at high risk for prolonged mechanical ventilation (PMV, > 21 days). PMV have been identified as independent predictors of unfavorable outcomes. Our previous study revealed that patients aged 70 years older and COPD severity were at a significantly higher risk for PMV. We aimed to analyze the impact of comorbidities and their associated risks in patients with COPD who require PMV. METHODS The data used in this study was collected from Kaohsiung Medical University Hospital Research Database. The COPD subjects were the patients first diagnosed COPD (index date) between January 1, 2012 and December 31, 2020. The exclusion criteria were the patients with age less than 40 years, PMV before the index date or incomplete records. COPD and non-COPD patients, matched controls were used by applying the propensity score matching method. RESULTS There are 3,744 eligible patients with COPD in the study group. The study group had a rate of 1.6% (60 cases) patients with PMV. The adjusted HR of PMV was 2.21 (95% CI 1.44-3.40; P < 0.001) in the COPD patients than in non-COPD patients. Increased risks of PMV were found significantly for patients with diabetes mellitus (aHR 4.66; P < 0.001), hypertension (aHR 3.20; P = 0.004), dyslipidemia (aHR 3.02; P = 0.015), congestive heart failure (aHR 6.44; P < 0.001), coronary artery disease (aHR 3.11; P = 0.014), stroke (aHR 6.37; P < 0.001), chronic kidney disease (aHR 5.81 P < 0.001) and Dementia (aHR 5.78; P < 0.001). CONCLUSIONS Age, gender, and comorbidities were identified as significantly higher risk factors for PMV occurrence in the COPD patients compared to the non-COPD patients. Beyond age, comorbidities also play a crucial role in PMV in COPD.
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Affiliation(s)
- Kuang-Ming Liao
- Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan
- Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan, Taiwan
| | - Hsueh-Yi Lu
- Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Yunlin, Taiwan.
| | - Chung-Yu Chen
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Bo-Ren Tang
- Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Yunlin, Taiwan
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Tafelmeier M, Kuettner S, Hauck C, Floerchinger B, Camboni D, Creutzenberg M, Zeman F, Schmid C, Maier LS, Wagner S, Arzt M. Sleep-Disordered Breathing, Advanced Age, and Diabetes Mellitus Are Associated with De Novo Atrial Fibrillation after Cardiac Surgery. Biomedicines 2024; 12:1035. [PMID: 38790998 PMCID: PMC11117485 DOI: 10.3390/biomedicines12051035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Postoperative de novo atrial fibrillation (POAF) is one of the most frequently encountered complications following cardiac surgery. Despite the identification of several risk factors, the link between sleep-disordered breathing (SDB) and POAF has barely been examined. The objective of this prospective observational study was to determine whether severe SDB is associated with POAF in patients after elective coronary artery bypass grafting (CABG) surgery. Study design and methods: The incidence and preoperative predictors of in-hospital POAF were assessed in 272 patients undergoing CABG surgery at the University Medical Center Regensburg (Germany). In-hospital POAF was detected by continuous telemetry-ECG monitoring and 12-lead resting ECGs within the first seven postoperative days. POAF that occurred after hospital discharge within 60 days post CABG surgery was classified as post-hospital POAF and was ascertained by standardized phone interviews together with the patients' medical files, including routinely performed Holter-ECG monitoring at 60 days post CABG surgery. The night before surgery, portable SDB monitoring was used to assess the presence and type of severe SDB, defined by an apnea-hypopnea index ≥ 30/h. Results: The incidence of in-hospital POAF was significantly higher in patients with severe SDB compared to those without severe SDB (30% vs. 15%, p = 0.009). Patients with severe SDB suffered significantly more often from POAF at 60 days post CABG surgery compared to patients without severe SDB (14% vs. 5%, p = 0.042). Multivariable logistic regression analysis showed that severe SDB (odds ratio, OR [95% confidence interval, CI]: 2.23 [1.08; 4.61], p = 0.030), age ≥ 65 years (2.17 [1.04; 4.53], p = 0.038), and diabetes mellitus (2.27 [1.15; 4.48], p = 0.018) were significantly associated with in-hospital POAF. After additional adjustment for heart failure, the association between sleep apnea and postoperative atrial fibrillation was attenuated (1.99 [0.92; 4.31], p = 0.081). Conclusions: Amongst established risk factors, severe SDB was significantly associated with in-hospital POAF in patients undergoing CABG surgery. Whether SDB contributes to POAF independently of heart failure and whether risk for POAF may be alleviated by proper treatment of SDB merits further investigation.
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Affiliation(s)
- Maria Tafelmeier
- Department of Internal Medicine II (Cardiology, Pneumology, and Intensive Care), University Medical Center Regensburg, 93053 Regensburg, Germany; (S.K.); (C.H.); (L.S.M.); (S.W.); (M.A.)
| | - Sabrina Kuettner
- Department of Internal Medicine II (Cardiology, Pneumology, and Intensive Care), University Medical Center Regensburg, 93053 Regensburg, Germany; (S.K.); (C.H.); (L.S.M.); (S.W.); (M.A.)
| | - Christian Hauck
- Department of Internal Medicine II (Cardiology, Pneumology, and Intensive Care), University Medical Center Regensburg, 93053 Regensburg, Germany; (S.K.); (C.H.); (L.S.M.); (S.W.); (M.A.)
| | - Bernhard Floerchinger
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (B.F.); (D.C.); (C.S.)
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (B.F.); (D.C.); (C.S.)
| | - Marcus Creutzenberg
- Department of Anesthesiology, University Medical Center Regensburg, 93053 Regensburg, Germany;
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, 93053 Regensburg, Germany;
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (B.F.); (D.C.); (C.S.)
| | - Lars Siegfried Maier
- Department of Internal Medicine II (Cardiology, Pneumology, and Intensive Care), University Medical Center Regensburg, 93053 Regensburg, Germany; (S.K.); (C.H.); (L.S.M.); (S.W.); (M.A.)
| | - Stefan Wagner
- Department of Internal Medicine II (Cardiology, Pneumology, and Intensive Care), University Medical Center Regensburg, 93053 Regensburg, Germany; (S.K.); (C.H.); (L.S.M.); (S.W.); (M.A.)
| | - Michael Arzt
- Department of Internal Medicine II (Cardiology, Pneumology, and Intensive Care), University Medical Center Regensburg, 93053 Regensburg, Germany; (S.K.); (C.H.); (L.S.M.); (S.W.); (M.A.)
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Halonen J, Kärkkäinen J, Jäntti H, Martikainen T, Valtola A, Ellam S, Väliaho E, Santala E, Räsänen J, Juutilainen A, Mahlamäki V, Vasankari S, Vasankari T, Hartikainen J. Prevention of Atrial Fibrillation After Cardiac Surgery: A Review of Literature and Comparison of Different Treatment Modalities. Cardiol Rev 2024; 32:248-256. [PMID: 36729126 DOI: 10.1097/crd.0000000000000499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Atrial fibrillation is the most common arrhythmia to occur after cardiac surgery, with an incidence of 10% to 50%. It is associated with postoperative complications including increased risk of stroke, prolonged hospital stays and increased costs. Despite new insights into the mechanisms of atrial fibrillation, no specific etiologic factor has been identified as the sole perpetrator of the arrhythmia. Current evidence suggests that the pathophysiology of atrial fibrillation in general, as well as after cardiac surgery, is multifactorial. Studies have also shown that new-onset postoperative atrial fibrillation following cardiac surgery is associated with a higher risk of short-term and long-term mortality. Furthermore, it has been demonstrated that prophylactic medical therapy decreases the incidence of postoperative atrial fibrillation after cardiac surgery. Of note, the incidence of postoperative atrial fibrillation has not changed during the last decades despite the numerous preventive strategies and operative techniques proposed, although the perioperative and postoperative care of cardiac patients as such has improved.
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Affiliation(s)
- Jari Halonen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jussi Kärkkäinen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Helena Jäntti
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
- Centre for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - Tero Martikainen
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Antti Valtola
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Sten Ellam
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Eemu Väliaho
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Elmeri Santala
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jenni Räsänen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Auni Juutilainen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Visa Mahlamäki
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Sini Vasankari
- Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Tommi Vasankari
- The UKK Institute for Health Promotion Research, Tampere, Finland
- The Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juha Hartikainen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
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9
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Ramos RS, Rocco IS, Viceconte M, Santo JADE, Berwanger O, Santos RHN, Kalil RAK, Jatene FB, Cavalcanti AB, Zilli AC, Pimentel WDS, Hossne Junior NA, Branco JNR, Trimer R, Evora PRB, Gomes WJ, Guizilin S. Association Between Body Mass Index, Obesity, and Clinical Outcomes Following Coronary Artery Bypass Grafting in Brazil: An Analysis of One Year of Follow-up of BYPASS Registry Patients. Braz J Cardiovasc Surg 2024; 39:e20230133. [PMID: 38569010 PMCID: PMC10987126 DOI: 10.21470/1678-9741-2023-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE To investigate the association between body mass index (BMI), obesity, clinical outcomes, and mortality following coronary artery bypass grafting (CABG) in Brazil using a large sample with one year of follow-up from the Brazilian Registry of Cardiovascular Surgeries in Adults (or BYPASS) Registry database. METHODS A multicenter cohort-study enrolled 2,589 patients submitted to isolated CABG and divided them into normal weight (BMI 20.0-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), and obesity (BMI > 30.0 kg/m2) groups. Inpatient postoperative outcomes included the most frequently described complications and events. Collected post-discharge outcomes included rehospitalization and mortality rates within 30 days, six months, and one year of follow-up. RESULTS Sternal wound infections (SWI) rate was higher in obese compared to normal-weight patients (relative risk [RR]=5.89, 95% confidence interval [CI]=2.37-17.82; P=0.001). Rehospitalization rates in six months after discharge were higher in obesity and overweight groups than in normal weight group (χ=6.03, P=0.049); obese patients presented a 2.2-fold increase in the risk for rehospitalization within six months compared to normal-weight patients (RR=2.16, 95% CI=1.17-4.09; P=0.045). Postoperative complications and mortality rates did not differ among groups during time periods. CONCLUSION Obesity increased the risk for SWI, leading to higher rehospitalization rates and need for surgical interventions within six months following CABG. Age, female sex, and diabetes were associated with a higher risk of mortality. The obesity paradox remains controversial since BMI may not be sufficient to assess postoperative risk in light of more complex and dynamic evaluations of body composition and physical fitness.
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Affiliation(s)
- Rodrigo Santin Ramos
- Cardiology Postgraduate Program, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Isadora Salvador Rocco
- Cardiology Postgraduate Program, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Marcela Viceconte
- Cardiology Postgraduate Program, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | | | - Otavio Berwanger
- Instituto de Pesquisa - IP, Hospital do Coração -
HCor, São Paulo, São Paulo, Brazil
| | | | - Renato Abdala Karam Kalil
- Instituto de Cardiologia do Rio Grande do Sul,
Fundação Universitária de Cardiologia, Porto Alegre, Rio Grande
do Sul, Brazil
| | - Fabio B. Jatene
- Instituto de Pesquisa - IP, Hospital do Coração -
HCor, São Paulo, São Paulo, Brazil
- Cardiovascular Surgery Division, Instituto do Coração
- InCor, Hospital das Clínicas da Faculdade de Medicina da Universidade de
São Paulo - HCFMUSP, São Paulo, São Paulo, Brazil
| | | | - Alexandre Cabral Zilli
- Cardiology Postgraduate Program, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Walace de Souza Pimentel
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Nelson Américo Hossne Junior
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - João Nelson Rodrigues Branco
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Renata Trimer
- Department of Physical Therapy, Universidade Federal de São
Carlos, São Carlos, São Paulo, Brazil
| | - Paulo Roberto Barbora Evora
- Department of Surgery and Anatomy, Escola de Medicina de
Riberão Preto, Universidade de São Paulo, Ribeirão Preto,
São Paulo, Brazil
| | - Walter J. Gomes
- Cardiology Postgraduate Program, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Solange Guizilin
- Cardiology Postgraduate Program, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina,
Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
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10
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Li J, Deng Y, Jiang Y. The effectiveness of a web-based information-knowledge-attitude-practice continuous intervention on the psychological status, medical compliance, and quality of life of patients after coronary artery bypass grafting surgery: a parallel randomized clinical trial. J Cardiothorac Surg 2024; 19:125. [PMID: 38481263 PMCID: PMC10935904 DOI: 10.1186/s13019-024-02618-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 03/05/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Coronary artery disease (CAD) patients who have undergone coronary artery bypass grafting (CABG) often experience a severe psychological burden for a long period of time, which can adversely affect their post-operative prognosis. Therefore, this study aimed to evaluate the effect of a web-based Information-Knowledge-Attitude-Practice (WIKAP) continuous intervention on the psychological status, medical compliance, and quality of life (QoL) in patients with CAD after CABG surgery. METHODS A parallel randomized clinical trial enrolled 174 CAD patients who underwent CABG at our hospital between January 2018 and December 2019. The participants were randomly divided into the Control and WIKAP group and received intervention for 12 months. The scores for anxiety, depression, medical compliance, and QoL were assessed on the first day (M0), 3rd month (M3), 6th month (M6), 9th month (M9) and 12th month (M12) after discharge. Furthermore, the occurrence of major adverse cardiac and cerebrovascular events (MACCE) was analyzed using the Kaplan-Meier curve and Cox proportional regression models for an additional 24-month follow-up period without any intervention. RESULTS After the 12-month intervention, the scores of anxiety and depression were significantly reduced in the WIKAP group at M9 and M12 compared to those in the Control group (all P < 0.05). Additionally, the scores of medical compliance in the WIKAP group were remarkably elevated at M6, M9, and M12 compared with those scores in the Control group (all P < 0.05). Furthermore, the QoL scores were lower in the WIKAP group at M6, M9, and M12 compared to the Control group (all P < 0.05). However, the MACCE-free survival showed no significant difference between the two groups (P > 0.05). Cox proportional regression analysis also showed that the nursing intervention (Control vs. WKIAP) was not associated with the incidence of MACCE. CONCLUSION WIKAP nursing intervention effectively improved the psychological health, medical compliance, and QoL in CAD patients who underwent CABG operation, but it did not prolong MACCE-free survival. TRAIL REGISTRATION The study is registered in isrctn.org: ISRCTN13653455.
