The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2022 Update on Outcomes and Research

Twenty percent human albumin solution fluid bolus administration therapy in patients after cardiac surgery-II: a multicentre randomised controlled trial

PURPOSE

After cardiac surgery, fluid bolus therapy (FBT) with 20% human albumin may facilitate less fluid and vasopressor administration than FBT with crystalloids. We aimed to determine whether, after cardiac surgery, FBT with 20% albumin reduces the duration of vasopressor therapy compared with crystalloid FBT.

METHODS

We conducted a multicentre, parallel-group, open-label, randomised clinical trial in six intensive care units (ICUs) involving cardiac surgery patients deemed to require FBT. We randomised 240 patients to receive up to 400 mL of 20% albumin/day as FBT, followed by 4% albumin for any subsequent FBT on that day, or to crystalloid FBT for at least the first 1000 mL, with use of crystalloid or 4% albumin FBT thereafter. The primary outcome was the cumulative duration of vasopressor therapy. Secondary outcomes included fluid balance.

RESULTS

Of 480 randomised patients, 466 provided consent and contributed to the primary outcome (mean age 65 years; median EuroSCORE II 1.4). The cumulative median duration of vasopressor therapy was 7 (interquartile range [IQR] 0-19.6) hours with 20% albumin and 10.8 (IQR 0-22.8) hours with crystalloids (difference - 3.8 h, 95% confidence interval [CI] - 8 to 0.4; P = 0.08). Day one fluid balance was less with 20% albumin FBT (mean difference - 701 mL, 95% CI - 872 to - 530).

CONCLUSIONS

In patients after cardiac surgery, when compared to a crystalloid-based FBT, 20% albumin FBT was associated with a reduced positive fluid balance but did not significantly reduce the duration of vasopressor therapy.

Long-term outcomes of isolated mechanical versus bioprosthetic mitral valve replacement in different age groups of propensity-matched patients

OBJECTIVES

Prothesis choice in isolated mitral valve replacement for patients aged 75 years or younger remains debated as most studies comparing prothesis type have included large proportions of combined operations and benefits are influenced by concomitant procedures. This study compared long-term outcomes of isolated mechanical versus bioprosthetic mitral valves in different age groups of propensity-matched populations.

METHODS

This is a retrospective, multicentre, propensity-matched observational study. Baseline characteristics, operative details and long-term outcomes (mortality and freedom from surgical/transcatheter reintervention) were collected.

RESULTS

Totally, 1536 isolated mitral valve replacements (806 mechanical, 730 bioprosthetic) were performed between 2000 and 2017. Over 90% of eligible patients successfully underwent propensity matching, yielding 226 each of mechanical and bioprosthetic valves in patients aged <65 years and 171 each of bioprosthetic and mechanical valves in patients aged 65-75 years with median follow-up of 13 years (maximum 20 years). In matched patients <65 years, 10-year survival was superior with mechanical valves versus bioprosthetic valves (78.2% vs 69.8%, P = 0.029), as was 10-year freedom from reintervention (96.2% vs 81.3%, P < 0.001). For matched patients between 65 and 75 years, there were no differences between mechanical and bioprosthetic valves in 10-year survival (64.6% vs 60.8%, P = 0.86) or 10-year freedom from reintervention (94.0% vs 97.2%, P = 0.23). Rates of post-operative stroke, gastrointestinal bleeding, renal failure and permanent pacemaker insertion were similar.

CONCLUSIONS

In patients requiring isolated mitral valve replacement, mechanical valves confer significantly better long-term survival and freedom from reintervention for patients <65 years, while no benefit is observed at age 65-75 years compared to bioprosthetic valves.

Noteworthy in Cardiothoracic Surgery 2023

Noteworthy in Cardiothoracic Surgery 2023 summarizes a few of the most high-impact trials and provocative trends in cardiothoracic surgery and transplantation this past year. Transplantation using organs procured from donation after circulatory death (DCD) continues to increase, and the American Society of Transplant Surgeons released recommendations on best practices in 2023. We review a summary of data on the impact of DCD on heart and lung transplantation. There has been increased interest in extracorporeal life support (ECLS), particularly after the COVID-19 pandemic, and we review the results of the highly discussed ECLS-SHOCK trial, which randomized patients in cardiogenic shock with planned revascularization to ECLS vs usual care. With improving survival outcomes in complex aortic surgery, there is a need for higher-quality evidence to guide which cooling and cerebral perfusion strategies may optimize cognitive outcomes in these patients. We review the short-term outcomes of the GOT ICE trial (Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest), a multicenter, randomized controlled trial of three different nadir temperatures, evaluating outcomes in cognition and associated changes in functional magnetic resonance imaging. Finally, both the Society of Thoracic Surgeons (STS) and the American College of Cardiology, American Heart Association, American College of Chest Physicians and Heart Rhythm Society (ACC/AHA/ACCP/HRS) updated atrial fibrillation guidelines in 2023, and we review surgically relevant updates to the guidelines and the evidence behind them.

Perfusion Measures and Outcomes (PERForm) registry: First annual report

BACKGROUND

The Perfusion Measures and Outcomes (PERForm) registry was established in 2010 to advance cardiopulmonary bypass (CPB) practices and outcomes. The registry is maintained through the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative and is the official registry of the American Society of Extracorporeal Technology.

