Postoperative complications of patients undergoing cardiac surgery:

The Effects of Corticosteroids on Survival in Pediatric and Nonelderly Adult Patients Undergoing Cardiac Surgery: A Meta-analysis of Randomized Studies

OBJECTIVE

Cardiac surgery can be complicated by the development of a systemic inflammatory response syndrome related to cardiopulmonary bypass. This potentially contributes to the occurrence of postoperative morbidity and mortality. Corticosteroids can be used to reduce such inflammation, but the overall balance between potential harm and benefit is unknown and may be age-dependent. The present meta-analysis aims to evaluate the effects of prophylactic corticosteroids in pediatric and non-elderly adult cardiac surgery patients.

DESIGN

Systematic review and meta-analysis of randomized trials.

SETTING

Cardiac surgery with cardiopulmonary bypass.

PARTICIPANTS

Patients younger than 65 years old (pediatric and non-elderly adults).

INTERVENTIONS

Perioperative use of corticosteroids versus placebo or standard care.

MEASUREMENTS AND MAIN RESULTS

Two independent investigators searched PubMed, EMBASE and the Cochrane Library from inception to January 20, 2024. The primary outcome was mortality at the longest follow-up available. Secondary outcomes included acute kidney injury, atrial fibrillation, myocardial injury, cerebrovascular events, and infections. Our search strategy identified a total of 17 randomized trials involving 6,598 patients. Mortality was significantly reduced in the corticosteroid group (78/3321 [2.3%] vs. 116/3277 [3.5%]; risk ratio = 0.69; 95% confidence interval, 0.52 to 0.92; P = 0.01; I2 = 0%; NNT = 91). Moreover, the highest postoperative vasoactive inotropic score (VIS) was significantly lower in corticosteroid group (MD: -2.07, 95% CI -3.69 to -0.45, P = 0.01, I2 = 0%). No significant differences in secondary outcomes between the two treatment groups were recorded.

CONCLUSIONS

This meta-analysis of randomized trials highlights the potential benefits of corticosteroids on survival in cardiac surgery for patients younger than 65 years old.

Quality of life and functional capacity in patients after cardiac surgery intensive care unit

Coronary heart disease and aortic stenosis are prevalent cardiovascular diseases worldwide, leading to morbidity and mortality. Coronary artery bypass grafting (CABG) and surgical aortic valve replacement (SAVR) have therapeutic benefits, including improved postoperative quality of life (QoL) and enhanced patient functional capacity which are key indicators of cardiac surgery outcome. In this article, we review the latest studies of QoL outcomes and functional capacity in patients who underwent cardiac surgery. Many standardized instruments are used to evaluate QoL and functional conditions. Preoperative health status, age, length of intensive care unit stay, operative risk, type of procedure, and other pre-, intra-, and postoperative factors affect postoperative QoL. Elderly patients experience impaired physical status soon after cardiac surgery, but it improves in the following period. CABG and SAVR are associated with increases of physical and mental health and functional capacity in the immediate postoperative and the long long-term. Cardiac rehabilitation improves patient functional capacity, QoL, and frailty following cardiac surgery.

The effect of a selenium-based anti-inflammatory strategy on postoperative functional recovery in high-risk cardiac surgery patients - A nested sub-study of the sustain CSX trial

AIM

The cardiac surgery-related ischemia-reperfusion-related oxidative stress triggers the release of cytotoxic reactive oxygen and nitrogen species, contributing to organ failure and ultimately influencing patients' short- and long-term outcomes. Selenium is an essential co-factor for various antioxidant enzymes, thereby contributing to the patients' endogenous antioxidant and anti-inflammatory defense mechanisms. Given these selenium's pleiotropic functions, we investigated the effect of a high-dose selenium-based anti-inflammatory perioperative strategy on functional recovery after cardiac surgery.

MATERIALS AND METHODS

This prospective study constituted a nested sub-study of the SUSTAIN CSX trial, a double-blinded, randomized, placebo-controlled multicenter trial to investigate the impact of high-dose selenium supplementation on high-risk cardiac surgery patients' postoperative recovery. Functional recovery was assessed by 6-min walk distance, Short Form-36 (SF-36) and Barthel Index questionnaires.

KEY FINDINGS

174 patients were included in this sub-study. The mean age (SD) was 67.3 (8.9) years, and 78.7 % of the patients were male. The mean (SD) predicted 30-day mortality by the European System for Cardiac Operative Risk Evaluation II score was 12.6 % (9.4 %). There was no difference at hospital discharge and after three months in the 6-min walk distance between the selenium and placebo groups (131 m [IQR: not performed - 269] vs. 160 m [IQR: not performed - 252], p = 0.80 and 400 m [IQR: 299-461] vs. 375 m [IQR: 65-441], p = 0.48). The SF-36 and Barthel Index assessments also revealed no clinically meaningful differences between the selenium and placebo groups.