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Affiliation(s)
- Jin Li
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Heping District, Shenyang, Liaoning Province, 110004, China
| | - Yueli Deng
- Department of Intensive Care Medicine, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Heping District, Shenyang, Liaoning Province, 110004, China
| | - Yan Jiang
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Heping District, Shenyang, Liaoning Province, 110004, China.
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11
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Czarnecka J, Neuschwander A, Aujoulat T, Balmier A, Belcour D, Boulanger B, Bourgain C, Caron M, Kiss G, Larghi M, Lebard C, Mellano V, Larson J, Megroian B, Lefrançois A, Fox S, Pollet A, Bourgoin P, Biland G, Braunberger E, Maccio G, Delmas B. Red Blood Cell Transfusion Requirements Before and After Implementation of a Perioperative Patient Blood Management Program in Adult Patients Undergoing Cardiac Surgery. A Before and After Observational Study. J Cardiothorac Vasc Anesth 2024; 38:73-79. [PMID: 37953174 DOI: 10.1053/j.jvca.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES Anemia and transfusion are common in cardiac surgery patients, and are associated with significant morbidity and mortality. Multiple perioperative interventions have been described to reduce blood transfusion, but are rarely combined altogether. The aim of this study was to compare the incidence of red blood cell (RBC) transfusion in adult patients undergoing cardiac surgery before and after the implementation of a perioperative patient blood management (PBM) program. DESIGN Before-and-after observational study. SETTING Single-center French university teaching hospital. PARTICIPANTS Adult patients scheduled for cardiac surgery. INTERVENTIONS Perioperative patient blood management program including pre-, intra-, and postoperative interventions aimed at identifying and correcting anemia, minimizing blood loss during surgery, and optimizing coagulation. MEASUREMENTS AND MAIN RESULTS Four hundred thirty-four patients were included in the study from January 2021 to July 2022. The incidence of perioperative RBC transfusion (intraoperatively and during the first 2 postoperative days) was significantly reduced from 43% (90/213) in the pre-PBM period to 27% (60/221) in the post-PBM period (p < 0.001). The application of a PBM program was associated with a reduction in perioperative RBC transfusion by multivariate analysis (odds ratio 0.55, 95% CI 0.36-0.85, p = 0.007), and was associated with a reduction in the median number of RBC units transfused within transfused patients (p = 0.025). These effects persisted at day 30 after surgery (p = 0.029). CONCLUSION A perioperative PBM program in adult patients undergoing cardiac surgery was associated with a significant reduction in perioperative RBC transfusion, which persisted at day 30.
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Affiliation(s)
- Jeremie Czarnecka
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Arthur Neuschwander
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France.
| | - Thomas Aujoulat
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Adrien Balmier
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Dominique Belcour
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Boris Boulanger
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Caroline Bourgain
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Margot Caron
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Gabor Kiss
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Mathilde Larghi
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Christophe Lebard
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Vincent Mellano
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Jonathan Larson
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Blandine Megroian
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Anaelle Lefrançois
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Sylvain Fox
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Arnaud Pollet
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Pierre Bourgoin
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France; Department of anesthesiology, University Hospital, Nantes, France
| | - Guillaume Biland
- Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Eric Braunberger
- Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Guillaume Maccio
- French Blood Establishment, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Benjamin Delmas
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
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12
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Gabriels JK, Schaller RD, Koss E, Rutkin BJ, Carrillo RG, Epstein LM. Lead management in patients undergoing percutaneous tricuspid valve replacement or repair: a 'heart team' approach. Europace 2023; 25:euad300. [PMID: 37772978 PMCID: PMC10629975 DOI: 10.1093/europace/euad300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/11/2023] [Accepted: 09/24/2023] [Indexed: 09/30/2023] Open
Abstract
Clinically significant tricuspid regurgitation (TR) has historically been managed with either medical therapy or surgical interventions. More recently, percutaneous trans-catheter tricuspid valve (TV) replacement and tricuspid trans-catheter edge-to-edge repair have emerged as alternative treatment modalities. Patients with cardiac implantable electronic devices (CIEDs) have an increased incidence of TR. Severe TR in this population can occur for multiple reasons but most often results from the interactions between the CIED lead and the TV apparatus. Management decisions in patients with CIED leads and clinically significant TR, who are undergoing evaluation for a percutaneous TV intervention, need careful consideration as a trans-venous lead extraction (TLE) may both worsen and improve TR severity. Furthermore, given the potential risks of 'jailing' a CIED lead at the time of a percutaneous TV intervention (lead fracture and risk of subsequent infections), consideration should be given to performing a TLE prior to a percutaneous TV intervention. The purpose of this 'state-of-the-art' review is to provide an overview of the causes of TR in patients with CIEDs, discuss the available therapeutic options for patients with TR and CIED leads, and advocate for including a lead management specialist as a member of the 'heart team' when making treatment decisions in patients TR and CIED leads.
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Affiliation(s)
- James K Gabriels
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, Manhasset, NY, USA
| | - Robert D Schaller
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Elana Koss
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, USA
| | - Bruce J Rutkin
- Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, USA
| | | | - Laurence M Epstein
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, Manhasset, NY, USA
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13
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Caplin DM, Young S, Kassin M, Dowell JD, Makary MS, Metwalli ZA, Charalel RA, Halin NJ, Kleedehn M, Lewis PB, Ward TJ, Shah RP. A History and Modern Framework for Quality Improvement in Interventional Radiology. J Vasc Interv Radiol 2023; 34:2012-2019. [PMID: 37517464 DOI: 10.1016/j.jvir.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/17/2023] [Accepted: 07/20/2023] [Indexed: 08/01/2023] Open
Abstract
Quality improvement (QI) initiatives have benefited patients as well as the broader practice of medicine. Large-scale QI has been facilitated by multi-institutional data registries, many of which were formed out of national or international medical society initiatives. With broad participation, QI registries have provided benefits that include but are not limited to establishing treatment guidelines, facilitating research related to uncommon procedures and conditions, and demonstrating the fiscal and clinical value of procedures for both medical providers and health systems. Because of the benefits offered by these databases, Society of Interventional Radiology (SIR) and SIR Foundation have committed to the development of an interventional radiology (IR) clinical data registry known as VIRTEX. A large IR database with participation from a multitude of practice environments has the potential to have a significant positive impact on the specialty through data-driven advances in patient safety and outcomes, clinical research, and reimbursement. This article reviews the current landscape of societal QI programs, presents a vision for a large-scale IR clinical data registry supported by SIR, and discusses the anticipated results that such a framework can produce.
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Affiliation(s)
- Drew M Caplin
- Division of Interventional Radiology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, New Hyde Park, New York.
| | - Shamar Young
- Department of Medical Imaging, University of Arizona College of Medicine, Tucson, Arizona
| | - Michael Kassin
- National Institutes of Health Clinical Center, Center for Interventional Oncology, Bethesda, Maryland
| | | | - Mina S Makary
- Division of Vascular and Interventional Radiology, Department of Radiology, Ohio State University Columbus, Ohio
| | - Zeyad A Metwalli
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Resmi A Charalel
- Division of Interventional Radiology, Department of Radiology, and Department of Population Health Sciences (R.A.C.), New York Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Neil J Halin
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Mark Kleedehn
- National Institutes of Health Clinical Center, Center for Interventional Oncology, Bethesda, Maryland
| | - Paul B Lewis
- Department of Radiology, University of Pittsburgh Physicians, Pittsburgh, Pennsylvania
| | - Thomas J Ward
- Department of Radiology, Advent Health Medical Group/Central Florida Division, Orlando, Florida
| | - Rajesh P Shah
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Department of Radiology, Stanford University, Stanford, California
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14
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Dobesh PP, Goldsweig AM. Antithrombotic therapy with Transcatheter aortic valve replacement. Pharmacotherapy 2023; 43:1064-1083. [PMID: 37464970 DOI: 10.1002/phar.2847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 07/20/2023]
Abstract
Aortic valve replacement is a necessary management strategy for patients with severe aortic stenosis. The use of transaortic valve replacement (TAVR) has increased significantly over the last decade and now exceeds traditional surgical aortic valve replacement. Since the valve systems used in TAVR consist of bioprosthetic valve tissue encased in a metal stent frame, antithrombotic therapy recommendations cannot be extrapolated from prior data with differently constructed surgical bioprosthetic or mechanical valves. Data on the use of antithrombotic therapy with TAVR are a rapidly developing area of medicine. Choice of agents depends on several patient factors. Patients undergoing TAVR also have a relatively high incidence of subclinical valve thrombosis. The clinical impact of this phenomenon and the implications for antithrombotic therapy continue to evolve. It is critical for clinicians who treat patients undergoing TAVR to have a firm understanding of practice guidelines, the evolving evidence, and its implications for the use of antithrombotic therapy in these patients.
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Affiliation(s)
- Paul P Dobesh
- Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andrew M Goldsweig
- Cardiac Catheterization Laboratory, Cardiovascular Clinical Research, Baystate Medical Center, Springfield, Massachusetts, USA
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15
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Schaffer AJ, Li G, McIlroy DR, Lopez MG, Freundlich RE. Effects of Postoperative Blood Pressure Management on Delirium Among Patients in the Intensive Care Unit After Cardiac Surgery: An Observational Cohort Study. J Cardiothorac Vasc Anesth 2023; 37:1683-1690. [PMID: 37244820 PMCID: PMC10524613 DOI: 10.1053/j.jvca.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/17/2023] [Accepted: 05/05/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVES This study aimed to determine whether blood pressure control in the early postoperative period was associated with postoperative delirium in the cardiovascular intensive care unit (ICU). DESIGN Observational cohort study. SETTING Single large academic institution with a high volume of cardiac surgery. PARTICIPANTS Cardiac surgery patients admitted to the cardiovascular ICU after surgery. INTERVENTIONS Observational study. MEASUREMENTS AND MAIN RESULTS A total of 517 cardiac surgery patients had mean arterial pressure (MAP) data recorded minute-by-minute for 12 postoperative hours. The time spent in each of the 7 prespecified blood pressure bands was calculated, and the development of delirium was recorded in the ICU. A multivariate Cox regression model was developed using the least absolute shrinkage and selection operator approach to identify associations between time spent in each MAP range band and delirium. Compared with the reference band of 60-to-69 mmHg, longer durations spent in 3 bands were independently associated with a lower risk of delirium: 50-to-59 mmHg band (adjusted hazard ratio [HR] 0.907 [per 10 minutes]; 95% CI 0.861-0.955); 70-to-79 mmHg band (adjusted HR 0.923 [per 10 minutes]; 95% CI 0.902-0.944); 90-to-99 mmHg band (adjusted HR 0.898 [per 10 minutes]; 95% CI 0.853-0.945). CONCLUSIONS The MAP range bands above and below the authors' reference band of 60-to- 69 mmHg were associated with decreased risk of ICU delirium development; however, this was difficult to reconcile with a plausible biologic mechanism. Therefore, the authors did not find a correlation between early postoperative MAP control and increased risk of the development of ICU delirium after cardiac surgery.
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Affiliation(s)
| | - Gen Li
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David R McIlroy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Anaesthesia & Perioperative Medicine, Monash University, Melbourne, Australia
| | - Marcos G Lopez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert E Freundlich
- Department of Anesthesiology, Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.