METHODS

This first annual PERForm registry report summarizes patient characteristics as well as CPB-related practice patterns in adult (≥18 years of age) patients between 2019 and 2022 from 42 participating hospitals. Data from PERForm are probabilistically matched to institutional surgical registry data. Trends in myocardial protection, glucose, anticoagulation, temperature, anemia (hematocrit), and fluid management are summarized. Additionally, trends in equipment (hardware/disposables) utilization and employed patient safety practices are reported.

RESULTS

A total of 40,777 adult patients undergoing CPB were matched to institutional surgical registry data from 42 hospitals. Among these patients, 54.9% underwent a CABG procedure, 71.6% were male, and the median (IQR) age was 66.0 [58.0, 73.0] years. Overall, 33.1% of the CPB procedures utilized a roller pump for the arterial pump device, and a perfusion checklist was employed 99.6% of the time. The use of conventional ultrafiltration decreased over the study period (2019 vs. 2022; 27.1% vs. 24.9%) while the median (IQR) last hematocrit on CPB has remained stable [27.0 (24.0, 30.0) vs. 27.0 (24.0, 30.0)]. Pump sucker termination before protamine administration increased over the study period: (54.8% vs. 75.9%).

CONCLUSION

Few robust clinical registries exist to collect data regarding the practice of CPB. Although data submitted to the PERForm registry demonstrate overall compliance with published perfusion evidence-based guidelines, noted opportunities to advance patient safety and outcomes remain.

Superlative performance in cardiovascular surgery

Achieving excellence in surgery is an ongoing endeavor, gained through experience, observation, and practice. It is difficult to evaluate enterprise excellence, but attempts include the ratings of the Society of Thoracic Surgeons. The surgery team at Baylor University Medical Center has achieved three-star ratings for 9 of the past 10 evaluations for coronary artery bypass. This accomplishment is a result of many factors, including teamwork, multidisciplinary conferences, application of the latest evidence, continuous efforts at quality improvement, and effective governance. Some aspects of the latter include individual excellence, enjoying the work, being bold, having psychological safety, and employing meritocracy. Discernment of contemporary issues, a clear vision of the common good, and virtuous service to all must be attained while preserving the highest level of patient-centered service to patients and the institution.

Genome Sequencing is Critical for Forecasting Outcomes following Congenital Cardiac Surgery

While genome sequencing has transformed medicine by elucidating the genetic underpinnings of both rare and common complex disorders, its utility to predict clinical outcomes remains understudied. Here, we used artificial intelligence (AI) technologies to explore the predictive value of genome sequencing in forecasting clinical outcomes following surgery for congenital heart defects (CHD). We report results for a cohort of 2,253 CHD patients from the Pediatric Cardiac Genomics Consortium with a broad range of complex heart defects, pre- and post-operative clinical variables and exome sequencing. Damaging genotypes in chromatin-modifying and cilia-related genes were associated with an elevated risk of adverse post-operative outcomes, including mortality, cardiac arrest and prolonged mechanical ventilation. The impact of damaging genotypes was further amplified in the context of specific CHD phenotypes, surgical complexity and extra-cardiac anomalies. The absence of a damaging genotype in chromatin-modifying and cilia-related genes was also informative, reducing the risk for adverse postoperative outcomes. Thus, genome sequencing enriches the ability to forecast outcomes following congenital cardiac surgery.

Quality improvement initiative to increase radial artery usage as a second arterial conduit in coronary artery bypass grafting

OBJECTIVES

Use of radial artery as a second arterial graft, compared to a saphenous vein, in coronary artery bypass grafting (CABG) can improve late outcomes. However, the radial artery remains underutilized. We initiated a quality improvement (QI) initiative to increase the usage of radial artery grafts.

METHODS

During our 4-month lead period, we disseminated evidence for radial artery graft usage to surgeons, developed a radial artery decision-making algorithm and adopted endoscopic harvesting. Our QI initiative was conducted over a 6-month period and included a postoperative survey of decision-making for graft selection and obstacles to radial artery usage.

RESULTS

Over the 6-month study period, 247 patients received isolated CABG which included 98 (40%) with radial arteries as a second arterial graft and 144 (58%) with greater saphenous veins. Radial artery usage increased with QI initiative implementation by 67% compared to 6 months prior to the study period (60 radial arteries/252 isolated CABG, 24%) (P = 0.006). The survey response rate was 93% (231/247). Barriers to radial artery graft usage were poor quality target vessel or stenosis <80% (24%), patient age >75 years (20%), ejection fraction ≤35% (8%) and renal insufficiency/dialysis (7%). No patients experienced significant complications from radial artery harvest.

CONCLUSIONS

Our institutional QI initiative was successful in (i) increasing the usage of radial artery as a second arterial graft and (ii) understanding barriers to radial artery graft usage. Implementation of a QI program can improve radial artery usage in CABG with low risk of patient morbidity from radial artery harvest.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: Intraoperative Echocardiography Reporting

OBJECTIVES

To identify trends in the reporting of intraoperative transesophageal echocardiographic (TEE) data in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) and the Adult Cardiac Anesthesiology (ACA) module by period, practice type, and geographic distribution, and to elucidate ongoing areas for practice improvement.

DESIGN

A retrospective study.

SETTING

STS ACSD.

PARTICIPANTS

Procedures reported in the STS ACSD between July 2017 and December 2021 in participating programs in the United States.