SIGNIFICANCE

A perioperative anti-inflammatory strategy with high-dose selenium supplementation did not improve functional recovery in high-risk cardiac surgery patients.

Perioperative Changes in Plasma Nitrite and IL-6 Levels Predict Postoperative Atrial Fibrillation (POAF) and Acute Kidney Injury (AKI) after Cardiac Surgery

Background: Postoperative atrial fibrillation (POAF) and acute kidney injury (AKI) are common yet significant complications after cardiac surgery, with incidences of up to 40% for each. Here, we assessed plasma nitrite and serum interleukin-6 (IL-6) levels before and after cardiac surgery to quantify the extent to which oxidative stress and inflammation contribute to POAF and AKI occurrence. Methods: We prospectively enrolled 206 cardiac surgical patients. Plasma nitrite and serum IL-6 levels were determined preoperatively and at 24 h, 48 h and 72 h postoperatively. The patients had continuous EKG monitoring for occurrence of POAF, while daily serum creatinine was measured for determination of stage 1 + AKI. Results: Postoperatively, 78 (38%) patients experienced AF, and 47 (23%) patients experienced stage 1 + AKI. POAF analysis: Age, ACE-inhibitor use, valve surgery and percent change in baseline plasma nitrite at 24 h postoperatively were associated with POAF in multiple logistic regression analysis. The inclusion of this new biomarker significantly improved the POAF prediction model (AUC 0.77 for clinical risk factors alone, to AUC 0.81). AKI analysis: A history of diabetes mellitus was associated with AKI in multiple logistic regression analysis, and the addition of preoperative IL-6 levels improved the prediction model for AKI occurrence (AUC 0.69 to AUC 0.74). Conclusions: We previously observed selective upregulation of NADPH oxidase isoform 4 (NOX4) in patients with AF, a critical causal role of NOX4 for AF in zebrafish and a robust inhibitory effect of nitric oxide (NO) on NOX4. Our data innovatively demonstrate that a reduction in circulating nitrite levels, likely implicative of elevated NOX4-mediated oxidative stress, independently associates with POAF and improves POAF prediction, whereas the inclusion of circulating IL-6 levels improves the prediction model for AKI. Therefore, therapeutic strategies to mitigate these pathophysiological sequalae of surgical stress may reduce the incidence of severe postoperative complications of POAF and AKI.

Effect of volatile versus propofol anaesthesia on major complications and mortality after cardiac surgery: a multicentre randomised trial

BACKGROUND

The comparative effectiveness of volatile anaesthesia and total intravenous anaesthesia (TIVA) in terms of patient outcomes after cardiac surgery remains a topic of debate.

METHODS

Multicentre randomised trial in 16 tertiary hospitals in China. Adult patients undergoing elective cardiac surgery were randomised in a 1:1 ratio to receive volatile anaesthesia (sevoflurane or desflurane) or propofol-based TIVA. The primary outcome was a composite of predefined major complications during hospitalisation and mortality 30 days after surgery.

RESULTS

Of the 3123 randomised patients, 3083 (98.7%; mean age 55 yr; 1419 [46.0%] women) were included in the modified intention-to-treat analysis. The composite primary outcome was met by a similar number of patients in both groups (volatile group: 517 of 1531 (33.8%) patients vs TIVA group: 515 of 1552 (33.2%) patients; relative risk 1.02 [0.92-1.12]; P=0.76; adjusted odds ratio 1.05 [0.90-1.22]; P=0.57). Secondary outcomes including 6-month and 1-yr mortality, duration of mechanical ventilation, length of ICU and hospital stay, and healthcare costs, were also similar for the two groups.

CONCLUSIONS

Among adults undergoing cardiac surgery, we found no difference in the clinical effectiveness of volatile anaesthesia and propofol-based TIVA.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR-IOR-17013578).

Maintenance of beta-blockers and cardiac surgery-related outcomes: a prospective propensity-matched multicentre analysis

BACKGROUND

We investigated the effects of maintaining beta-blockers on the day of surgery on the incidence of atrial fibrillation and postoperative acute kidney injury (AKI) in patients undergoing cardiac surgery.

METHODS

We conducted a multicentre prospective observational study with propensity matching on patients treated with beta-blockers. We collected their baseline patient characteristics, comorbidities, and operative and postoperative outcomes. The endpoints were postoperative atrial fibrillation and AKI after cardiac surgery.