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16
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Newell P, Javadikasgari H, Rojas-Alexandre M, Hirji S, Harloff M, Cherkasky O, McGurk S, Malarczyk A, Shah P, Sabe A, Kaneko T. All-cause procedural readmissions following transcatheter aortic valve replacement. JTCVS OPEN 2023; 15:83-93. [PMID: 37808066 PMCID: PMC10556937 DOI: 10.1016/j.xjon.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 04/12/2023] [Accepted: 05/01/2023] [Indexed: 10/10/2023]
Abstract
Objective With expanding eligibility criteria, transcatheter aortic valve replacement is being performed on patients with longer life expectancy, and subsequent procedures after index transcatheter aortic valve replacement are inevitable. This study examines the incidence and outcomes of patients undergoing subsequent procedural readmissions after transcatheter aortic valve replacement. Methods All patients who underwent index transcatheter aortic valve replacement and were discharged alive from January 2012 to December 2019 at a single institution were evaluated. Study end points were mortality and readmission for procedure with more than 1-day hospital stay. Effect on survival was evaluated by treating procedural readmission as a time-dependent variable by Cox proportional hazard model and competing risk analysis. Results A total of 1092 patients met inclusion criteria with a median follow-up time of 34 months. A total of 218 patients (20.0%) had 244 subsequent procedural readmissions. During the 244 procedural readmissions, there were 260 procedures; 96 (36.9%) were cardiac (most commonly pacemaker implantation, percutaneous coronary interventions, and surgical aortic valve replacements), and 164 (63.1%) were noncardiac (most commonly orthopedic and gastrointestinal procedures). The overall procedural readmission rates were 32%, 39%, and 42%, and all-cause mortality was 27%, 44%, and 54% at 20, 40, and 60 months, respectively. Procedural readmissions were not associated with a survival penalty in any surgical risk group or on Cox regression (hazard ratio, 1.25; 0.91-1.64, P = .17). Conclusions After transcatheter aortic valve replacement, procedural interventions are seen frequently, with most procedures occurring within the first year after transcatheter aortic valve replacement. However, subsequent procedural readmissions do not appear to have a survival penalty for patients after transcatheter aortic valve replacement. After transcatheter aortic valve replacement with resolution of aortic stenosis, subsequent procedures can and should be pursued if they are needed.
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Affiliation(s)
- Paige Newell
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Hoda Javadikasgari
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Mehida Rojas-Alexandre
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Morgan Harloff
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Olena Cherkasky
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Alexandra Malarczyk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Pinak Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Ashraf Sabe
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Washington University School of Medicine, St Louis, Mo
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Liu TX, Tanenbaum MT, Seo CH, Park D, Lystash JC, Joseph M, Arnold WS. Left Ventricular Diastolic Dysfunction and Pulmonary Hypertension: Outcomes in SAVR. Thorac Cardiovasc Surg 2023; 71:398-406. [PMID: 33862634 DOI: 10.1055/s-0041-1727138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Severe pulmonary hypertension (PH) and left ventricular diastolic dysfunction (LVDD) are independently associated with poor outcomes in cardiac surgery. We evaluated the relationship of several measures of LVDD, PH, and hemodynamic subtypes of PH including precapillary pulmonary hypertension(pcPH) and isolated post-capillary pulmonary hypertension(ipcPH) and combined pre and post capillary pulmonary hypertension(cpcPH) capillary PH to postoperative outcomes in a cohort of patients who underwent elective isolated-AVR. METHODS We evaluated (n = 206) patients in our local STS database who underwent elective isolated-AVR between 2014 and 2018, with transthoracic echocardiogram (n = 177) or right heart catheterization (n = 183) within 1 year of operation (or both, n = 161). The primary outcome was a composite end point of death, prolonged ventilation, ICU readmission, and hospital stay >14 days. RESULTS Severe PH was associated with worse outcomes (moderate: OR, 1.1, p = 0.09; severe: OR, 1.28, p = 0.01), but degree of LVDD was not associated with worse outcomes. Across hemodynamic subtypes of PH, odds of composite outcome were similar (p = 0.89), however, patients with cpcPH had more postoperative complications (67 vs. 36%, p = 0.06) and patients with ipcPH had greater all-cause mortality at 1 (8 vs. 1%, p = 0.03) and 3 years (27 vs. 4%, p = 0.008). CONCLUSION Severe PH conferred modestly greater risk of adverse events, and both LVDD grade and the combination of severe PH and LVDD were not associated with worse outcomes. However, hemodynamic stratification of PH revealed higher postoperative complications and worse long-term outcomes for those with cpcPH and ipcPH. Preoperative stratification of PH by hemodynamic subtype in valve replacement surgery may improve our risk stratification in this heterogenous condition. Further evaluation of the significance of LVDD and PH in other cardiac operations is warranted.
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Affiliation(s)
- Tom X Liu
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - Mira T Tanenbaum
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
| | - Claire H Seo
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
| | - Dan Park
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
| | - John C Lystash
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - Mark Joseph
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - William S Arnold
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States
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Lauck SB, Yu M, Pu A, Virani S, Meier D, Akodad M, Sathananthan J, Chan AW, Price J, Wong D, Wood DA, Webb JG, Abel JG. Temporal Changes in Quality Indicators in a Regional System of Care After Surgical and Transcatheter Aortic Valve Replacement. CJC Open 2023; 5:508-521. [PMID: 37496781 PMCID: PMC10366640 DOI: 10.1016/j.cjco.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/27/2023] [Indexed: 07/28/2023] Open
Abstract
Background Historically, quality-of-care monitoring was performed separately for transcatheter and surgical aortic valve replacement (TAVR, SAVR). Using consensus indicators, we provide a global report on the quality of care for treatment of aortic stenosis across the highest-volume treatments: transfemoral (TF) TAVR, isolated SAVR, and SAVR combined with coronary artery bypass graft. Methods Retrospective observational cohort study of consecutive patients in a regional system of care. Primary endpoint was 30-day and 1-year mortality (2015-2019). Secondary endpoints included rate of new pacemaker, rate of readmission, and length of stay (2012-2019). Following multivariable logistic regressions, we developed mortality case-mix adjustment models to report risk estimates. Results The proportion of patients receiving TAVR grew from 32% to 53% (2015-2019). Those receiving TF TAVR were significantly older, with higher rates of comorbidities. Observed 30-day and 1-year all-cause mortality after TF TAVR decreased from 3.1% to 0.6% (P = 0.03), and 13.6% to 6.6% (P = 0.09), respectively; surgical mortality rates for isolated SAVR and SAVR combined with coronary artery bypass graft were low and did not change significantly over time, ranging from 0.3% to 1.4% and from 0.9% to 3.4%, respectively at 30 days, and from 0.9% to 3.4% and from 4.7% to 6.7 at 1 year. In the TF TAVR cohort, the observed vs expected ratio for 30-day and 1-year mortality decreased significantly from 1.9 (95% confidence interval [CI] 0.9, 3.5) to 0.3 (95% CI 0.1, 0.8), and from 1.3 (95% CI 0.9, 1.7) to 0.7 (95% CI 0.5, 0.99), respectively; no change occurred in risk-adjusted surgical mortality. Conclusions Consensus quality indicators provide unique insights on the quality of care for patients receiving treatment for aortic stenosis.
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Affiliation(s)
- Sandra B. Lauck
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Maggie Yu
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Aihua Pu
- Cardiac Services BC, Vancouver, British Columbia, Canada
| | - Sean Virani
- Cardiac Services BC, Vancouver, British Columbia, Canada
| | - David Meier
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mariam Akodad
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques-Cartier, Ramsay Santé, Massy, France
| | - Janarthanan Sathananthan
- University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Albert W. Chan
- Division of Cardiology, Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Joel Price
- Division of Cardiovascular and Thoracic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniel Wong
- Department of Cardiac Surgery, Royal Columbian Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - David A. Wood
- University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - John G. Webb
- University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - James G. Abel
- University of British Columbia, Vancouver, British Columbia, Canada
- Division of Cardiovascular and Thoracic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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19
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Colson PH, Gaudard P, Meunier C, Seguret F. Impact of Red Blood Cell Transfusion on In-hospital Mortality of Isolated Coronary Artery Bypass Graft Surgery: A Retrospective Observational Study of French Nationwide 3-year Cohort. Ann Surg 2023; 278:e184-e189. [PMID: 35762599 DOI: 10.1097/sla.0000000000005488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the relationship between red blood cell (RBC) transfusion exposure and in-hospital mortality after isolated coronary artery bypass graft (CABG) surgery. BACKGROUND RBC transfusion was commonly used to treat anemia in isolated CABG surgery, but transfusion was found an independent risk factor of postoperative mortality; recent guidelines on patient blood management strategy issued in the last decade may have changed transfusion incidence and related mortality. METHODS A retrospective cohort study was conducted from the National database on patients' hospital discharge reports. Consecutive adult patients who underwent isolated CABG surgery in France from January 1, 2016, to December 31, 2018, were included. The primary outcome was the in-hospital mortality rate. RBC transfusion during the hospital stay was identified by specific codes and ordered as categorical variables (no, moderate, or massive transfusion). RESULTS A total of 37,498 participants were studied [mean (SD) age, 66.5 (9.6) years, 31,587 (84.2%) were men]. In-hospital mortality rate was 1.45% (n=541) and RBC transfusion rate was 9.4% (n=3521). In-hospital deaths were more frequent among transfused patients [1.06% (361) if no transfusion up to 10.2% (n=113) if massive transfusion]. After adjustment for confounding variables, RBC transfusion remained a significant independent factor of in-hospital mortality: odds ratio=1.66 (95% confidence interval: 1.27-2.19, P <0.001) for moderate transfusion, 6.40 (95% confidence interval: 5.07-8.09, P <0.001) if massive. CONCLUSIONS AND RELEVANCE Despite a modest patients' exposure to transfusion, this study suggests that RBC administration is an independent factor of in-hospital mortality in isolated CABG surgery.
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Affiliation(s)
- Pascal H Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, Montpellier, France
- Montpellier University, INSERM, CNRS, Institute of Functional Genomics, Montpellier, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, Montpellier, France
- Montpellier University, INSERM, CNRS, PhyMedExp, Montpellier, France
| | - Charles Meunier
- Unit of Evaluation and Epidemiologic Studies on National Hospitalization Activity Databases, Department of Epidemiology, Biostatistics and Medical Information, Montpellier University Hospital, Montpellier, France
| | - Fabienne Seguret
- Unit of Evaluation and Epidemiologic Studies on National Hospitalization Activity Databases, Department of Epidemiology, Biostatistics and Medical Information, Montpellier University Hospital, Montpellier, France
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20
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Sattar L, Reyaz I, Rawat A, Mannam R, Karumanchi A, Depa VGR, Batool S, Usama M. Comparison Between Dexmedetomidine and Propofol for Sedation on Outcomes After Cardiac Surgery in Patients Requiring Mechanical Ventilation: A Meta-Analysis of Randomized-Control Trials. Cureus 2023; 15:e42212. [PMID: 37609090 PMCID: PMC10441820 DOI: 10.7759/cureus.42212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 08/24/2023] Open
Abstract
The aim of this study was to compare outcomes between dexmedetomidine and propofol for sedation after cardiac surgery in patients requiring mechanical ventilation. This meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Online databases, including EMBASE, PubMed, and the Cochrane Library, were comprehensively searched to identify relevant randomized controlled trials (RCTs) comparing the safety and efficacy of dexmedetomidine and propofol in patients undergoing cardiac surgery and requiring mechanical ventilation. The examined outcomes included the mean length of intensive care unit (ICU) stay in hours, duration of mechanical ventilation in hours, length of hospital stay in days, and number of patients diagnosed with delirium. A total of 14 studies were included in the present meta-analysis while 1360 patients undergoing cardiac surgery were involved in these studies. Pooled results showed that the duration of mechanical ventilation was lower in the dexmedetomidine group compared to the propofol group (mean difference (MD): 0.75, 95% confidence interval (CI): 0.06-1.44, p-value: 0.03). We also found a significantly low length of stay in ICU in the dexmedetomidine group compared to the propofol (MD: 0.89, 95% CI: 0.04-1.74, p-value: 0.04). The length of hospital stay was also significantly lower in patients receiving dexmedetomidine as compared to the propofol group (MD: 0.51, 95% CI: 0.32-0.70, p-value<0.001). Risk of delirium was significantly higher in patients receiving propofol compared to patients receiving dexmedetomidine (RR: 2.02, 95% CI: 1.48-2.74, p-value<0.001). In conclusion, our meta-analysis provides evidence of the beneficial impacts of dexmedetomidine on clinical outcomes in patients undergoing cardiac surgery. Dexmedetomidine was associated with a significant reduction in the duration of mechanical ventilation, length of stay in the intensive care unit (ICU) and hospital, and the risk of delirium.