INTERVENTIONS

None MEASUREMENTS AND MAIN RESULTS: Intraoperative TEE is reported for 73% of all procedures in ACSD. Although the intraoperative TEE data reporting rate increased from 2017 to 2021 for isolated coronary artery bypass graft surgery, it remained low at 62.2%. The reporting of relevant echocardiographic variables across a wide range of procedures has steadily increased over the study period but also remained low. The reporting in the ACA module is high for most variables and across all anesthesia care models; however, the overall contribution of the ACA module to the ACSD remains low.

CONCLUSIONS

This progress report suggests a continued need to raise awareness regarding current practices of reporting intraoperative TEE in the ACSD and the ACA, and highlights opportunities for improving reporting and data abstraction.

Hemodynamic Comparison of the On-X and Top Hat Mechanical Aortic Valve Prostheses

BACKGROUND

There are limited data comparing hemodynamic valve function in mechanical aortic valve prostheses. This study compared the hemodynamic function of 2 commonly used mechanical aortic valve (AV) prostheses, the On-X (Artivion) and Top Hat (CarboMedics Inc) valves.

METHODS

This study was a retrospective analysis of 512 patients who underwent AV replacement with the On-X (n = 252; 49%) or Top Hat (n = 260; 51%) mechanical valves between 2011 and 2019. Patients were matched on the basis of selected variables. Echocardiographic data were collected preoperatively and postoperatively over a median follow-up of 1.39 years.

RESULTS

A total of 320 patients were matched, 160 patients in each group. Despite being matched for left ventricular outflow tract diameter, patients in the Top Hat group received a greater prevalence of smaller tissue annulus diameter valves (≤21 mm) (83% vs 38%; P < .001). Patients in the On-X group had longer aortic cross-clamp times (78 minutes vs 64 minutes; P < .001) during isolated aortic valve replacement. Discharge echocardiography showed no difference in the AV area index between both groups (1.00 cm2/m2 vs 1.02 cm2/m2; P = .377). During longer-term echocardiographic follow-up, the AV area index remained stable for both valves within their respective tissue annulus diameter groups (P = .060).

CONCLUSIONS

There was no difference between the 2 valves with respect to the AV area index at discharge, and hemodynamic function was stable during longer-term follow-up. The longer aortic cross-clamp time observed in the On-X group may indicate increased complexity of implantation compared with the Top Hat group.

Utility of growth differentiation factor-15 as a predictor of cardiovascular surgery outcomes: Current research and future directions

In a world increasingly confronted by cardiovascular diseases (CVDs) and an aging population, accurate risk assessment prior to cardiac surgery is critical. Although effective, traditional risk calculators such as the Japan SCORE, Society of Thoracic Surgeons score, and EuroSCORE II may not completely capture contemporary risks, particularly due to emerging factors such as frailty and sarcopenia. These calculators often focus on regional and ethnic specificity and rely heavily on evaluations based on age and underlying diseases. Growth differentiation factor-15 (GDF-15) is a stress-responsive cytokine that has been identified as a potential biomarker for sarcopenia and a tool for future cardiac risk assessment. Preoperative plasma GDF-15 levels have been associated with preoperative, intraoperative, and postoperative factors and short- and long-term mortality rates in patients undergoing cardiac surgery. Increased plasma GDF-15 levels have prognostic significance, having been correlated with the use of cardiopulmonary bypass during surgery, amount of bleeding, postoperative acute kidney injury, and intensive care unit stay duration. Notably, the inclusion of preoperative levels of GDF-15 in risk stratification models enhances their predictive value, especially when compared with those of the N-terminal prohormone of brain natriuretic peptide, which does not lead to reclassification. Thus, this review examines traditional risk assessments for cardiac surgery and the role of the novel biomarker GDF-15. This study acknowledges that the relationship between patient outcomes and elevated GDF-15 levels is not limited to CVDs or cardiac surgery but can be associated with variable diseases, including diabetes and cancer. Moreover, the normal range of GDF-15 is not well defined. Given its promise for improving patient care and outcomes in cardiovascular surgery, future research should explore the potential of GDF-15 as a biomarker for postoperative outcomes and target therapeutic intervention.

Toward 3D printed microfluidic artificial lungs for respiratory support

Microfluidic artificial lungs (μALs) are a new class of membrane oxygenators. Compared to traditional hollow-fiber oxygenators, μALs closely mimic the alveolar microenvironment due to their size-scale and promise improved gas exchange efficiency, hemocompatibility, biomimetic blood flow networks, and physiologically relevant blood vessel pressures and shear stresses. Clinical translation of μALs has been stalled by restrictive microfabrication techniques that limit potential artificial lung geometries, overall device size, and throughput. To address these limitations, a high-resolution Asiga MAX X27 UV digital light processing (DLP) 3D printer and custom photopolymerizable polydimethylsiloxane (PDMS) resin were used to rapidly manufacture small-scale μALs via vat photopolymerization (VPP). Devices were designed in SOLIDWORKS with 500 blood channels and 252 gas channels, where gas and blood flow channels were oriented orthogonally and separated by membranes on the top and bottom, permitting two-sided gas exchange. Successful devices were post-processed to remove uncured resin from microchannels and assembled with external tubing in preparation for gas exchange performance testing with ovine whole blood. 3D printed channel dimensions were 172 μm-tall × 320 μm-wide, with 62 μm-thick membranes and 124 μm-wide support columns. Measured outlet blood oxygen saturation (SO2) agreed with theoretical models and rated flow of the device was 1 mL min-1. Blood side pressure drop was 1.58 mmHg at rated flow. This work presents the highest density of 3D printed microchannels in a single device, one of the highest CO2 transfer efficiencies of any artificial lung to date, and a promising approach to translate μALs one step closer to the clinic.