RESULTS

Of the 1789 included patients, propensity matching led to 583 patients in each group. Maintenance of beta-blockers was not associated with a reduced risk of atrial fibrillation (odds ratio: 0.86 [95% confidence interval 0.66-1.14], P=0.335; 141 patients [24.2%] vs 126 patients [21.6%]). Sensitivity analysis did not demonstrate association between beta-blocker maintenance and atrial fibrillation after cardiac surgery (odds ratio: 0.93 [95% confidence interval: 0.72-1.22], P=0.625). Maintenance of beta-blockers was associated with a higher rate of norepinephrine use (415 [71.2%] vs 465 [79.8%], P=0.0001) and postoperative AKI (124 [21.3%] vs 159 [27.3%], P=0.0127). No statistically significant difference was observed in ICU length of stay.

CONCLUSIONS

Maintenance of beta-blockers on the day of surgery was not associated with a reduced incidence of postoperative atrial fibrillation. However, maintenance of beta-blockers was associated with increased usage of vasopressors, potentially contributing to adverse postoperative renal events.

CLINICAL TRIAL REGISTRATION

NCT04769752.

Pain Intensity After Cardiac Surgery and its Association With Kinesiophobia: A Descriptive Study

PURPOSE

Severe pain and fear of pain may decrease physical activity and restrict movements after cardiac surgery. This study aimed to determine pain intensity after cardiac surgery and its association with kinesiophobia.

DESIGN

This was a descriptive and correlational study.

METHODS

The study was conducted with cardiac surgery patients (n = 170). The sample size was calculated by using the G*POWER 3.1 program. According to the power analysis, the sample size was calculated as 170, taking into account the dependent variable with the largest sample size (kinesiophobia) and 20% loss. The outcome measures were pain and kinesiophobia collected using the Visual Analog Scale and Tampa Kinesiophobia Scale.

FINDINGS

Married patients were at the greatest risk for kinesiophobia, higher than that for single patients (β = -3.765, β = -3.609; P < .05). Obese patients were at the greatest risk for kinesiophobia higher when compared to patients of normal weight (β = -2.907, P < .05). No statistically significant correlation was found between the pain intensity and kinesiophobia scores (P > 0.05).

CONCLUSIONS

Kinesiophobia was higher in patients after cardiac surgery. Married and obese patients were predictors of kinesiophobia; however, pain was not associated with kinesiophobia.

Is Incentive Spirometry Superior to Standard Care in Postoperative Cardiac Surgery on Clinical Outcomes and Length of Hospital and Intensive Care Unit Stay? A Systematic Review with Meta-Analysis

INTRODUCTION

Cardiac surgery is a frequent surgical procedure and may present a high risk of complications. Among the prophylactic strategies studied to decrease the rates of negative outcomes, respiratory care seems to reduce pulmonary complications. Incentive spirometry (IS) is a low-cost, respiratory exercise technique, used for the prevention and treatment of postoperative pulmonary complications (PPC). The aim of this review was to evaluate whether IS is superior to respiratory care, mobilization exercises, and noninvasive ventilation on PPC, and clinical outcomes.

METHODS

Systematic review. Medical Literature Analysis and Retrieval System Online (or MEDLINE®), Embase®, Cochrane Central Register of Controlled Trials (or CENTRAL), Physiotherapy Evidence Database (or PEDro), Cumulative Index of Nursing and Allied Health (or CINAHL®), Latin American and Caribbean Health Sciences Literature (or LILACS), Scientific Electronic Library Online (or SciELO), Allied, Scopus®, and OpenGrey databases, clinical trial registration sites, conferences, congresses, and symposiums were searched.

RESULTS

Twenty-one randomized trials and one quasi-randomized trial (1,677 participants) were included. For partial pressure of oxygen (PaO2), IS was inferior to respiratory care (mean difference [MD] -4.48; 95% confidence interval [CI] -8.32 to -0.63). Flow-oriented IS was inferior to respiratory care on PaO2 (MD -4.53; 95% CI -8.88 to -0.18). However, compared to respiratory care, flow-oriented IS was superior on recovery vital capacity.

CONCLUSIONS

This meta-analysis revealed that IS was not superior to standard respiratory care for PPCs and clinical outcomes, therefore its use should not be widely recommended until further studies with high quality be performed to ensure this clinical guidance.

Protocol for the PORT study: short-term perioperative rehabilitation to improve outcomes in cardiac valvular surgery - a randomised control trial

INTRODUCTION

Perioperative rehabilitation (PORT) has shown a positive effect on patients undergoing cardiac surgery. However, there are minimal data on the impact of short-term PORT in cardiac surgery, which is associated with higher postoperative morbidity and mortality. The trial will assess the efficacy of short-term PORT in reducing in-hospital mortality, postoperative pulmonary complications and length of stay, compared with the usual care in cardiac surgical patients.