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Affiliation(s)
- Lubna Sattar
- Medicine, Shadan Institute of Medical Sciences, Hyderabad, IND
| | - Ibrahim Reyaz
- Internal Medicine, Christian Medical College and Hospital, Ludhiana, IND
| | - Anurag Rawat
- Interventional Cardiology, Himalayan Institute of Medical Sciences, Dehradun, IND
| | - Raam Mannam
- General Surgery, Narayana Medical College, Nellore, IND
| | | | | | - Saima Batool
- Internal Medicine, Hameed Latif Hospital, Lahore, PAK
| | - Muhammad Usama
- Neurology, Sheikh Zayed Medical College & Hospital, Rahim Yar Khan, PAK
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21
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Percy ED, Harloff M, Hirji S, Tartarini RJ, McGurk S, Cherkasky O, Kaneko T. Outcomes of procedural complications in transfemoral transcatheter aortic valve replacement. J Thorac Cardiovasc Surg 2023; 165:1346-1355.e5. [PMID: 34053738 DOI: 10.1016/j.jtcvs.2021.04.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES As the application of transcatheter aortic valve replacement (TAVR) expands, the longitudinal implications of periprocedural complications are increasingly relevant. We examine the influence of TAVR complications on midterm survival. METHODS Patients undergoing transfemoral TAVR at our institution between November 2011 and June 2018 were reviewed. Stroke severity was classified according to the National Institutes of Health stroke score. Kaplan-Meier analysis was used to assess survival, and a Cox proportional hazards model was created to examine independent associations with survival. The median follow-up time was 36 months for a total of 2789 patient-years. RESULTS Overall, 866 patients were included. The mean age was 80 ± 9.5 years and mean Society of Thoracic Surgeons score was 4.8% ± 2.7%. The mortality rate at 30-days was 2.8% and 11.8% at 1 year. In-hospital left bundle branch block and 30-day permanent pacemaker insertion occurred in 14.8% and 7.9%, respectively. Postprocedural greater-than-mild paravalvular leak was present in 4.4% and stroke occurred in 3.8% at 30-days. Greater-than-mild paravalvular leak was associated with decreased survival at 2 years (P = .02), but not at 5 years. Severe stroke was independently associated with decreased survival at 5 years (hazard ratio, 5.73; 95% confidence interval, 2.29-14.36; P ≤ .001); however, the effect of nonsevere stroke did not reach significance (hazard ratio, 1.69; 95% confidence interval, 0.82-3.47; P = .152). CONCLUSIONS Severe stroke was independently associated with decreased 5-year survival and initial risks associated with paravalvular leak may be attenuated over the midterm following transfemoral TAVR. Strategies to minimize the incidence of stroke and paravalvular leak must be prioritized to improve longitudinal outcomes after TAVR.
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Affiliation(s)
- Edward D Percy
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Division of Cardiovascular Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Morgan Harloff
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sameer Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | | | - Siobhan McGurk
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Olena Cherkasky
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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22
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Colson P, Fellahi JL, Gaudard P, Provenchère S, Rozec B. Cost Analysis of Aprotinin Reintroduction in French Cardiac Surgery Centres: A Real-World Data-Based Analysis. Adv Ther 2023; 40:1803-1817. [PMID: 36867329 PMCID: PMC10070296 DOI: 10.1007/s12325-023-02464-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/14/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION The European Medicines Agency restored aprotinin (APR) use for preventing blood loss in patients undergoing isolated coronary artery bypass graft (iCABG) in 2016 but requested the collection of patient and surgery data in a registry (NAPaR). The aim of this analysis was to evaluate the impact of APR reintroduction in France on the main hospital costs (operating room, transfusion and intensive unit stay) compared to the current use of tranexamic acid (TXA), which was the only antifibrinolytic available before APR reinstatement. METHODS A multicenter before-after post-hoc analysis to compare APR and TXA was carried out in four French university hospitals. APR use followed the ARCOTHOVA (French Association of Cardiothoracic and Vascular Anesthetists) protocol, which had framed three main indications in 2018. Data from 236 APR patients were retrieved from the NAPaR (N = 874); 223 TXA patients were retrospectively retrieved from each center database and matched to APR patients upon indication classes. Budget impact was evaluated using both direct costs associated with antifibrinolytics and transfusion products (within the first 48 h) and other costs such as surgery duration and ICU stay. RESULTS The 459 collected patients were distributed as: 17% on-label; 83% off-label. Mean cost per patient until ICU discharge tended to be lower in the APR group versus the TXA group, which resulted in an estimated gross saving of €3136 per patient. These savings concerned operating room and transfusion costs but were mainly driven by reduced ICU stays. When extrapolated to the whole French NAPaR population, the total savings of the therapeutic switch was estimated at around €3 million. CONCLUSION The budget impact projected that using APR according to ARCOTHOVA protocol resulted in decreased requirement for transfusion and complications related to surgery. Both were associated with substantial cost savings from the hospital's perspective compared with exclusive use of TXA.
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Affiliation(s)
- Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, 371 avenue du doyen Gaston Giraud, 34295, Montpellier, France.
- Montpellier University, INSERM, CNRS, Institut de Génomique Fonctionnelle, Montpellier, France.
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care Medicine, Louis Pradel Hospital, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France
- Laboratoire CarMeN, Inserm U1060, Université Claude Bernard Lyon 1, Lyon, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, 371 avenue du doyen Gaston Giraud, 34295, Montpellier, France
- University of Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Sophie Provenchère
- Department of Anesthesiology and Critical Care Medecine, AP-HP, Bichat-Claude-Bernard Hospital, Paris, France
- INSERM Clinical Investigation Center 007, Paris, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes, France
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, 44093, Nantes, France
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23
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Cordoves EM, Vunjak-Novakovic G, Kalfa DM. Designing Biocompatible Tissue Engineered Heart Valves In Situ: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:994-1003. [PMID: 36889879 PMCID: PMC10666973 DOI: 10.1016/j.jacc.2022.12.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/19/2022] [Indexed: 03/08/2023]
Abstract
Valvular heart disease is a globally prevalent cause of morbidity and mortality, with both congenital and acquired clinical presentations. Tissue engineered heart valves (TEHVs) have the potential to radically shift the treatment landscape for valvular disease by functioning as life-long valve replacements that overcome the current limitations of bioprosthetic and mechanical valves. TEHVs are envisioned to meet these goals by functioning as bioinstructive scaffolds that guide the in situ generation of autologous valves capable of growth, repair, and remodeling within the patient. Despite their promise, clinical translation of in situ TEHVs has proven challenging largely because of the unpredictable and patient-specific nature of the TEHV and host interaction following implantation. In light of this challenge, we propose a framework for the development and clinical translation of biocompatible TEHVs, wherein the native valvular environment actively informs the valve's design parameters and sets the benchmarks by which it is functionally evaluated.
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Affiliation(s)
- Elizabeth M Cordoves
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University, New York, New York, USA; Department of Medicine, Columbia University, New York, New York, USA.
| | - David M Kalfa
- Division of Cardiac, Thoracic and Vascular Surgery, Section of Pediatric and Congenital Cardiac Surgery, New-York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, USA.
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Kim KM, Arghami A, Habib R, Daneshmand MA, Parsons N, Elhalabi Z, Krohn C, Thourani V, Bowdish ME. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2022 Update on Outcomes and Research. Ann Thorac Surg 2023; 115:566-574. [PMID: 36623634 DOI: 10.1016/j.athoracsur.2022.12.033] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/05/2022] [Accepted: 12/10/2022] [Indexed: 01/08/2023]
Abstract
The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It is one of the most respected clinical data registries in health care, providing accurate risk-adjusted benchmarks, a foundation for quality measurement and improvement activities, and the ability to perform novel research. This report encompasses data from the years 2020 and 2021 and is the seventh in a series of reports that provide updated volumes, outcomes, database-related developments, and research summaries using the Adult Cardiac Surgery Database.
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Affiliation(s)
- Karen M Kim
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert Habib
- The Society of Thoracic Surgeons, Chicago, Illinois
| | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Carole Krohn
- The Society of Thoracic Surgeons, Chicago, Illinois
| | - Vinod Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Mariani S, van Bussel BCT, Ravaux JM, Roefs MM, De Piero ME, Di Mauro M, Willers A, Segers P, Delnoij T, van der Horst ICC, Maessen J, Lorusso R. Variables associated with in-hospital and postdischarge outcomes after postcardiotomy extracorporeal membrane oxygenation: Netherlands Heart Registration Cohort. J Thorac Cardiovasc Surg 2023; 165:1127-1137.e14. [PMID: 36229294 DOI: 10.1016/j.jtcvs.2022.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) for postcardiotomy cardiogenic shock has been increasingly used without concomitant mortality reduction. This study aims to investigate determinants of in-hospital and postdischarge mortality in patients requiring postcardiotomy ECMO in the Netherlands. METHODS The Netherlands Heart Registration collects nationwide prospective data from cardiac surgery units. Adults receiving intraoperative or postoperative ECMO included in the register from January 2013 to December 2019 were studied. Survival status was established through the national Personal Records Database. Multivariable logistic regression analyses were used to investigate determinants of in-hospital (3 models) and 12-month postdischarge mortality (4 models). Each model was developed to target specific time points during a patient's clinical course. RESULTS Overall, 406 patients (67.2% men, median age, 66.0 years [interquartile range, 55.0-72.0 years]) were included. In-hospital mortality was 51.7%, with death occurring in a median of 5 days (interquartile range, 2-14 days) after surgery. Hospital survivors (n = 196) experienced considerable rates of pulmonary infections, respiratory failure, arrhythmias, and deep sternal wound infections during a hospitalization of median 29 days (interquartile range, 17-51 days). Older age (odds ratio [OR], 1.02; 95% CI, 1.0-1.04) and preoperative higher body mass index (OR, 1.08; 95% CI, 1.02-1.14) were associated with in-hospital death. Within 12 months after discharge, 35.1% of hospital survivors (n = 63) died. Postoperative renal failure (OR, 2.3; 95% CI, 1.6-4.9), respiratory failure (OR, 3.6; 95% CI, 1.3-9.9), and re-thoracotomy (OR, 2.9; 95% CI, 1.3-6.5) were associated with 12-month postdischarge mortality. CONCLUSIONS In-hospital and postdischarge mortality after postcardiotomy ECMO in adults remains high in the Netherlands. ECMO support in patients with higher age and body mass index, which drive associations with higher in-hospital mortality, should be carefully considered. Further observations suggest that prevention of re-thoracotomies, renal failure, and respiratory failure are targets that may improve postdischarge outcomes.
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Affiliation(s)
- Silvia Mariani
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
| | - Bas C T van Bussel
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Justine M Ravaux
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Maaike M Roefs
- Netherlands Heart Registration, Utrecht, The Netherlands
| | - Maria Elena De Piero
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Anne Willers
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Patrique Segers
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Thijs Delnoij
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jos Maessen
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; Netherlands Heart Registration, Utrecht, The Netherlands
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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Chen J, Zhang T, Feng D, Liu Y, Zhang T, Wang J, Liu L. A 9-year analysis of medical malpractice litigations in coronary artery bypass grafting in China. J Cardiothorac Surg 2023; 18:73. [PMID: 36782245 PMCID: PMC9926683 DOI: 10.1186/s13019-023-02172-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 01/27/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND The coronary artery bypass grafting (CABG) is one of the high-risk litigated medical specialties. Further elucidating the causes behind these malpractice claims can help physicians avoid patient injury. This study analyzed CABG litigations occurred in different level hospitals to outline the basic characteristics, as well as present a analysis on the medical malpractice that result in lawsuits. METHODS This study utilized the "China Judgments Online" database to compile litigations from 2012 to 2021 across China. 109 cases related to the CABG were included in the study, and were analyzed for demographic, patient outcomes and verdict characteristics in different levels of hospitals. RESULTS The median age of plaintiff patient was 62 years, the median length of stay was 25 days, and the median responsibility ratio of the litigation cases was 30%. The average proportion of responsibility of national, provincial and municipal hospitals were 29.6%, 28.4% and 39.5% respectively, and the median days after surgery to death of that were 15, 9 and 5 separately. The top 5 postoperative complications in dispute cases were: low cardiac output syndrome, postoperative hemorrhage, non-surgical site infections, surgical site infections and arrhythmia. CONCLUSIONS The diagnosis and treatment capabilities of coronary artery bypass grafting in different levels of hospitals in China were inconsistent, and the treatment capabilities in prefecture-level hospitals were lower than that in national hospitals. The procedural error, failure to properly monitor the patient and diagnostic errors were common in CABG litigations. Postoperative complications related to surgical injuries and insufficient basic postoperative management lead to a higher responsibility proportion.
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Affiliation(s)
- Jie Chen
- grid.488137.10000 0001 2267 2324Medical School of Chinese People’s Liberation Army, Beijing, China ,grid.411634.50000 0004 0632 4559Department of Medical Quality Management, Peking University People’s Hospital, Beijing, China
| | - Tianyi Zhang
- grid.414252.40000 0004 1761 8894Institution of Hospital Management, Medical Innovation Research Division of Chinese PLA General Hospital, Beijing, China
| | - Dan Feng
- grid.414252.40000 0004 1761 8894Institution of Hospital Management, Medical Innovation Research Division of Chinese PLA General Hospital, Beijing, China
| | - Yuehui Liu
- grid.414252.40000 0004 1761 8894Institution of Hospital Management, Medical Innovation Research Division of Chinese PLA General Hospital, Beijing, China
| | - Tao Zhang
- grid.411634.50000 0004 0632 4559Department of Vascular Surgery, Peking University People’s Hospital, Beijing, China
| | - Jingtong Wang
- Department of Medical Quality Management, Peking University People's Hospital, Beijing, China.
| | - Lihua Liu
- Institution of Hospital Management, Medical Innovation Research Division of Chinese PLA General Hospital, Beijing, China.