Frozen elephant trunk technique using hybrid grafts: 15-year outcomes from a single-centre experience

OBJECTIVES

The purpose of the study is to compare the short- and long-term outcomes of the frozen elephant trunk (FET) technique based on 2 different hybrid grafts implanted from January 2007 to July 2022.

METHODS

The study includes patients who underwent an elective or emergency FET procedure. Short-term, long-term mortality and freedom from thoracic endovascular aortic repair (TEVAR) were the primary end points. Analyses were carried out separately for the periods 2007-2012 and 2013-2022.

RESULTS

Of the 367 enrolled, 49.3% received E-Vita Open implantation and 50.7% received Thoraflex Hybrid implants. Overall mean age was 61 years [standard deviation (SD) = 11] and 80.7% were male. The average annual volume of FET procedures was 22.7 cases/year. Compared to E-Vita Open, patients implanted with Thoraflex Hybrid grafts were more likely to receive distal anastomosis in zone 2 (68.3% vs 11.6%, P < 0.001) with a shorter stent portion, mean = 103mm (SD = 11.3) vs mean = 149 mm (SD = 12.7; P < 0.001) and they underwent a reduced visceral ischaemia time, mean = 42.5 (SD = 14.2) vs mean= 61.0 (SD = 20.2) min, P < 0.001. In the period 2013-2022, overall survival at 1, 2 and 5 years was 74.8%, 72.5% and 63.2% for Thoraflex and 73.2%, 70.7% and 64.1% for E-Vita, without significant differences between groups (log-rank test = 0.01, P = 0.907). Overall freedom from TEVAR at 1, 2 and 5 years was 66.7%, 57.6% and 39.3% for Thoraflex and 79%, 69.7% and 66% for E-Vita, with significant differences between groups (log-rank test = 5.28, P = 0.029). In a competing risk analysis adjusted for chronic/residual aortic syndromes and stent diameter, the Thoraflex group was more likely to receive TEVAR during follow-up (subdistribution hazard ratio SHR = 2.12, 95% confidence interval 1.06-4.22).

CONCLUSIONS

The FET technique addresses acute and chronic arch disease with acceptable morbidity and mortality. Downstream endovascular reinterventions are very common during follow-up.

Effects of RBT-1 on preconditioning response biomarkers in patients undergoing coronary artery bypass graft or heart valve surgery: a multicentre, double-blind, randomised, placebo-controlled phase 2 trial

Background

RBT-1 is a combination drug of stannic protoporfin (SnPP) and iron sucrose (FeS) that elicits a preconditioning response through activation of antioxidant, anti-inflammatory, and iron-scavenging pathways, as measured by heme oxygenase-1 (HO-1), interleukin-10 (IL-10), and ferritin, respectively. Our primary aim was to determine whether RBT-1 administered before surgery would safely and effectively elicit a preconditioning response in patients undergoing cardiac surgery.

Methods

This phase 2, double-blind, randomised, placebo-controlled, parallel-group, adaptive trial, conducted in 19 centres across the USA, Canada, and Australia, enrolled patients scheduled to undergo non-emergent coronary artery bypass graft (CABG) and/or heart valve surgery with cardiopulmonary bypass. Patients were randomised (1:1:1) to receive either a single intravenous infusion of high-dose RBT-1 (90 mg SnPP/240 mg FeS), low-dose RBT-1 (45 mg SnPP/240 mg FeS), or placebo within 24-48 h before surgery. The primary outcome was a preoperative preconditioning response, measured by a composite of plasma HO-1, IL-10, and ferritin. Safety was assessed by adverse events and laboratory parameters. Prespecified adaptive criteria permitted early stopping and enrichment. This trial is registered with ClinicalTrials.gov, NCT04564833.

Findings

Between Aug 4, 2021, and Nov 9, 2022, of 135 patients who were enrolled and randomly allocated to a study group (46 high-dose, 45 low-dose, 44 placebo), 132 (98%) were included in the primary analysis (46 high-dose, 42 low-dose, 44 placebo). At interim, the trial proceeded to full enrollment without enrichment. RBT-1 led to a greater preconditioning response than did placebo at high-dose (geometric least squares mean [GLSM] ratio, 3.58; 95% CI, 2.91-4.41; p < 0.0001) and low-dose (GLSM ratio, 2.62; 95% CI, 2.11-3.24; p < 0.0001). RBT-1 was generally well tolerated by patients. The primary drug-related adverse event was dose-dependent photosensitivity, observed in 12 (26%) of 46 patients treated with high-dose RBT-1 and in six (13%) of 45 patients treated with low-dose RBT-1 (safety population).

Interpretation

RBT-1 demonstrated a statistically significant cytoprotective preconditioning response and a manageable safety profile. Further research is needed. A phase 3 trial is planned.