METHODS AND ANALYSIS

This is a single-centre prospective, randomised, open, controlled trial with a 1:1 ratio. Consecutive 800 adult patients undergoing elective valve surgery will be randomised to either usual care or in-hospital short-term PORT that consists of education, inspiratory muscle training, active cycle of breathing techniques and early mobilisation. The primary outcome of this study will be a composite of in-hospital all-cause mortality, incidence of postoperative pulmonary complications and the ratio of postoperative hospitalisation >7 days.

ETHICS AND DISSEMINATION

The PORT study was granted by the Medical Research Ethics Committee of Guangdong Provincial People's Hospital in August 2018. Findings will be disseminated to patients, clinicians and commissioning groups through peer-reviewed publication.

TRIAL REGISTRATION NUMBER

NCT03709511.

Del Nido cardioplegia or potassium induces Nrf2 and protects cardiomyocytes against oxidative stress

Open heart surgery is often an unavoidable procedure for the treatment of coronary artery disease. The procedure-associated reperfusion injury affects postoperative cardiac performance and long-term outcomes. We addressed here whether cardioplegia essential for cardiopulmonary bypass surgery activates Nrf2, a transcription factor regulating the expression of antioxidant and detoxification genes. With commonly used cardioplegic solutions, high K+, low K+, Del Nido (DN), histidine-tryptophan-ketoglutarate (HTK), and Celsior (CS), we found that DN caused a significant increase of Nrf2 protein in AC16 human cardiomyocytes. Tracing the ingredients in DN led to the discovery of KCl at the concentration of 20-60 mM capable of significant Nrf2 protein induction. The antioxidant response element (ARE) luciferase reporter assays confirmed Nrf2 activation by DN or KCl. Transcriptomic profiling using RNA-seq revealed that oxidation-reduction as a main gene ontology group affected by KCl. KCl indeed elevated the expression of classical Nrf2 downstream targets, including TXNRD1, AKR1C, AKR1B1, SRXN1, and G6PD. DN or KCl-induced Nrf2 elevation is Ca2+ concentration dependent. We found that KCl decreased Nrf2 protein ubiquitination and extended the half-life of Nrf2 from 17.8 to 25.1 mins. Knocking out Keap1 blocked Nrf2 induction by K+. Nrf2 induction by DN or KCl correlates with the protection against reactive oxygen species generation or loss of viability by H2O2 treatment. Our data support that high K+ concentration in DN cardioplegic solution can induce Nrf2 protein and protect cardiomyocytes against oxidative damage.NEW & NOTEWORTHY Open heart surgery is often an unavoidable procedure for the treatment of coronary artery disease. The procedure-associated reperfusion injury affects postoperative cardiac performance and long-term outcomes. We report here that Del Nido cardioplegic solution or potassium is an effective inducer of Nrf2 transcription factor, which controls the antioxidant and detoxification response. This indicates that Del Nido solution is not only essential for open heart surgery but also exhibits cardiac protective activity.

Application progress of nursing intervention in cardiac surgery

As a stressor, cardiac surgery affects the physiology and psychology of patients, as well as their postoperative recovery. Patients tend to worry about cognitive deficiency, pain, discomfort, the risk of death, sleep, complications, and other factors, resulting in stress and anxiety. Moreover, serious adverse events, such as circulatory and respiratory dysfunction and infection, tend to occur after cardiac surgery and increase the economic burden on patients. Therefore, appropriate nursing interventions should be selected to strengthen patients’ cognitive levels, compliance, and postoperative practices to accelerate their recovery, reduce complications, and shorten hospital stays so as to contribute to patients’ lives and health.

The effect of hospital-to-home transitional care using a digital messaging application on the health outcomes of patients undergoing CABG and their family caregivers: a randomized controlled trial study protocol

Objectives

Given the increasing trend of care transition from healthcare settings to patients' own home, patients and their family caregivers should take more responsibilities for care at own home. This study is going to investigate the effect of a transitional care program from hospital to own home using a digital messaging application on patients' undergoing coronary artery bypass graft (CABG) surgery and their family caregivers' health outcomes.

Methods

A parallel randomized controlled trial study will be conducted in a hospital in a metropolis located in southwestern Iran. Sampling will be performed sequentially and the eligible dyad of patients and family caregivers will be randomly assigned to intervention and control groups. The intervention group will receive a transitional care program for 8 weeks using the WhatsApp on the mobile phone based on the person-centered care approach, but the control group will receive routine care for patient's transition. Data collection will be conducted at baseline, immediately after the intervention, and two months after the intervention using demographic questionnaire, Cardiac Self-Efficacy Scale (CSES), MacNew Heart Disease Health-Related Quality of Life questionnaire (MNHD-Q), Cardiac Symptom Scale (CSS), Morisky Medication Adherence Scale, and Caregiver Burden Scale (CBS). Descriptive and inferential statistics will be used for data analysis.