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Newell P, Percy E, Hirji S, Harloff M, McGurk S, Malarczyk A, Chowdhury M, Yazdchi F, Kaneko T. Outcomes of Mitral Valve Repair Among High- and Low-Volume Surgeons Within a High-Volume Institution. Ann Thorac Surg 2023; 115:412-419. [PMID: 35779603 DOI: 10.1016/j.athoracsur.2022.05.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/02/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Volume-outcome relationships have been described for mitral valve repair at the institution and surgeon level. We aimed to assess whether this relationship is mitigated at high-volume (HV) mitral repair centers between HV and low-volume (LV) surgeons. METHODS All mitral repair cases at an HV mitral center (mean, 192 annual repairs) from 1992 to 2018 were considered. Cases with concomitant procedures other than tricuspid and atrial fibrillation procedures were excluded. Surgeons who performed ≥25 repairs per year were considered HV. The primary outcome was operative mortality; secondary outcomes were operative complications, long-term mortality, and reoperation. RESULTS In total, 2653 mitral repairs from 19 surgeons were included. The mean age of the patients in the HV and LV groups was 59.6 years and 61.8 years, respectively (P = .005), with no difference in other baseline characteristics. HV surgeons had significantly shorter median aortic cross-clamp times (80 vs 87 minutes; P < .001) compared with LV surgeons; however, there was no significant difference in operative mortality (0.9% vs 1.6%; P = .19), reoperation, perioperative complications, or length of stay. LV surgeons had higher repair conversion to replacement than HV surgeons did (9.0% vs 3.4%; P < .001). In the risk-adjusted analyses, surgeon volume group did not have an impact on longitudinal survival or reoperation. CONCLUSIONS At an HV mitral repair institution, LV surgeons appear to have short- and long-term outcomes similar to those of HV surgeons despite increased conversion rates. These findings suggest that institutional volume may mitigate the surgeon volume outcome. However, complex repairs may benefit from referral to HV surgeons, given the lower conversion rate.
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Affiliation(s)
- Paige Newell
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Edward Percy
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Division of Cardiac Surgery, University of British Columbia, Vancouver, British Columbia
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Morgan Harloff
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Alexandra Malarczyk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Farhang Yazdchi
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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Liu Q, Luo Q, Li Y, Wu X, Wang H, Huang J, Jia Y, Yuan S, Yan F. A simple-to-use nomogram for predicting prolonged mechanical ventilation for children after Ebstein anomaly corrective surgery: a retrospective cohort study. BMC Anesthesiol 2023; 23:24. [PMID: 36639642 PMCID: PMC9839444 DOI: 10.1186/s12871-022-01942-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/13/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Prolonged mechanical ventilation (PMV) after pediatric cardiac surgery imposes a great burden on patients in terms of morbidity, mortality as well as financial costs. Ebstein anomaly (EA) is a rare congenital heart disease, and few studies have been conducted about PMV in this condition. This study aimed to establish a simple-to-use nomogram to predict the risk of PMV for EA children. METHODS The retrospective study included patients under 18 years who underwent corrective surgeries for EA from January 2009 to November 2021. PMV was defined as postoperative mechanical ventilation time longer than 24 hours. Through multivariable logistic regression, we identified and integrated the risk factors to develop a simple-to-use nomogram of PMV for EA children and internally validated it by bootstrapping. The calibration and discriminative ability of the nomogram were determined by calibration curve, Hosmer-Lemeshow goodness-of-fit test and receiver operating characteristic (ROC) curve. RESULTS Two hundred seventeen children were included in our study of which 44 (20.3%) were in the PMV group. After multivariable regression, we obtained five risk factors of PMV. The odds ratios and 95% confidence intervals (CI) were as follows: preoperative blood oxygen saturation, 0.876(0.805,0.953); cardiothoracic ratio, 3.007(1.107,8.169); Carpentier type, 4.644(2.065,10.445); cardiopulmonary bypass time, 1.014(1.005,1.023) and postoperative central venous pressure, 1.166(1.016,1.339). We integrated the five risk factors into a nomogram to predict the risk of PMV. The area under ROC curve of nomogram was 0.805 (95% CI, 0.725,0.885) and it also provided a good discriminative information with the corresponding Hosmer-Lemeshow p values > 0.05. CONCLUSIONS We developed a nomogram by integrating five independent risk factors. The nomogram is a practical tool to early identify children at high-risk for PMV after EA corrective surgery.
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Affiliation(s)
- Qiao Liu
- grid.506261.60000 0001 0706 7839Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Qipeng Luo
- grid.411642.40000 0004 0605 3760Department of Pain Medicine, Peking University Third Hospital, Beijing, China
| | - Yinan Li
- grid.506261.60000 0001 0706 7839Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Xie Wu
- grid.506261.60000 0001 0706 7839Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Hongbai Wang
- grid.506261.60000 0001 0706 7839Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Jiangshan Huang
- grid.506261.60000 0001 0706 7839Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Yuan Jia
- grid.506261.60000 0001 0706 7839Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Su Yuan
- grid.506261.60000 0001 0706 7839Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
| | - Fuxia Yan
- grid.506261.60000 0001 0706 7839Department of Anesthesiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037 China
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Ramdat Misier NL, van Schie MS, Li C, Oei FBS, van Schaagen FRN, Knops P, Taverne YJHJ, de Groot NMS. Epicardial high-resolution mapping of advanced interatrial block: Relating ECG, conduction abnormalities and excitation patterns. Front Cardiovasc Med 2023; 9:1031365. [PMID: 36712256 PMCID: PMC9878276 DOI: 10.3389/fcvm.2022.1031365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/29/2022] [Indexed: 01/15/2023] Open
Abstract
Background Impairment of conduction across Bachmann's Bundle (BB) may cause advanced interatrial block (a-IAB), which in turn is associated with development of atrial fibrillation. However, the exact relation between a complete transverse line of conduction block (CB) across BB and the presence of a-IAB has not been studied. Objective The aims of this study are to determine whether (1) a complete transversal line of CB across BB established by high resolution mapping correlates with a-IAB on the surface ECG, (2) conduction abnormalities at the right and left atria correlate with a-IAB, and (3) excitation patterns are associated with ECG characteristics of a-IAB. Methods We included 40 patients in whom epicardial mapping revealed a complete transverse line of CB across BB. Pre-operative ECGs and post-operative telemetry were assessed for the presence of (a) typical a-IAB and de novo early post-operative AF (EPOAF), respectively. Total atrial excitation time (TAET) and RA-LA delay were calculated. Entry site and trajectory of the main sinus rhythm wavefront at the pulmonary vein area (PVA) were assessed. Results Thirteen patients were classified as a-IAB (32.5%). In the entire atria and BB there were no differences in conduction disorders, though, patients with a-IAB had an increased TAET and longer RA-LA delay compared to patients without a-IAB (90.0 ± 21.9 ms vs. 74.9 ± 13.0 ms, p = 0.017; 160.0 ± 27.0 ms vs. 136.0 ± 24.1 ms, p = 0.012, respectively). Patients with typical a-IAB solely had caudocranial activation of the PVA, without additional cranial entry sites. Prevalence of de novo EPOAF was 69.2% and was similar between patients with and without a-IAB. Conclusion A transverse line of CB across BB partly explains the ECG characteristics of a-IAB. We found atrial excitation patterns underlying the ECG characteristics of both atypical and typical a-IAB. Regardless of the presence of a-IAB, the clinical impact of a complete transverse line of CB across BB was reflected by a high incidence of de novo EPOAF.
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Affiliation(s)
| | | | - Chunsheng Li
- Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Frans B. S. Oei
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
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Oettinger V, Hilgendorf I, Wolf D, Stachon P, Heidenreich A, Zehender M, Westermann D, Kaier K, von zur Mühlen C. Treatment of pure aortic regurgitation using surgical or transcatheter aortic valve replacement between 2018 and 2020 in Germany. Front Cardiovasc Med 2023; 10:1091983. [PMID: 37200971 PMCID: PMC10187752 DOI: 10.3389/fcvm.2023.1091983] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/17/2023] [Indexed: 05/20/2023] Open
Abstract
Background In pure aortic regurgitation, transcatheter aortic valve replacement (TAVR) is not yet used on a regular base. Due to constant development of TAVR, it is necessary to analyze current data. Methods By use of health records, we analyzed all isolated TAVR or surgical aortic valve replacements (SAVR) for pure aortic regurgitation between 2018 and 2020 in Germany. Results 4,861 procedures-4,025 SAVR and 836 TAVR-for aortic regurgitation were identified. Patients treated with TAVR were older, showed a higher logistic EuroSCORE, and had more pre-existing diseases. While results indicate a slightly higher unadjusted in-hospital mortality for transapical TAVR (6.00%) vs. SAVR (5.71%), transfemoral TAVR showed better outcomes, with self-expanding compared to balloon-expandable transfemoral TAVR having significantly lower in-hospital mortality (2.41% vs. 5.17%; p = 0.039). After risk adjustment, balloon-expandable as well as self-expanding transfemoral TAVR were associated with a significantly lower mortality vs. SAVR (balloon-expandable: risk adjusted OR = 0.50 [95% CI 0.27; 0.94], p = 0.031; self-expanding: OR = 0.20 [0.10; 0.41], p < 0.001). Furthermore, the observed in-hospital outcomes of stroke, major bleeding, delirium, and mechanical ventilation >48 h were significantly in favor of TAVR. In addition, TAVR showed a significantly shorter length of hospital stay compared to SAVR (transapical: risk adjusted Coefficient = -4.75d [-7.05d; -2.46d], p < 0.001; balloon-expandable: Coefficient = -6.88d [-9.06d; -4.69d], p < 0.001; self-expanding: Coefficient = -7.22 [-8.95; -5.49], p < 0.001). Conclusions TAVR is a viable alternative to SAVR in the treatment of pure aortic regurgitation for selected patients, showing overall low in-hospital mortality and complication rates, especially with regard to self-expanding transfemoral TAVR.
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Affiliation(s)
- Vera Oettinger
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Correspondence: Vera Oettinger
| | - Ingo Hilgendorf
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dennis Wolf
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Adrian Heidenreich
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center—University of Freiburg, Freiburg, Germany
| | - Constantin von zur Mühlen
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Eikelboom R, Whitlock RP, Lopes RD, Siegal D, Jaffer IH, Drakos P, Schulman S, Belley-Côté EP. How Did We Get Here? Antithrombotic Therapy after Bioprosthetic Aortic Valve Replacement: A Review. Thromb Haemost 2023; 123:6-15. [PMID: 36513278 DOI: 10.1055/s-0042-1758128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Aortic stenosis is the most common valvular disease, and more than 90% of patients who undergo aortic valve replacement receive a bioprosthetic valve. Yet optimal antithrombotic therapy after bioprosthetic aortic valve replacement remains uncertain, and guidelines provide contradictory recommendations. OBSERVATIONS Randomized studies of antithrombotic therapy after bioprosthetic aortic valve replacement are small and underpowered. Observational data present opposing, and likely confounded, results. Historically, changes to guidelines have not been informed by high-quality new data. Current guidelines from different professional bodies provide contradictory recommendations despite citing the same evidence. CONCLUSION Insufficient antithrombotic therapy after bioprosthetic aortic valve replacement has serious implications: ischemic stroke, systemic arterial thromboembolism, and clinical and subclinical valve thromboses. Unnecessarily intense antithrombotic therapy, however, increases risk of bleeding and associated morbidity and mortality. Professional bodies have used the current low-quality evidence and generated incongruent recommendations. Researchers should prioritize generating high-quality, randomized evidence evaluating the risks and benefits of antiplatelet versus anticoagulant therapy after bioprosthetic aortic valve replacement.
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Affiliation(s)
- Rachel Eikelboom
- Department of Surgery, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Richard P Whitlock
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Renato D Lopes
- Division of Cardiology, Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States
| | - Deborah Siegal
- Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Iqbal H Jaffer
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Paul Drakos
- Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Sam Schulman
- Division of Hematology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Emilie P Belley-Côté
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Minimal Extracorporeal Circulation and Microplegia in the Setting of Urgent Coronary Artery Bypass Grafting. J Clin Med 2022; 11:jcm11247488. [PMID: 36556103 PMCID: PMC9781499 DOI: 10.3390/jcm11247488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/01/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Background: We aimed to analyse the performance of minimal invasive extracorporeal circulation (MiECC) concomitantly with Microplegia, in patients with recent myocardial infarction (MI) undergoing urgent coronary artery bypass grafting (CABG) surgery. Methods: We included patients with a recent MI (≤7 days) undergoing isolated CABG surgery using MiECC. The primary endpoint was a major cardiovascular or cerebrovascular event (MACCE). In a secondary analysis, we compared our institutional Microplegia concept with the use of a crystalloid single-shot cardioplegic solution. Results: In total, 139 patients (mean ± standard deviation (SD) age 66 ± 10 years) underwent urgent CABG surgery using Microplegia; 55% (n = 77) of the patients had an acute MI within 1−7 days preoperatively; 20% (n = 28) had an acute MI within 6−24 h; and 24% (n = 34) had an acute MI within <6 h preoperatively. The number of distal anastomoses was a geometric mean of 4 (95% confidence interval 3−4). The MACCE and in-hospital mortality were 7% (n = 10) and 1% (n = 2), respectively. The results were confirmed in a secondary analysis comparing Microplegia with crystalloid cardioplegic solution (n = 271). Conclusion: The use of MiECC with Microplegia in urgent CABG surgery is feasible and safe and provides a straight-forward intraoperative setting. Therefore, it can also be considered to retain the benefits of MiECC in urgent CABG surgery.