Funding

Renibus Therapeutics, Inc.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2023 Update on Procedure Data and Research

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database is one of the largest and most comprehensive contemporary clinical databases in use. It now contains >9 million procedures from 1010 participants and 3651 active surgeons. Using audited data collection, it has provided the foundation for multiple risk models, performance metrics, health policy decisions, and a trove of research studies to improve the care of patients in need of cardiac surgical procedures. This annual report provides an update on the current status of the database and summarizes the development of new risk models and the STS Online Risk Calculator. Further, it provides insights into current practice patterns, such as the change in the demographics among patients undergoing aortic valve replacement, the use of minimally invasive techniques for valve and bypass surgery, or the adoption of surgical ablation and left atrial appendage ligation among patients with atrial fibrillation. Lastly, an overview of the research conducted using the STS Adult Cardiac Surgery Database and future directions for the database are provided.

Thirteen Years of Impactful, Minimally Invasive Coronary Surgery: Short- and Long-Term Results for Single and Multi-Vessel Disease

OBJECTIVES

Minimally invasive coronary surgery (MICS) via lateral thoracotomy is a less invasive alternative to the traditional median full sternotomy approach for coronary surgery. This study investigates its effectiveness for short- and long-term revascularization in cases of single and multi-vessel diseases.

METHODS

A thorough examination was performed on the databases of two cardiac surgery programs, focusing on patients who underwent minimally invasive coronary bypass grafting procedures between 2010 and 2023. The study involved patients who underwent either minimally invasive direct coronary artery bypass grafting (MIDCAB) for the revascularization of left anterior descending (LAD) artery stenosis or minimally invasive multi-vessel coronary artery bypass grafting (MICSCABG). Our assessment criteria included in-hospital mortality, long-term mortality, and freedom from reoperations due to failed aortocoronary bypass grafts post-surgery. Additionally, we evaluated significant in-hospital complications as secondary endpoints.

RESULTS

A total of 315 consecutive patients were identified between 2010 and 2023 (MIDCAB 271 vs. MICSCABG 44). Conversion to median sternotomy (MS) occurred in eight patients (2.5%). The 30-day all-cause mortality was 1.3% (n = 4). Postoperative AF was the most common complication postoperatively (n = 26, 8.5%). Five patients were reoperated for bleeding (1.6%), and myocardial infarction (MI) happened in four patients (1.3%). The mean follow-up time was six years (±4 years). All-cause mortality was 10.3% (n = 30), with only five (1.7%) patients having a confirmed cardiac cause. The reoperation rate due to graft failure or the progression of aortocoronary disease was 1.4% (n = 4).

CONCLUSIONS

Despite the complexity of the MICS approach, the results of our study support the safety and effectiveness of this procedure with low rates of mortality, morbidity, and conversion for both single and multi-vessel bypass surgeries. These results underscore further the necessity to implement such programs to benefit patients.

Establishing a High-Quality Pediatric Cardiac Surgery Program in Post-Conflict Regions: A Model for Limited Resource Countries

BACKGROUND

Congenital Heart Disease stands as a prominent cause of infant mortality, with notable disparities in surgical outcomes evident between high-income and low- to middle-income countries.

OBJECTIVE

This study presents a collaborative partnership between a local governmental entity and an international private organization to establish a high-quality Pediatric Cardiac Surgery Program in a post-conflict limited resource country, Iraq.

METHODS

A descriptive retrospective study analyzed pediatric cardiac surgery procedures performed by a visiting pediatric heart surgery team from October 2021 to October 2022, funded by the Ministry of Health (MOH). We used the STS-EACTS complexity scoring model (STAT) to assess mortality risks associated with surgical procedures.

RESULTS

A total of 144 patients underwent 148 procedures. Infants comprised 58.3% of the patients. The most common anomalies included tetralogy of Fallot, ventricular septal defect, and various single ventricle categories, constituting 76% of the patient cohort. The overall surgical mortality rate was 4.1%, with an observed/expected surgical mortality rate of 1.1 (95% CI 0.5, 2.3). There was no significant difference between our observed surgical mortality in Category 2, 3, and 4 and those expected/reported by the STS-EACTS Database (p = 0.07, p = 0.72, and p = 0.12, respectively). The expenses incurred by the MOH for conducting surgeries in Iraq were lower than the alternative of sending patients abroad for the same procedures.

CONCLUSION

The partnership model between a local public entity committed to infrastructure development and funding and an international private organization delivering clinical and training services can provide the foundation for building sustainable, high-quality in situ programs in upper-middle-income countries.

Temporal Changes in the Surface Chemistry and Topography of Reactive Ion Plasma-Treated Poly(vinyl alcohol) Alter Endothelialization Potential

Synthetic small-diameter vascular grafts (<6 mm) are used in the treatment of cardiovascular diseases, including coronary artery disease, but fail much more readily than similar grafts made from autologous vascular tissue. A promising approach to improve the patency rates of synthetic vascular grafts is to promote the adhesion of endothelial cells to the luminal surface of the graft. In this study, we characterized the surface chemical and topographic changes imparted on poly(vinyl alcohol) (PVA), an emerging hydrogel vascular graft material, after exposure to various reactive ion plasma (RIP) surface treatments, how these changes dissipate after storage in a sealed environment at standard temperature and pressure, and the effect of these changes on the adhesion of endothelial colony-forming cells (ECFCs). We showed that RIP treatments including O2, N2, or Ar at two radiofrequency powers, 50 and 100 W, improved ECFC adhesion compared to untreated PVA and to different degrees for each RIP treatment, but that the topographic and chemical changes responsible for the increased cell affinity dissipate in samples treated and allowed to age for 230 days. We characterized the effect of aging on RIP-treated PVA using an assay to quantify ECFCs on RIP-treated PVA 48 h after seeding, atomic force microscopy to probe surface topography, scanning electron microscopy to visualize surface modifications, and X-ray photoelectron spectroscopy to investigate surface chemistry. Our results show that after treatment at higher RF powers, the surface exhibits increased roughness and greater levels of charged nitrogen species across all precursor gases and that these surface modifications are beneficial for the attachment of ECFCs. This study is important for our understanding of the stability of surface modifications used to promote the adhesion of vascular cells such as ECFCs.