Conclusions

The results of this study will allow evaluating the effectiveness of an innovative transitional care program to patients' own home using a digital messaging application. If the transitional program is shown feasible and effective it can be incorporated into existing care programs and stimulate further studies on the use of digital solutions for improving the continuity of care in own home.

A machine learning approach for predicting complications in descending and thoracoabdominal aortic aneurysms

OBJECTIVE

To use machine learning to predict rupture, dissection, and all-cause mortality for patients with descending and thoracoabdominal aortic aneurysms in an effort to improve on diameter-based surgical intervention criteria.

METHODS

Retrospective data from 1083 patients with descending aortic diameters 3.0 cm or greater were collected, with a mean follow-up time of 3.52 years and an average descending diameter of 4.13 cm. Six machine learning classifiers were trained using 44 variables to predict the occurrence of dissection, rupture, or all-cause mortality within 1, 2, or 5 years of initial patient encounter for a total of 54 (6 × 3 × 3) separate classifiers. Classifier performance was measured using area under the receiver operator curve.

RESULTS

Machine learning models achieved area under the receiver operator curves of 0.842 to 0.872 when predicting type B dissection, 0.847 to 0.856 when predicting type B dissection or rupture, and 0.820 to 0.845 when predicting type B dissection, rupture, or all-cause mortality. All models consistently outperformed descending aortic diameter across all end points (area under the receiver operator curve = 0.713-0.733). Feature importance inspection showed that other features beyond aortic diameter, such as a history of myocardial infarction, hypertension, and patient sex, play an important role in improving risk prediction.

CONCLUSIONS

This study provides surgeons with a more accurate, machine learning-based, risk-stratification metric to predict complications for patients with descending aortic aneurysms.

Influence of Anesthetics on Cardiac Index and Metabolic Outcomes in Mitral and Aortic Valve Replacement in Adults: A Randomized Clinical Study

Background

Cardiac index (CI) and metabolic response to surgery are important indicators of the course of the intraoperative period.

Objectives

This study aimed to determine the effect of sevoflurane, isoflurane, and propofol on CI and metabolic outcomes during aortic and mitral valve replacement in adults.

Methods

In this single-center prospective randomized controlled clinical study, a total of 75 patients were randomly assigned into 3 groups according to the type of anesthesia: The propofol group (n = 25), the sevoflurane group (n = 25), and the isoflurane group (n = 25). Cardiac stroke volume (SV) was determined by intraesophageal echocardiography (SV = end-diastolic volume - end-systolic volume). Cardiac output (CO) and CI were calculated according to the formulas. Oxygen consumption during surgery = CI × arteriovenous difference. Indirect calorimetry was used to determine energy expenditure during anesthesia using a spirometry device.

Results

The use of anesthetics did not change CI. Cardiac index decreased from 3 to 2.9 L/min/m2 in the propofol group, increased from 3.1 to 3.2 L/min/m2 in the sevoflurane group, and decreased from 2.9 to 2.7 L/min/m2 in the isoflurane group. Compared to inhaled anesthetics, propofol significantly reduced VO2 from 179.1 to 135.7 mL/min/m2. Propofol reduced energy expenditure from 1483.7 to 1333.5 kcal.

Conclusions

Volatile anesthetics, propofol has practically no effect on CI in an uncomplicated surgery. Anesthesia with propofol is associated with lower VO2 and better oxygen delivery to tissues. Energy consumption during propofol anesthesia decreases.

Relationships Between Systemic Inflammation, Intestinal Damage and Postoperative Organ Dysfunction in Adults Undergoing Low-Risk Cardiac Surgery

BACKGROUND

Approximately half of patients who undergo cardiac surgery develop systemic inflammatory response syndrome. Extracorporeal circulation and intestinal injury may play a role in this inflammatory response, although their relative contributions remain elusive. Moreover, it is largely unknown to what extent these factors contribute to cardiac surgery-induced postoperative organ dysfunction.

METHOD

In this secondary analysis, we measured circulating levels of the intestinal damage marker intestinal fatty acid binding protein (I-FABP) and of the inflammatory cytokines tumour necrosis factor (TNF)-α, interleukin (IL)-6, IL-8, IL-10, IL-1RA, monocyte chemoattractant protein (MCP)-1, macrophage inflammatory protein (MIP)-1α, and MIP-1β in 180 patients undergoing on-pump cardiac surgery. The average Z-score of levels of the different cytokines was used as an integral measure of the cytokine response. Relationships between duration of extracorporeal circulation, extent of intestinal injury, inflammation, and postoperative organ dysfunction were explored.