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Velders BJ, Vriesendorp MD, Sabik JF, Dagenais F, Labrousse L, Bapat V, Aldea GS, Anyanwu AC, Cai Y, Klautz RJ. Pledgeted versus nonpledgeted sutures in aortic valve replacement: Insights from a prospective multicenter trial. JTCVS Tech 2022; 17:23-46. [PMID: 36820352 PMCID: PMC9938379 DOI: 10.1016/j.xjtc.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
Objective The objective of this study was to compare short- and midterm clinical and echocardiographic outcomes according to the use of pledgeted sutures during aortic valve replacement. Methods Patients with aortic stenosis or regurgitation requiring aortic valve replacement were enrolled in a prospective cohort study to evaluate the safety of a new stented bioprosthesis. Outcomes were analyzed according to the use of pledgets (pledgeted group) or no pledgets (nonpledgeted group). The primary outcome was a composite of thromboembolism, endocarditis, and major paravalvular leak at 5 years of follow-up. Secondary outcomes included multiple clinical endpoints and hemodynamic outcomes. Propensity score matching was performed to adjust for prognostic factors, and subanalyses with small valve sizes (<23 mm) and suturing techniques were performed. Results The pledgeted group comprised 640 patients (59%), and the nonpledgeted group 442 (41%), with baseline discrepancies in demographic characteristics, comorbidities, and stenosis severity. There were no differences between groups in any outcome. After propensity score matching, the primary outcome occurred in 41 (11.7%) patients in the pledgeted and 36 (9.8%) in the nonpledgeted group (P = .51). The effective orifice area was smaller in the pledgeted group (P = .045), whereas no difference was observed for the mean or peak pressure gradient. Separate subanalyses with small valve sizes and suturing techniques did not show relevant differences. Conclusions In this large propensity score-matched cohort, comprehensive clinical outcomes were comparable between patients who underwent aortic valve replacement with pledgeted and nonpledgeted sutures up to 5 years of follow-up, but pledgets might lead to a slightly smaller effective orifice area in the long run.
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Key Words
- AVR, aortic valve replacement
- BMI, body mass index
- BSA, body surface area
- EOA, effective orifice area
- EOAi, effective orifice area indexed
- LVOT, left ventricular outflow tract
- PERIGON, PERIcardial SurGical AOrtic Valve ReplacemeNt
- PPM, prosthesis–patient mismatch
- PVL, paravalvular leak
- STS, Society of Thoracic Surgeons
- endocarditis
- paravalvular leak
- pledgets
- surgical aortic valve replacement
- suturing technique
- thromboembolism
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Affiliation(s)
- Bart J.J. Velders
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, the Netherlands,Address for reprints: Bart J. J. Velders, MD, Department of Cardiothoracic Surgery, Leiden University Medical Centre, Albinusdreef 2, Leiden, Zuid-Holland 2333 ZA, The Netherlands.
| | - Michiel D. Vriesendorp
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Joseph F. Sabik
- Department of Surgery, University Hospitals, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Francois Dagenais
- Division of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec, Quebec, Canada
| | - Louis Labrousse
- Medico-Surgical Department of Valvulopathies, Bordeaux Heart University Hospital, Bourdeaux-Pessac, France
| | - Vinayak Bapat
- Department of Cardiothoracic Surgery, NHS Foundation Trust–St Thomas' Hospital, London, United Kingdom
| | - Gabriel S. Aldea
- Department of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Anelechi C. Anyanwu
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yaping Cai
- Core Clinical Solutions, Medtronic, Mounds View, Minn
| | - Robert J.M. Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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Liu VY, Pawar A, Weissman JS, Kim DH. Clinical outcomes of cardiovascular procedures in older patients with dementia. J Am Geriatr Soc 2022; 70:3315-3317. [PMID: 35770876 PMCID: PMC9669092 DOI: 10.1111/jgs.17936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/01/2022] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Victor Y. Liu
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Joel S. Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Dae Hyun Kim
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA
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Abstract
PURPOSE OF REVIEW Coronary artery disease (CAD) is responsible for >50% of heart failures cases. Patients with ischemic left ventricular systolic dysfunction (iLVSD) are known to have poorer outcomes after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) compared to patients with a normal ejection fraction. Nevertheless, <1% of patients in coronary revascularization trials to date had iLVSD. The purpose of this review is to describe coronary revascularization modalities in patients with iLVSD and highlight the need for randomized controlled trial evidence comparing these treatments in this patient population. RECENT FINDINGS Network meta-analytic findings of observational studies suggest that PCI is associated with higher rates of mortality, cardiac death, myocardial infarction, and repeat revascularization but not stroke compared to CABG in iLVSD. In recent years, outcomes for patients undergoing PCI have improved as a result of advances in technologies and techniques. SUMMARY The optimal coronary revascularization modality in patients with iLVSD remains unknown. In observational studies, CABG appears superior to PCI; however, direct randomized evidence is absent and developments in PCI techniques have improved post-PCI outcomes in recent years. The Surgical Treatment for Ischemic Heart Failure 3.0 consortium of trials will seek to address the clinical equipoise in coronary revascularization in patients with iLVSD.
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Mentias A, Desai MY, Keshvani N, Gillinov AM, Johnston D, Kumbhani DJ, Hirji SA, Sarrazin MV, Saad M, Peterson ED, Mack MJ, Cram P, Girotra S, Kapadia S, Svensson L, Pandey A. Ninety-Day Risk-Standardized Home Time as a Performance Metric for Cardiac Surgery Hospitals in the United States. Circulation 2022; 146:1297-1309. [PMID: 36154237 PMCID: PMC10776028 DOI: 10.1161/circulationaha.122.059496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 07/12/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Assessing hospital performance for cardiac surgery necessitates consistent and valid care quality metrics. The association of hospital-level risk-standardized home time for cardiac surgeries with other performance metrics such as mortality rate, readmission rate, and annual surgical volume has not been evaluated previously. METHODS The study included Medicare beneficiaries who underwent isolated or concomitant coronary artery bypass graft, aortic valve, or mitral valve surgery from January 1, 2013, to October 1, 2019. Hospital-level performance metrics of annual surgical volume, 90-day risk-standardized mortality rate, 90-day risk-standardized readmission rate, and 90-day risk-standardized home time were estimated starting from the day of surgery using generalized linear mixed models with a random intercept for the hospital. Correlations between the performance metrics were assessed using the Pearson correlation coefficient. Patient-level clinical outcomes were also compared across hospital quartiles by 90-day risk-standardized home time. Last, the temporal stability of performance metrics for each hospital during the study years was also assessed. RESULTS Overall, 919 698 patients (age 74.2±5.8 years, 32% women) were included from 1179 hospitals. Median 90-day risk-standardized home time was 71.2 days (25th-75th percentile, 66.5-75.6), 90-day risk-standardized readmission rate was 26.0% (19.5%-35.7%), and 90-day risk-standardized mortality rate was 6.0% (4.0%-8.8%). Across 90-day home time quartiles, a graded decline was observed in the rates of in-hospital, 90-day, and 1-year mortality, and 90-day and 1-year readmission. Ninety-day home time had a significant positive correlation with annual surgical volume (r=0.31; P<0.001) and inverse correlation with 90-day risk-standardized readmission rate (r=-0.40; P <0.001) and 90-day risk-standardized mortality rate (r=-0.60; P <0.001). Use of 90-day home time as a performance metric resulted in a meaningful reclassification in performance ranking of 22.8% hospitals compared with annual surgical volume, 11.6% compared with 90-day risk-standardized mortality rate, and 19.9% compared with 90-day risk-standardized readmission rate. Across the 7 years of the study period, 90-day home time demonstrated the most temporal stability of the hospital performance metrics. CONCLUSIONS Ninety-day risk-standardized home time is a feasible, comprehensive, patient-centered metric to assess hospital-level performance in cardiac surgery with greater temporal stability than mortality and readmission measures.
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Affiliation(s)
- Amgad Mentias
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Milind Y. Desai
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - A. Marc Gillinov
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Douglas Johnston
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Dharam J. Kumbhani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Sameer A. Hirji
- Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mary-Vaughan Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA
- Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA
| | - Marwan Saad
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, RI, USA
| | - Eric D. Peterson
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Michael J. Mack
- Division of Cardiology, Baylor Scott and White Health, Plano, TX
| | - Peter Cram
- Department of Internal Medicine University of Texas Medical Branch Galveston TX
| | - Saket Girotra
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA
- Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA
| | - Samir Kapadia
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lars Svensson
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
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Hospital intervention volume affects outcomes of emergency transcatheter aortic valve implantations in Germany. Sci Rep 2022; 12:17483. [PMID: 36261572 PMCID: PMC9581927 DOI: 10.1038/s41598-022-20336-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 09/12/2022] [Indexed: 01/12/2023] Open
Abstract
The literature has shown an inverse volume-outcome relationship for transcatheter aortic valve implantation (TAVI). However, little is known about emergency admissions in Germany. Using German national electronic health records, we identified all isolated balloon-expandable and self-expanding transfemoral TAVI in 2018. The focus was on those patients with emergency admission. 17,295 patients were treated with TAVI, including 1682 emergency cases. 49.2% of the emergency admissions were female, the mean age was 81.2 years and the logistic EuroSCORE was 23.3%. The percentage of emergency cases was higher in lower volume than in higher volume centers (p < 0.001): In detail, centers performing < 50 TAVI showed an emergency admission rate of ~ 15%, those with > 200 TAVI a rate of ~ 11%. After propensity score adjustment, analyzing the outcomes for an increase in volume per 10 emergency admissions, higher volume centers showed significantly better outcomes regarding in-hospital mortality (OR = 0.872, p = 0.043), major bleeding (OR = 0.772, p = 0.001), stroke (OR = 0.816, p = 0.044), mechanical ventilation > 48 h (OR = 0.749, p = 0.001), length of hospital stay (risk adjusted difference in days of hospitalization per 10 emergency admissions: - 1.01 days, p < 0.001), and reimbursement (risk adjusted difference in reimbursement per 10 emergency admissions: -€314.89, p < 0.001). Results were not significant for acute kidney injury (OR = 0.951, p = 0.104), postoperative delirium (OR = 0.975, p = 0.480), and permanent pacemaker implantation (OR = 1.010, p = 0.732). In conclusion, regarding transfemoral TAVI, the percentage of emergency cases was higher in lower volume centers in Germany. However, higher volume centers show significantly better outcomes for in-hospital mortality and complication rates as well as resource utilization parameters.
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Luthra S, Leiva-Juarez MM, Malvindi PG, Navaratanaraja M, Curzen N, Ohri SK. Reconsidered surgical aortic valve replacement after declined transcatheter valve implantation. Asian Cardiovasc Thorac Ann 2022; 30:1001-1009. [PMID: 36210789 DOI: 10.1177/02184923221132202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Outcomes for high surgical risk patients who declined transcatheter aortic valve implantation (TAVI) and then reconsidered for conventional aortic valve replacement (rSAVR) for severe calcific aortic stenosis are not well known. METHODS This single-centre, case-control study (rSAVR vs Conservative group) retrospectively analysed patients for rSAVR (2009-2019). Multivariable logistic regression was used to identify independent predictors of composite of neurological sequelae/renal failure/deep sternal wound infection/re-exploration and death. Survival was compared using Kaplan-Meier curves and log-rank test. A Cox proportional hazards model was used to determine predictors of survival. RESULTS TAVI was denied in 519/1095 patients, 114(10.4%) had rSAVR (cases) and 405 (37%) were managed conservatively (controls). Mean age for rSAVR was 80 years (IQR: 73.5-85 years). The commonest reason for declining TAVI was prohibitive high risk due to multiple comorbidities. Among rSAVR, hospital mortality was 2.2% and stroke was 4.4%. Median follow-up was conservative; 14.4 months versus rSAVR; 34.8 months. Five-year survival was conservative; 12.6% versus rSAVR; and 59.5% (overall conservative; 38.0% vs. rSAVR; 60.5%, p < 0.001). rSAVR was protective (hazard ratio [HR]: 0.37, 95% confidence interval [CI]: 0.26, 0.51, p < 0.001) and high comorbidities had high hazard (HR: 1.57, 95% CI: 1.19, 2.07, p = 0.001). rSAVR had fewer hospital readmission episodes (Conservative; 13.6/patient-year vs. rSAVR; 6.9/patient-year, p = 0.002). CONCLUSIONS rSAVR may be considered in high surgical risk elderly patients who have been declined TAVI in centres with low operative mortality. rSAVR may be superior to conservative management in carefully selected patients.