Medical Malpractice Claims Related to Performance of Transesophageal Echocardiography by Anesthesiologists

More than 300,000 adults have cardiac surgery in the United States annually, and most undergo intraoperative transesophageal echocardiography (TEE). This patient population is often older with multiple comorbidities, increasing their risk for complications for even routine procedures. Major morbidity or mortality caused by TEE is rare, and it is unknown how often such complications lead to malpractice lawsuits. The authors identified 13 cases out of 2,564 in a closed claims database that involved TEE and reviewed their etiology. Esophageal injury accounted for most of the suits, and only 2 were related to diagnosis. Most expert reviews deemed the care provided by the anesthesiologist to be appropriate.

External Stenting for Saphenous Vein Grafts in Coronary Surgery: A Systematic Review and Meta-Analysis

The external stenting of saphenous vein grafts (SVGs) during coronary artery bypass grafting (CABG) has been proven to reduce intimal hyperplasia (IH) in animal models, paving the way for human randomized controlled trials (RCTs) to be conducted. Herein, we performed a study-level meta-analysis to assess the impact of the Venous External SupporT (VEST) device, an external stent, on the outcomes of SVGs. A systematic search was conducted to identify all RCTs comparing VEST-stented to non-stented SVGs in patients undergoing CABG. The primary outcome was graft occlusion. The main secondary outcomes were repeat revascularization, SVG IH area, and intimal-medial thickness. Two RCTs totaling 407 patients were included. At a mean follow-up of 1.5 years, there was no difference in graft occlusion between groups (incidence rate ratio: 1.11; 95% confidence interval (CI): 0.80-1.53). The rate of repeat revascularization was also similar (odds ratio: 0.66; 95% CI: 0.27-1.64). The IH area (standardized mean difference (SMD): -0.45; 95% CI: -0.79 to -0.10) and intimal-medial thickness (SMD: -0.50; 95% CI: -0.90 to -0.10) were significantly reduced in the VEST group. Our findings show that significant reductions in the IH area and the intimal-medial thickness in VEST-stented SVGs do not currently translate into a lesser need for repeat revascularization or less graft occlusion events compared to non-stented SVGs at 1.5 years after CABG.

The VEST External Support for Saphenous Vein Grafts in Coronary Surgery: A Review of Randomized Clinical Trials

Saphenous vein grafts (SVGs) are the most frequently used conduits in coronary artery bypass grafting (CABG), but their higher rate of occlusion compared to arterial conduits remains a concern. Previous studies have shown that SVG failure is mainly driven by intimal hyperplasia, an adaptative response to higher pressures of the arterial circulation. The VESTTM device (Vascular Graft Solutions, Tel Aviv, Israel), an external support designed to mitigate intimal hyperplasia in SVGs, has been tested in few clinical trials (RCTs). Herein, we descriptively evaluated the randomized evidence on the VEST device.

Pulmonary Vasodilator and Inodilator Drugs in Cardiac Surgery: A Systematic Review With Bayesian Network Meta-Analysis

OBJECTIVE

The authors performed a systematic review to evaluate the effect of pharmacologic therapy on pulmonary hypertension in the perioperative setting of elective cardiac surgery (PROSPERO CRD42023321041).

DESIGN

Systematic review of randomized controlled trials with a Bayesian network meta-analysis.

SETTING

The authors searched biomedical databases for randomized controlled trials on the perioperative use of inodilators and pulmonary vasodilators in adult cardiac surgery, with in-hospital mortality as the primary outcome and duration of ventilation, length of stay in the intensive care unit, stage 3 acute kidney injury, cardiogenic shock requiring mechanical support, and change in mean pulmonary artery pressure as secondary outcomes.

PARTICIPANTS

Twenty-eight studies randomizing 1,879 patients were included.

INTERVENTIONS

Catecholamines and noncatecholamine inodilators, arterial pulmonary vasodilators, vasodilators, or their combination were considered eligible interventions compared with placebo or standard care.

MEASUREMENTS AND MAIN RESULTS

Ten studies reported in-hospital mortality and assigned 855 patients to 12 interventions. Only inhaled prostacyclin use was supported by a statistically discernible improvement in mortality, with a number-needed-to-treat estimate of at least 3.3, but a wide credible interval (relative risk 1.26 × 10-17 - 0.7). Inhaled prostacyclin and nitric oxide were associated with a reduction in intensive care unit stay, and none of the included interventions reached a statistically evident difference compared to usual care or placebo in the other secondary clinical outcomes.

CONCLUSIONS

Inhaled prostacyclin was the only pharmacologic intervention whose use is supported by a statistically discernible improvement in mortality in the perioperative cardiac surgery setting as treatment of pulmonary hypertension. However, available evidence has significant limitations, mainly the low number of events and imprecision.