RESULTS

Plasma I-FABP levels increased during surgery, with peak levels observed at the end of cardiopulmonary bypass (CPB). Except for TNF-α, the levels of all cytokines increased during surgery, with peak levels observed either 2 (MCP-1, MIP-1α, and MIP-1β), 4 (IL-6, IL-8, and IL-1RA) or 6 (IL-10) hours after the end of CPB. While the duration of CPB significantly correlated with cytokine Z-score (r=0.544, p<0.05), no relationship with I-FABP levels was found. Furthermore, no significant correlations between I-FABP and cytokine levels were observed. The duration of CPB correlated with a deterioration in postoperative kidney function (estimated glomerular filtration rate [eGFR]) and troponin levels. Cytokine Z-score was associated with postoperative troponin levels, fluid administration, inotropic score, pulmonary alveolar-arterial gradient on the first postoperative morning, and deterioration of kidney function (eGFR). I-FABP levels did not correlate with any of the cardiovascular, pulmonary, or renal parameters.

CONCLUSIONS

In patients undergoing low-risk cardiac surgery, the duration of CPB represents an important determinant of the systemic cytokine response, whereas both the CPB duration and the systemic inflammatory response contribute to subsequent organ dysfunction. Intestinal damage does not appear to play a relevant role in the postoperative inflammatory response and development of postoperative organ dysfunction in these patients.

The effect of preoperative statins on postoperative mortality, renal, and neurological complications in patients undergoing cardiac surgeries: a retrospective cohort study

BACKGROUND

Cardiac surgery is performed worldwide to treat severe cases of cardiovascular diseases. Statins have shown controversial effects on complications after cardiac surgeries. We aimed to investigate the effect of preoperative statin therapy on the frequency of postoperative mortality, renal, and neurological complications.

METHODS

In a retrospective cohort study, the database of patients operated on in two hospitals in southern Iran during 2008-2019 was used to compare preoperative statin use with no use on the composite outcome of mortality, renal, and neurological complications as well as on each component of the composite, separately. Effects of low dose (<40 mg simvastatin equivalence) vs. high dose (≥40 mg) statins were also evaluated. Confounders that could affect the outcomes were considered in the logistic regression model, and multiple imputation techniques were used to categorize patients with unknown statin dose use as either high or low-dose users.

RESULTS

Of total 7329 patients, 17.6% of statin users and 17% of non-statin users developed the composite outcome (P=0.51). Statin use had no statistically significant association with the composite outcome (aRR 1.01 [95% CI: 0.88-1.16]). There was no significant association with mortality [aRR: 0.75 (95% CI: 0.34-1.69)], neurological [aRR: 1.25 (95% CI: 0.77-2.12)], or renal complications [aRR: 1.03 (95% CI 0.90-1.19)] after surgery. Neither low nor high doses had any statistically significant effect on the composite or any of its components.

CONCLUSIONS

In this large study, preoperative statin use, either high dose or low dose, did not affect short-term postoperative mortality, neurological, or renal complications.

Outcome Monitoring After Cardiac Surgery (OMACS): a single-centre prospective cohort study of cardiac surgery patients

INTRODUCTION

More than 30 000 cardiac surgery procedures are performed in the UK each year, however, postoperative complications and long-term failure of interventions are common, leading to repeated surgeries. This represents a significant burden on the patient and health service.Routinely, patients are discharged to their general practitioner 6 weeks postoperatively and research studies typically only report short-term outcomes up to 1 year after surgery, together this makes long-term outcomes of cardiac surgery difficult to monitor. Further, traditional research methods have yet to advance understanding of what causes early complications and why surgical interventions fail.

METHODS AND ANALYSIS

This prospective cohort study will characterise participants undergoing cardiac surgery at baseline, describe short-term, medium-term and long-term health outcomes postoperatively and collect tissue samples.All eligible adult patients undergoing cardiac surgery at the Bristol Heart Institute, UK will be approached for consent. Recruitment is expected to continue for up to 10 years resulting in the largest cohort of cardiac patients reported to date. Blood, urine and waste tissue samples will be collected during admission. Samples, along with anonymised data, will be used to investigate outcomes and inform predictive models of complications associated with cardiac surgery.Data about the surgical admission will be obtained from hospital databases and medical notes. Participants may be monitored up to 5 years postoperatively using data obtained from NHS digital. Participants will complete health questionnaires 3 months and 12 months postoperatively.The analysis of data and tissue samples to address specific research questions will require separate research protocols and ethical approval.

ETHICS AND DISSEMINATION

This study was approved by the East Midlands Nottingham 2 Research Ethics Committee.Findings will be disseminated through peer-reviewed publications and presentation at national and international meetings. Participants will be informed of results in annual newsletters.