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Affiliation(s)
- Suvitesh Luthra
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, 7425Southampton University Hospital NHS Trust, Southampton, UK.,Academic Department of Human Development and Health, 7423University of Southampton, Southampton, UK
| | | | - Pietro G Malvindi
- Cardiac Surgery Unit, Azienda Ospedaliero Universitaria, Ancona, Italy
| | - Manoraj Navaratanaraja
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, 7425Southampton University Hospital NHS Trust, Southampton, UK
| | - Nick Curzen
- Wessex Cardiothoracic Centre, Division of Cardiology, Southampton University Hospital NHS Trust, Southampton, UK
| | - Sunil K Ohri
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, 7425Southampton University Hospital NHS Trust, Southampton, UK.,Academic Department of Human Development and Health, 7423University of Southampton, Southampton, UK
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Mejia OAV, Borgomoni GB, Palma Dallan LR, Mioto BM, Duenhas Accorsi TA, Lima EG, de Matos Soeiro A, Lima FG, Manuel de Almeida Brandão C, Alberto Pomerantzeff PM, Oliveira Dallan LA, Ferreira Lisboa LA, Jatene FB. Quality improvement program at Latin America. Int J Surg 2022; 106:106931. [PMID: 36126857 DOI: 10.1016/j.ijsu.2022.106931] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The current challenge of cardiac surgery (CS) is to improve outcomes in adverse scenarios. The aim of this study was to assess the impact of a quality improvement program (QIP) on hospital mortality in the largest CS center in Latin America. METHODS Patients were divided into two groups: before (Jan 2013-Dec 2015, n = 3534) and after establishment of the QIP (Jan 2017-Dec 2019, n = 3544). The QIP consisted of the implementation of 10 central initiatives during 2016. The procedures evaluated were isolated coronary artery bypass grafting surgery (CABG), mitral valve surgery, aortic valve surgery, combined mitral and aortic valve surgery, and CABG associated with heart valve surgery. Propensity Score Matching (PSM) was used to adjust for inequality in patients' preoperative characteristics before and after the implementation of QIP. A multivariate logistic regression model was built to predict hospital mortality and validated using discrimination and calibration metrics. RESULTS The PMS paired two groups using 5 variables, obtaining 858 patients operated before (non-QIP) and 858 patients operated after the implementation of the QIP. When comparing the QIP versus Non-QIP group, there was a shorter length of stay in all phases of hospitalization. In addition, the patients evolved with less anemia (P = 0.001), use of intra-aortic balloon pump (P = 0.003), atrial fibrillation (P = 0.001), acute kidney injury (P < 0.001), cardiogenic shock (P = 0.011), sepsis (P = 0.046), and hospital mortality (P = 0.001). In the multiple model, among the predictors of hospital mortality, the lack of QIP increased the chances of mortality by 2.09 times. CONCLUSION The implementation of a first CS QIP in Latin America was associated with a reduction in length of hospital stay, complications and mortality after the cardiac surgeries analyzed.
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Affiliation(s)
- Omar Asdrúbal Vilca Mejia
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Gabrielle Barbosa Borgomoni
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Luís Roberto Palma Dallan
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Bruno Mahler Mioto
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Tarso Augusto Duenhas Accorsi
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Eduardo Gomes Lima
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Alexandre de Matos Soeiro
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Felipe Gallego Lima
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Carlos Manuel de Almeida Brandão
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Pablo Maria Alberto Pomerantzeff
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Luís Alberto Oliveira Dallan
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Luiz Augusto Ferreira Lisboa
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Fábio Biscegli Jatene
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
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40
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Montalto C, Munafò AR, Arzuffi L, Soriano F, Mangieri A, Nava S, De Maria GL, Burzotta F, D’Ascenzo F, Colombo A, Latib A, Oreglia JA, Banning AP, Porto I, Crimi G. Large-bore arterial access closure after transcatheter aortic valve replacement: a systematic review and network meta-analysis. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac043. [PMID: 36117948 PMCID: PMC9472788 DOI: 10.1093/ehjopen/oeac043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/27/2022] [Indexed: 02/03/2023]
Abstract
Aims As the indications to transcatheter aortic valve replacement (TAVR) expand to patients at increasingly lower risk, procedure-related vascular and bleeding complications events must be minimized. We aimed to evaluate the impact of different large-bore arterial access closure devices on clinical outcomes after TAVR. Methods and results We searched for papers that reported outcomes according to the type of vascular closure device/technique used after TAVR and performed a Bayesian network meta-analysis (NMA). Fifteen studies involving 9259 patients who underwent access site closure using PROSTAR™ XL percutaneous vascular surgical system (Abbott Vascular, Santa Clara, CA, USA), Perclose ProGlide™ suture-mediated closure system (Abbott), or MANTATM vascular closure device (Teleflex, Morrisville, NC, USA) were included. NMA showed MANTA to have the highest likelihood of reducing a primary composite endpoint of intra-hospital death, major vascular complications, and major or life-threatening bleedings [surface under the cumulative ranking curve analysis (SUCRA) 94.8%], but this was mitigated when only randomized clinical trials and propensity-matched cohorts were included (SUCRA 56.1%). The ProGlide showed the highest likelihood to reduce major or life-threatening bleedings, especially with increasing procedural complexity, and the MANTA device to reduce major and minor vascular complications. The ProStar XL device performed poorly in all explored endpoints. Conclusion Available evidence summarized through a NMA shows that ProGlide and MANTA devices appear to be both valid vascular closure devices globally and to be the best options to minimize vascular complications and reduce bleeding in patients undergoing TAVR, respectively.
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Affiliation(s)
- Claudio Montalto
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy,De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, 20172 Milan, Italy
| | | | | | - Francesco Soriano
- De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, 20172 Milan, Italy
| | | | - Stefano Nava
- De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, 20172 Milan, Italy
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford OX3 9DU, UK
| | - Francesco Burzotta
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Turin, Italy,Cardiology, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | | | - Azeem Latib
- Montefiore Medical Center, New York 10467, USA
| | - Jacopo Andrea Oreglia
- De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, 20172 Milan, Italy
| | - Adrian P Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford OX3 9DU, UK
| | | | - Gabriele Crimi
- Division of Cardiovascular Medicine, Policlinico San Martino, University of Genova, 16132 Genova, Italy
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De Hert S, Ouattara A, Royston D, van der Linden J, Zacharowski K. Use and safety of aprotinin in routine clinical practice: A European postauthorisation safety study conducted in patients undergoing cardiac surgery. Eur J Anaesthesiol 2022; 39:685-694. [PMID: 35766393 PMCID: PMC9451913 DOI: 10.1097/eja.0000000000001710] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Aprotinin has been used to reduce blood loss and blood product transfusions in patients at high risk of major blood loss during cardiac surgery. Approval by the European Medicines Agency (EMA) for its current indication is limited to patients at high risk of major blood loss undergoing isolated coronary artery bypass graft surgery (iCABG). OBJECTIVE To report current real-world data on the use and certain endpoints related to the safety of aprotinin in adult patients. DESIGN The Nordic aprotinin patient registry (NAPaR) received data from 83 European centres in a noninterventional, postauthorisation safety study (PASS) performed at the request of the EMA. SETTING Cardiac surgical centres committed to enrolling patients in the NAPaR. PATIENTS Patients receiving aprotinin agreeing to participate. INTERVENTION The decision to administer aprotinin was made by the treating physicians. MAIN OUTCOME MEASURES Aprotinin safety endpoints were in-hospital death, thrombo-embolic events (TEEs), specifically stroke, renal impairment, re-exploration for bleeding/tamponade. RESULTS From 2016 to 2020, 5309 patients (male 71.5%; >75 years 18.9%) were treated with aprotinin; 1363 (25.7%) underwent iCABG and 3946 (74.3%) another procedure, including a surgical treatment for aortic dissection ( n = 660, 16.7%); 54.5% of patients received the full-dose regimen. In-hospital mortality in iCABG patients was 1.3% (95% CI, 0.66 to 1.84%) vs. 8.3% (7.21 to 8.91%) in non-iCABG patients; incidence of TEEs and postoperative rise in creatinine level greater than 44 μmol l -1 2.3% (1.48 to 3.07%) and 2.7% (1.79 to 3.49%) vs. 7.2% (6.20 to 7.79%) and 15.5% (13.84 to 16.06%); patients undergoing re-exploration for bleeding 1.4% (0.71 to 1.93%) vs. 3.0% (2.39 to 3.44%). Twelve cases of hypersensitivity/anaphylactic reaction (0.2%) were reported as Adverse Drug Reactions. CONCLUSION The data in the NApaR indicated that in this patient population, at high risk of death or blood loss undergoing cardiac surgery, including complex cardiac surgeries other than iCABG, the incidence of adverse events is in line with data from current literature, where aprotinin was not used. TRIAL REGISTRATION EU PAS register number: EUPAS11384.
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Affiliation(s)
- Stefan De Hert
- From the Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital - Ghent University, Corneel Heymanslaan 10, Ghent, Belgium (SDH), CHU Bordeaux, Department of Anaesthesia and Critical Care Diseases (AO), Univ. Bordeaux, INSERM, UMR 1034, Biology and Cardiovascular Diseases, Pessac, France (AO), Anaesthetics Department, RBH Foundation Trust, Harefield Hospital, Hill End Rd Harefield, Uxbridge, UK (DR), Department of Perioperative Medicine, Section of Cardiothoracic Anaesthesiology and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden (JVDL) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy at the University Hospital Frankfurt, Theodor-Stern-Kai 7, Goethe University, Frankfurt am Main, Germany (KZ)
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Warner MA, Patel PA, Hensley NB, Mazzeffi M. COVID-19-Related Blood Shortages and Cardiac Surgery: Do We Have Too Many Eggs in One Basket? J Cardiothorac Vasc Anesth 2022; 36:1823-1826. [PMID: 35304043 PMCID: PMC8864082 DOI: 10.1053/j.jvca.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Matthew A Warner
- Mayo Clinic School of Medicine, Department of Anesthesiology, Rochester, MN
| | - Prakash A Patel
- Yale University School of MedicineDepartment of Anesthesiology, New Haven, CT
| | - Nadia B Hensley
- Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine, Baltimore, MD
| | - Michael Mazzeffi
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC.
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van Schie MS, Veen D, Kharbanda RK, Heida A, Starreveld R, van Schaagen FRN, Bogers AJJC, Taverne YJHJ, de Groot NMS. Characterization of pre-existing arrhythmogenic substrate associated with de novo early and late postoperative atrial fibrillation. Int J Cardiol 2022; 363:71-79. [PMID: 35705170 DOI: 10.1016/j.ijcard.2022.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/01/2022] [Accepted: 06/10/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND PoAF is the most common complication after cardiac surgery and may occur in patients with pre-existing arrhythmogenic substrate. Characterization of this substrate could aid in identifying patients at risk for PoAF. We therefore compared intra-atrial conduction parameters and electrogram morphology between patients without and with early- (≤5 days after surgery) and late- (up to 5 years) postoperative atrial fibrillation (PoAF). METHODS AND RESULTS Epicardial mapping of the right and left atrium and Bachmann's Bundle (BB) was performed during sinus rhythm (SR) in 263 patients (207male, 67 ± 11 years). Unipolar potentials were classified as single, short or long double and fractionated potentials. Unipolar voltage, fractionation delay (time difference between the first and last deflection), conduction velocity (CV) and conduction block (CB) prevalence were measured. Comparing patients without (N = 166) and with PoAF (N = 97), PoAF was associated with lower CV and more CB at BB. Unipolar voltages were lower and more low-voltage areas were found at the left and right atrium and BB in PoAF patients. These differences were more pronounced in patients with late-PoAF (6%), which could even occur up to 5 years after surgery. Although several electrophysiological parameters were related to PoAF, age was the only independent predictor. CONCLUSIONS Patients with de novo PoAF have more extensive arrhythmogenic substrate prior to cardiac surgery compared to those who remained in SR, which is even more pronounced in late-PoAF patients. Future studies should evaluate whether intra-operative electrophysiological examination enables identification of patients at risk for developing PoAF and hence (preventive) therapy.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Danny Veen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Annejet Heida
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Roeliene Starreveld
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Frank R N van Schaagen
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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Peters AS, Duggan JP, Trachiotis GD, Antevil JL. Epidemiology of Valvular Heart Disease. Surg Clin North Am 2022; 102:517-528. [PMID: 35671771 DOI: 10.1016/j.suc.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Acquired diseases of the aortic and mitral valves are the most common cause of morbidity and mortality among Valvular heart diseases. Aortic stenosis (AS) is increasing in incidence in the United States (4,43 US), driven largely by an aging demographic. Aortic valve replacement is the only effective treatment of AS and has a dramatic mortality benefit. Mitral valve regurgitation (MR) is the most common form of valvular heart disease (VHD) in the US, whereby MR is most often the result of mitral valve prolapse; rheumatic heart disease (RHD) is a more common etiology of MR in underdeveloped countries. interventions for MR in the US are increasing.