The association of intraoperative and early postoperative events with risk of pneumonia following cardiac surgery

BACKGROUND

Pneumonia, the most common infection following cardiac surgery, is associated with major morbidity and mortality. Although prior work has identified preoperative risk factors for pneumonia, the present study evaluated the role and associated impact of intraoperative and postoperative risk factors on pneumonia after cardiac surgery.

METHODS

This observational cohort study evaluated 71,165 patients undergoing coronary and/or aortic valve surgery across 33 institutions between 2011 and 2021. Terciles of estimated pneumonia risk were compared between a validated preoperative model (Model One) and a model additionally accounting for significant intraoperative (eg, bypass duration) and postoperative (eg, extubation time) factors (Model Two). Logistic regression was used to develop and validate Model Two.

RESULTS

Postoperative pneumonia occurred in 2.62% of the patients. A total of 9 significant intraoperative and early postoperative risk factors were identified. The absolute risk of pneumonia increased across Model One terciles: low (≤1.04%), medium (1.04%-2.40%), and high (>2.40%). Model two performed well (c-statistic = 0.771). Most patients (60.1%) had no change in their preoperative versus intraoperative/postoperative risk tercile. The 19.6% of patients who increased their risk tercile with Model Two accounted for 18.6% of all pneumonia events.

CONCLUSIONS

This study identified 9 significant perioperative risk factors for pneumonia. Nearly 1 of every 5 patients moved into a higher pneumonia risk category based on their intraoperative and postoperative course. These findings may serve as the focus of future quality improvement efforts to reduce a patient's risk of postoperative pneumonia.

Remote monitoring following adult cardiac surgery: A paradigm shift?

Background

The Perfect Care (PC) initiative engages, educates, and enrolls adult cardiac surgery patients into a transformational program that includes an app for appointment scheduling, tracking biometric data and patient-reported outcomes, audiovisual visits, and messaging, paired with a digital health kit (consisting of a fitness tracker, scale, and sphygmomanometer). PC aims to reduce postoperative length of stay (LOS) as well as 30-day readmission and mortality.

Methods

This was a retrospective review of patients who underwent coronary artery bypass (CAB), valve, or combined CAB and valve procedures at either of the 2 participating hospitals between April 2018 and March 2022. Patients who participated in the PC quality improvement initiative were compared to propensity-matched controls (1:1 matching). The evaluation focused on postoperative LOS and a novel composite measure comprising 30-day readmission and mortality.

Results

Remote monitoring (PC) was associated with a shorter postoperative LOS, lower combined rate of 30-day readmission and mortality, and less variation compared to matched non-PC controls.

Conclusions

Integrated improvements in postoperative remote monitoring of adult cardiac surgery patients may reduce time in the hospital and post-acute care facilities. Future prioritized efforts include the development of additional, personalized biometric monitoring devices, use of biometric data to augment risk assessment, and investigation of the value of remote monitoring on various patient risk profiles to address potential disparities in care.

Unplanned postoperative catheterization during admission for coronary artery bypass grafting is neither cheap nor benign, but may rescue patients

OBJECTIVE

Literature describing outcomes of myocardial ischemia after coronary artery bypass grafting is sparse. We hypothesized these patients had more complications and incurred higher costs of care.

METHODS

Using adult cardiac surgery data and cardiac catheterization (CathPCI) data from the Virginia Cardiac Services Quality Initiative, we identified patients who underwent unplanned cardiac catheterization after coronary artery bypass grafting from 2018 to 2021. Adult cardiac surgery data were matched to CathPCI data examining earliest in-hospital catheterization. Patients not requiring catheterization served as the control group.

RESULTS

We identified 10,597 patients who underwent isolated coronary artery bypass grafting, of whom 41 of 10,597 underwent unplanned cardiac catheterization. A total of 21 of 41 patients (51%) received percutaneous coronary intervention, most commonly for non-ST-elevation myocardial infarction (n = 7, 33%) and ST-elevation myocardial infarction (n = 6, 29%). Postoperative cardiac arrest occurred in 14 patients (40%). In patients who underwent percutaneous coronary intervention, 14 (67%) had a single lesion, 4 (19%) had 2 lesions, and 3 (14%) had 3 lesions. The left anterior descending artery (38%) was the most frequently intervened upon vessel. Patients who underwent catheterization were more likely to require balloon pump support (26% vs 11%), to have prolonged ventilation (57% vs 20%), to have renal failure (17% vs 7.1%), and to undergo reintubation (37% vs 3.8%, all P < .04). There was no statistical difference in operative mortality (4.9% vs 2.3%, P = .2) or failure to rescue (4.9% vs 1.6%, P = .14). Total costs were higher in patients who underwent unplanned catheterization ($81,293 vs $37,011, P < .001).

CONCLUSIONS

Unplanned catheterization after coronary artery bypass grafting is infrequent but associated with more complications and a higher cost of care. Therefore, determination of an association with operative mortality in patients with suspected ischemia after coronary artery bypass grafting requires additional study.

Trends in SAVR with biological vs. mechanical valves in middle-aged patients: results from a French large multi-centric survey

Background/introduction

Currently, despite continued issues with durability ( 1), biological prosthetic valves are increasingly chosen over mechanical valves for surgical aortic valve replacement (SAVR) in adult patients of all ages, at least in Western countries. For younger patients, this choice means assuming the risks associated with a redo SAVR or valve-in-valve procedure.