TRIAL REGISTRATION NUMBER

ISRCTN90204321.

Hemoadsorption in Complex Cardiac Surgery-A Single Center Experience

(1) Background: Cardiac surgery may evoke a generalized inflammatory response, typically magnified in complex, combined, redo, and emergency procedures with long aortic cross-clamp times. Various treatment options have been introduced to help regain control over post-cardiac surgery hyper-inflammation, including hemoadsorptive immunomodulation with CytoSorb^®. (2) Methods: We conducted a single-center retrospective observational study of patients undergoing complex cardiac surgery. Patients intra-operatively treated with CytoSorb^® were compared to a control group. The primary outcome was the change in the vasoactive-inotropic score (VIS) from pre-operatively to post-operatively. (3) Results: A total of 52 patients were included in the analysis, where 23 were treated with CytoSorb^® (CS) and 29 without (controls). The mean VIS increase from pre-operative to post-operative values was significantly lower in the CS group compared to the control group (3.5 vs. 5.5, respectively, p = 0.05). In-hospital mortality in the control group was 20.7% (6 patients) and 9.1% (2 patients) in the CS group (p = 0.26). Lactate level changes were comparable, and the median intensive care unit and hospital lengths of stay were similar between groups. (4) Conclusions: Despite notable imbalances between the groups, the signals revealed point toward better hemodynamic stability with CytoSorb^® hemoadsorption in complex cardiac surgery and a trend of lower mortality.

Utility and safety of nafamostat mesilate for anticoagulation in dogs

BACKGROUND

Surgical interventions are recommended for cases of advanced mitral regurgitation, however, limited facilities are available. The most prominent complication in such procedures is heparin-derived bleeding. An alternative anticoagulant to heparin, nafamostat mesilate (NM), can reduce the occurrence of complications associated with heparin such as bleeding or shock.

OBJECTIVES

This study aimed to evaluate the utility and safety of using NM during anaesthesia in canines.

METHODS

Six healthy adult Beagle dogs were anaesthetised, and NM was administered intravenously as a 10 mg/kg bolus dose over 5 min, followed by a continuous infusion of 10 mg/kg/h over 20 min. Blood tests and blood pressure measurements were performed at 0, 5, 25 and 55 min after NM administration.

RESULTS

Activated thromboplastin times at 0, 25 and 55 min were 13.0 ± 0.7 s, 106.7 ± 13.3 s and 28.2 ± 2.9 s, respectively, with a significant difference between 0 and 25 min (p < 0.01) only. No significant differences were observed in prothrombin time, antithrombin, fibrinogen and fibrin degradation product concentrations between timepoints. Activated clotting times (ACTs) at 0, 5, 25 and 55 min were 119.5 ± 9.6 s, 826.7 ± 78.6 s, 924.8 ± 42.4 s and 165.2 ± 13.5 s, respectively. Significant differences were observed between 0 and 5 min (p < 0.05) and between 0 and 25 min (p < 0.05). Blood pressure changes occurred in four dogs (66.7%). No other serious adverse effects were observed.

CONCLUSIONS

ACT results indicated that NM use in anaesthetised healthy dogs was sufficient to obtain procedural anticoagulation with minimal adverse effects. However, these preliminary data require validation in further studies on cardiopulmonary bypass surgery.

Serum level of calpains product as a novel biomarker of acute lung injury following cardiopulmonary bypass

OBJECTIVE

The aim of this study was to test the hypothesis whether serum level of calpains could become a meaningful biomarker for diagnosis of acute lung injury (ALI) in clinical after cardiac surgery using cardiopulmonary bypass (CPB) technology.

METHODS AND RESULTS

Seventy consecutive adults underwent cardiac surgery with CPB were included in this prospective study. Based on the American-European Consensus Criteria (AECC), these patients were divided into ALI (n = 20, 28.57%) and non-ALI (n = 50, 71.43%) groups. Serum level of calpains in terms of calpains' activity which was expressed as relative fluorescence unit (RFU) per microliter and measured at beginning of CPB (baseline), 1 h during CPB, end of CPB as well as 1, 12, and 24 h after CPB. Difference of serum level of calpains between two groups first appeared at the end of CPB and remained different at subsequent test points. Univariate and multivariate logistic regression analysis indicated that serum level of calpains 1 h after CPB was an independent predictor for postoperative ALI (OR 1.011, 95% CI 1.001, 1.021, p = 0.033) and correlated with a lower PaO₂/FiO₂ ratio in the first 2 days (The first day: r = -0.389, p < 0.001 and the second day: r = -0.320, p = 0.007) as well as longer mechanical ventilation time (r = 0.440, p < 0.001), intensive care unit (ICU) length of stay (LOS) (r = 0.419, p < 0.001) and hospital LOS (r = 0.297, p = 0.013).