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Affiliation(s)
- Alex S Peters
- Department of Surgery, Walter Reed National Military Medical Center, 4494 Palmer Road North, Bethesda, MD 20814, USA
| | - John P Duggan
- Department of Surgery, Walter Reed National Military Medical Center, 4494 Palmer Road North, Bethesda, MD 20814, USA
| | - Gregory D Trachiotis
- Division of Cardiology, Cardiothoracic Surgery and Heart Center, Washington DC Veterans Affairs Medical Center, 50 Irving Street Northwest, Washington, DC 20422, USA; Department of Surgery, George Washington University Hospital, 900 23rd St NW, Washington, DC 20037, USA
| | - Jared L Antevil
- Division of Cardiothoracic Surgery, Washington DC Veterans Affairs Medical Center, 50 Irving Street Northwest, Washington, DC 20422, USA.
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Chai T, Zhuang X, Tian M, Yang X, Qiu Z, Xu S, Cai M, Lin Y, Chen L. Meta-Analysis: Shouldn't Prophylactic Corticosteroids be Administered During Cardiac Surgery with Cardiopulmonary Bypass? Front Surg 2022; 9:832205. [PMID: 35722531 PMCID: PMC9198450 DOI: 10.3389/fsurg.2022.832205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 05/02/2022] [Indexed: 12/04/2022] Open
Abstract
Background Corticosteroids can effectively inhibit systemic inflammation induced by cardiopulmonary bypass. Recently clinical trials and meta-analyses and current guidelines for cardiac surgery do not support corticosteroids prophylaxis during cardiac surgery because of an increase in myocardial infarction and no benefit for patients. The aim of this study is to determine whether specific corticosteroids dose ranges might provide clinical benefits without increasing myocardial infarction. Methods The PubMed, Web of Science, Embase, Clinical Trials, and Cochrane databases were searched for randomized controlled trials (RCTs) published before August 1, 2021. Results 88 RCTs with 18,416 patients (17,067 adults and 1,349 children) were identified. Relative to placebo and high-dose corticosteroids, low-dose corticosteroids (≤20 mg/kg hydrocortisone) during adult cardiac surgery did not increase the risks of myocardial infarction (odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.43-2.17; p = 0.93). However, low-dose corticosteroids were associated with lower risks of atrial fibrillation (OR: 0.58, 95% CI: 0.44-0.76; p < 0.0001) and kidney injury (OR: 0.29, 95% CI: 0.09-0.96; p = 0.04). Furthermore, low-dose corticosteroids significantly shortened the mechanical ventilation times (mean difference [MD]: -2.74 h, 95% CI: -4.14, -1.33; p = 0.0001), intensive care unit (ICU) stay (MD: -1.48 days, 95% CI: -2.73, -0.22; p = 0.02), and hospital stay (MD: -2.29 days, 95% CI: -4.51, -0.07; p = 0.04). Conclusion Low-dose corticosteroids prophylaxis during cardiac surgery provided significant benefits for adult patients, without increasing the risks of myocardial infarction and other complications.
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Affiliation(s)
- Tianci Chai
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
- Department of anesthesiology, Xinyi People’s Hospital, Xuzhou, China
| | - Xinghui Zhuang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
| | - Mengyue Tian
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Xiaojie Yang
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhihuang Qiu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
| | - Shurong Xu
- Nursing Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Meiling Cai
- Nursing Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yanjuan Lin
- Nursing Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
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Sanders J, Bowden T, Woolfe-Loftus N, Sekhon M, Aitken LM. Predictors of health-related quality of life after cardiac surgery: a systematic review. Health Qual Life Outcomes 2022; 20:79. [PMID: 35585633 PMCID: PMC9118761 DOI: 10.1186/s12955-022-01980-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health-related quality of life (HRQoL) is important in determining surgical success, particularly from the patients' perspective. AIMS To identify predictors for HRQoL outcome after cardiac surgery in order to identify potentially modifiable factors where interventions to improve patient outcomes could be targeted. METHODS Electronic databases (including MEDLINE, CINAHL, Embase) were searched between January 2001 and December 2020 for studies determining predictors of HRQoL (using a recognised and validated tool) in adult patients undergoing cardiac surgery. Data extraction and quality assessments were undertaken and data was summarised using descriptive statistics and narrative synthesis, as appropriate. RESULTS Overall, 3924 papers were screened with 41 papers included in the review. Considerable methodological heterogeneity between studies was observed. Most were single-centre (75.6%) prospective observational studies (73.2%) conducted in patients undergoing coronary artery bypass graft (CABG) (n = 51.2%) using a version of the SF-36 (n = 63.4%). Overall, 103 independent predictors (62 pre-operative, five intra-operative and 36 post-operative) were identified, where 34 (33.0%) were reported in more than one study. Potential pre-operative modifiable predictors include alcohol use, BMI/weight, depression, pre-operative quality of life and smoking while in the post-operative period pain and strategies to reduce post-operative complications and intensive care and hospital length of stay are potential therapeutic targets. CONCLUSION Despite a lack of consistency across studies, several potentially modifiable predictors were identified that could be targeted in interventions to improve patient or treatment outcomes. This may contribute to delivering more person-centred care involving shared decision-making to improve patient HRQoL after cardiac surgery.
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Affiliation(s)
- Julie Sanders
- St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, EC1A 7DN, UK.
- William Harvey Research Institute, Charterhouse Square, Queen Mary University of London, London, EC1M 6BQ, UK.
| | - Tracey Bowden
- School of Health Sciences, City, University of London, London, EC1V 0HB, UK
| | - Nicholas Woolfe-Loftus
- St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, EC1A 7DN, UK
| | - Mandeep Sekhon
- School of Health Sciences, City, University of London, London, EC1V 0HB, UK
| | - Leanne M Aitken
- School of Health Sciences, City, University of London, London, EC1V 0HB, UK
- School of Nursing and Midwifery, Griffith University, Nathan, QLD, 4111, Australia
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Patel A, Ngo L, Woodman RJ, Aliprandi-Costa B, Bennetts J, Psaltis PJ, Ranasinghe I. Institutional variation in early mortality following isolated coronary artery bypass graft surgery. Int J Cardiol 2022; 362:35-41. [PMID: 35504451 DOI: 10.1016/j.ijcard.2022.04.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/04/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Thirty-day mortality following coronary artery bypass grafting (CABG) is a widely accepted marker for quality of care. Although surgical mortality has declined, the utility of this measure to profile quality has not been questioned. We assessed the institutional variation in risk-standardised mortality rates (RSMR) following isolated CABG within Australia and New Zealand (ANZ). METHODS We used an administrative dataset from all public and most private hospitals across ANZ to capture all isolated CABG procedures recorded between 2010 and 2015. The primary outcome was all-cause death occurring in-hospital or within 30-days of discharge. Hospital-specific RSMRs and 95% CI were estimated using a hierarchical generalised linear model accounting for differences in patient characteristics. RESULTS Overall, 60,953 patients (mean age 66.1 ± 10.1y, 18.7% female) underwent an isolated CABG across 47 hospitals. The observed early mortality rate was 1.69% (n = 1029) with 81.8% of deaths recorded in-hospital. The risk-adjustment model was developed with good discrimination (C-statistic = 0.81). Following risk-adjustment, a 3.9-fold variation was observed in RSMRs among hospitals (median:1.72%, range:0.84-3.29%). Four hospitals had RSMRs significantly higher than average, and one hospital had RSMR lower than average. When in-hospital mortality alone was considered, the median in-hospital RSMR was 1.40% with a 5.6-fold variation across institutions (range:0.57-3.19%). CONCLUSIONS Average mortality following isolated CABG is low across ANZ. Nevertheless, in-hospital and 30-day mortality vary among hospitals, highlighting potential disparities in care quality and the enduring usefulness of 30-day mortality as an outcome measure. Clinical and policy intervention, including participating in clinical quality registries, are needed to standardise CABG care.
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Affiliation(s)
- Aayush Patel
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Linh Ngo
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; School of Clinical Medicine, The University of Queensland, Brisbane, Australia; Cardiovascular Centre, E Hospital, Hanoi, Viet Nam
| | - Richard J Woodman
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, South Australia, Australia
| | | | - Jayme Bennetts
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia; Department of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Peter J Psaltis
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia.; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, Australia; Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Isuru Ranasinghe
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; School of Clinical Medicine, The University of Queensland, Brisbane, Australia.
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Quality of Life and Social Functioning of Patients After Cardiosurgical Interventions. Fam Med 2022. [DOI: 10.30841/2307-5112.1-2.2022.260507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The objective: to study the quality of life (QOL) and social functioning of patients who underwent cardiosurgery intervention (CSI) with the use of artificial circulation (AR) in the postoperative period, to determine and improve the system for further medical, psychological and social rehabilitation.
Materials and methods. 700 patients who underwent CSI with the use of AR were treated at the Heart Institute of the Ministry of Health of Ukraine. 86 patients had cerebral infarction (CI), 217 patients with signs of postoperative encephalopathy, and 504 patients with signs of cognitive dysfunction. The level of QOL and social functioning in patients with this pathology was analyzed.
Statistical analysis of differences in the quantitative values of indicators was performed using the nonparametric Mann-Whitney test.
Results. It was found that patients after CSI had generally low levels of QOL in all fields, namely in the indicators of psychological (emotional) well-being, general perception of life, ability to work, physical well-being, personal realization, selfcare and independence; interpersonal interaction.
The presence of ischemic and neurological complications in patients after CSI significantly reduces the QOL indicators in all areas, with differences in the quantitative values of such patients statistically significant (p<0,01) compared to the groups of patients without such complications.
The most significant deterioration of QOL is found in patients with cerebral infarction in the postoperative period, slightly less significant – in patients with signs of postoperative encephalopathy, and the smallest changes – in patients with signs of cognitive dysfunction.
Conclusions. The main task of modern cardiac surgery is not only to save the patient from death, but also to improve the quality of life (QOL). At the same time, patients after cardiac surgery are at risk of developing ischemic, neurological complications that significantly reduce QOL in all areas of life. That is why it is necessary to take into account the findings of the study in the development of treatment and rehabilitation programs and preventive measures for such patients.
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Hensley NB, Ariyo PT, Holmes SD, Williams MS, Joseph Robert Whitman G, Ad N, Metkus TS. Center Variation in Use of Preoperative Dual Antiplatelet Therapy and Platelet Function Testing at the Time of Coronary Artery Bypass Grafting in Maryland. Anesth Analg 2022; 135:567-575. [PMID: 35426835 DOI: 10.1213/ane.0000000000005964] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients presenting with acute coronary syndrome are administered a P2Y12 inhibitor and aspirin before coronary catheterization to prevent further myocardial injury from thrombosis. Guidelines recommend a standard waiting period between the time patients are administered dual antiplatelet therapy (DAPT) and elective cardiac surgery. Since 25% to 30% of the population may be considered nonresponders to clopidogrel, platelet function testing can be utilized for timing of surgery and to assess bleeding risks. The extent to which a standard waiting period or platelet function testing is used across centers is not established, representing an important opportunity to standardize practice. METHODS We conducted a retrospective cohort study from 2011 to 2020 using data from the Maryland Cardiac Surgical Quality Initiative, a consortium of all 10 hospitals in the state performing cardiac surgery. The proportion of patients administered DAPT within 5 days of surgery was examined by hospital over the time period. Mixed-effects multivariable logistic regressions were used to examine the association of preoperative DAPT with ischemic and bleeding outcomes. Centers were surveyed on use or nonuse of preoperative platelet function testing, and bleeding outcomes were compared. RESULTS There was significant heterogeneity of preoperative DAPT usage across centers ranging from 2% to 54% (P < .001). DAPT within 5 days of isolated coronary artery bypass grafting (CABG) was associated with higher odds of reoperation for bleeding (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.19-2.01; P = .001), >2 units of red blood cells (RBCs) transfused (OR, 1.62; 95% CI, 1.44-1.81; P < .001), and >2 units of non-RBCs transfused (OR, 1.79; 95% CI, 1.60-2.00; P < .001). In the 5 hospitals using preoperative platelet function testing to guide timing of surgery, there were greater odds for DAPT within 5 days (OR, 1.33; 95% CI, 1.22-1.45; P < .001), fewer RBCs >2 units transfusions (22% vs 33%; P < .001), and non-RBCs >2 units (17% vs 28%; P < .001) transfusions within DAPT patients. CONCLUSIONS There is significant variability in DAPT usage within 5 days of CABG between hospital centers. Preoperative platelet function testing may allow for earlier timing of surgery for those on DAPT without increased bleeding risks.
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Affiliation(s)
- Nadia B Hensley
- From the Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Promise T Ariyo
- From the Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sari D Holmes
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Marlene S Williams
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn Joseph Robert Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Niv Ad
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.,Division of Cardiac Surgery, Adventist Health Care White Oak Medical Center, Silver Spring, Maryland
| | - Thomas Stephen Metkus
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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How to use the aortic valve calcium score to improve the results of transcatheter aortic valve implantation with a self-expanding prosthesis. Arch Cardiovasc Dis 2022; 115:305-314. [DOI: 10.1016/j.acvd.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 02/27/2022] [Accepted: 03/01/2022] [Indexed: 11/24/2022]
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