Purpose

To assess the use of mechanical vs. biological valve prostheses for SAVR relative to patient's age and implant time in a large population extracted from the French National Database EPICARD.

Methods

Patients in EPICARD undergoing SAVR from 2007 to 2022 were included from 22 participating public or private centers chosen to represent a balanced representation of centre sizes and geographical discrepancies. Patients with associated pathology of the aorta (aneurysm or dissection) and requiring a vascular aortic prosthesis were excluded. Comparisons were made amongst centers, valve choice, implant date range, and patient age.

Results

We considered 101,070 valvular heart disease patients and included 72,375 SAVR (mean age 71.4 ± 12.2 years). We observed a mechanical vs. biological prosthesis ratio (MBPR) of 0.14 for the overall population. Before 50 years old (y-o), MBPR was >1.3 (p < 0.001) while patients above 60 years-old received principally biological SAVR (p < 0.0001). Concerning patients between 50 and 60 years-old patients, MPVR was 1.04 (p = 0.03). Patients 50-60 years-old from the first and second study duration quartile (before August 2015) received preferentially mechanical SAVR (p < 0.001). We observed a shift towards more biological SAVR (p < 0.001) for patients from the third and fourth quartile to reach a MBPR at 0.43 during the last years of the series. Incidentally, simultaneous mitral valve replacement were more common in case of mechanical SAVR (p < 0.0001), while associated CABGs were more frequent in case of biological SAVR (p < 0.0001).

Conclusion

In a large contemporary French patient population, real world practice showed a recent shift towards a lower age-threshold for biological SAVR as compared to what would suggest contemporary guidelines.

[Analysis of cardiac surgeries and operative mortality at the National Cardiovascular Institute during 2022]

Objective

To describe cardiac surgeries, their approaches, and determine operative mortality according to the type of surgery and the main complications recorded within 30 days postoperatively, performed at the National Cardiovascular Institute of Peru.

Materials and methods

A descriptive study was conducted on all patients over 18 years of age who underwent cardiovascular surgery at the National Cardiovascular Institute "Carlos Alberto Peschiera Carrillo".

Results

During the year 2022, a total of 503 cardiac surgeries were performed. Of the patients undergoing surgery, 63.6% (320) were males. Isolated valvular surgery, primarily aortic or mitral valve replacement, was the most frequent surgical procedure, with 136 surgeries (27.0%). This was followed by myocardial revascularization surgery with 110 procedures (21.9%). Throughout the year, there were 23 deaths, resulting in an overall mortality rate of 4.5%. The mortality rate for elective surgeries was 2.8%, while for emergency surgeries, it was 14.3%. The most common complication was paroxysmal atrial fibrillation (14.0%), followed by surgical site infection with 52 cases (10.3%).

Conclusions

Valvular surgery, whether isolated or combined with other procedures, was the most frequently performed. The obtained mortality rate is considered acceptable for a reference center.

Quantitative flow ratio-guided versus angiography-guided operation for valve disease accompanying coronary heart disease

Background

Valve replacement combined with coronary artery bypass graft (CABG) operation (VR + CABG) is usually associated with higher mortality and complication rates. Currently, angiography remains the most commonly used approach to guide CABG. The aim of this study is to investigate whether a quantitative flow ratio (QFR)-guided strategy can improve the clinical outcomes of VR + CABG.

Methods

Patients (n = 536) treated by VR + CABG between January 2018 and December 2021 were retrospectively assessed. In 116 patients, all lesions were revascularized entirely based on QFR (the QFR-guided group), whereas in 420 patients, all lesions were revascularized entirely based on angiography (the angiography-guided group). To minimize selection bias between the 2 groups, propensity score matching was performed at a ratio of 1:2. The primary endpoint of the study was the rate of major adverse cardiac and cerebrovascular events (MACCE) at 1-year, which was defined as a composite of cardiac mortality, myocardial infarction (MI), any repeat revascularization, and stroke.

Results

No statistically significant differences were observed in the baseline clinical characteristics between the QFR-guided and angiography-guided groups after propensity score matching. The mean age of all patients was 66.2 years [standard deviation (SD) = 8.3], 370 (69%) were men, the mean body-mass index of the population was 24.8 kg/m² (SD = 4.5), 129 (24%) had diabetes, and 229 (43%) had angina symptoms. When compared with the angiography-guided group, the QFR-guided group had a significantly shorter operative time (323 ± 60 min vs. 343 ± 71 min, P = 0.010), extra corporal circulation time (137 ± 38 min vs. 155 ± 62 min, P = 0.004), clamp time (73 ± 19 min vs. 81 ± 18 min, P < 0.001), and less intraoperative bleeding volume (640 ± 148 ml vs. 682 ± 166 ml, P = 0.022). Compared with the angiography-guided group, the 1-year MACCE was significantly lower in the QFR-guided group (6.9% vs. 14.7%, P = 0.036, hazard ratio = 0.455, 95% confidence interval: 0.211-0.982).

Conclusion

Our results raise the hypothesis that among patients who undergo VR + CABG, QFR-guided strategy is associated with optimized surgical procedure and a superior clinical outcome, as evidenced by a lower rate of MACCE at 1-year compared with conventional angiography-guided strategy.