CONCLUSION

Elevated serum level of calpains correlate with impaired lung function and poor clinical outcomes, indicating serum level of calpains could act as a potential biomarker for postoperative ALI following CPB in adults.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/show/NCT05610475], identifier [NCT05610475].

Emergent Bedside Resternotomy: An Innovative Simulation Model for Training Pediatric Cardiac Intensive Care Teams

Cardiac tamponade after cardiac surgery is a life-threatening event that requires simultaneous resuscitation and emergent resternotomy by the intensive care team. A simulated scenario using an innovative mannequin with sternotomy wound has the capability of reproducing cardiac arrest associated with postoperative tamponade. We evaluated the validity of this mannequin to investigate the confidence level and crisis resource management skills of the team during bedside resternotomy to manage postoperative cardiac tamponade. The simulation scenario was developed using the sternotomy mannequin for a pediatric cardiac intensive care unit (CICU) team. The case involved a 3-year-old male, intubated, and mechanically ventilated after surgical repair of congenital heart disease, progressing to cardiac arrest due to cardiac tamponade. We conducted a formative learner assessment before and after each scenario as well as a structured, video debriefing following each encounter. The simulation was repeated in a 6-month interval to assess knowledge retention and improvement in clinical workflow. The data were analyzed using student t-test and chi-square test, when appropriate. Of the 72 CICU providers, a significant proportion of providers (p < 0.0001) showed improved confidence in assessing and managing cardiac arrest associated with postoperative cardiac tamponade. All providers scored ≥3 for the impact of the scenario on practice, teamwork, communication, assessment skills, improvement in cardiopulmonary resuscitation, and opening the chest and their confidence in attending similar clinical situations in future. Most (96–100%) scored ≥3 for the perception on the realism of mannequin, the scenario, reopening the sternotomy, and level of stress. Time to diagnosis of cardiac tamponade (p = 0.004), time to the first dose of epinephrine (p = 0.045), and median number of interruptions to chest compressions (p = 0.006) all significantly decreased between the two sessions. Time to completion of resternotomy improved by 81.4 seconds; however, this decrease was not statistically significant. Implementation of a high-fidelity mannequin for postoperative cardiac tamponade simulation can achieve a realistic and reproducible training model with positive impacts on multidisciplinary team education.

Mobile health vs. standard care after cardiac surgery: results of The Box 2.0 study

AIMS

Postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery, yet difficult to detect in ambulatory patients. The primary aim of this study is to investigate the effect of a mobile health (mHealth) intervention on POAF detection after cardiac surgery.

METHODS AND RESULTS

We performed an observational cohort study among 730 adult patients who underwent cardiac surgery at a tertiary care hospital in The Netherlands. Of these patients, 365 patients received standard care and were included as a historical control group, undergoing surgery between December 2017 and September 2018, and 365 patients were prospectively included from November 2018 and November 2020, undergoing an mHealth intervention which consisted of blood pressure, temperature, weight, and electrocardiogram (ECG) monitoring. One physical outpatient follow-up moment was replaced by an electronic visit. All patients were requested to fill out a satisfaction and quality of life questionnaire. Mean age in the intervention group was 62 years, 275 (70.4%) patients were males. A total of 4136 12-lead ECGs were registered. In the intervention group, 61 (16.7%) patients were diagnosed with POAF vs. 25 (6.8%) patients in the control group [adjusted risk ratio (RR) of POAF detection: 2.15; 95% confidence interval (CI): 1.55-3.97]. De novo atrial fibrillation was found in 13 patients using mHealth (6.5%) vs. 4 control group patients (1.8%; adjusted RR 3.94, 95% CI: 1.50-11.27).

CONCLUSION

Scheduled self-measurements with mHealth devices could increase the probability of detecting POAF within 3 months after cardiac surgery. The effect of an increase in POAF detection on clinical outcomes needs to be addressed in future research.

An unusual case of stabbing chest pain …literally: a case report

Background

Cardiac surgery is associated with a significant risk of potential postoperative complications. We describe a case of a patient with an unusual late cardiac perforation caused by a needle used to fix temporary epicardial pacing wires to the skin, which slowly migrated across subcutaneous tissues for 2 years following postoperative period.

Case summary

We report a case of middle-aged woman admitted to the cardiac intensive care unit due to suspected acute myocardial infarction. Multimodality imaging revealed the presence of an unusual intracardiac foreign body, located inside the interventricular septum and perforating towards the left atria, complicated by a small intracardiac fistula between septal coronary branches and the right ventricle. Analysis of previous examinations revealed that a needle used to fix temporary epicardial pacing wires to the skin had been left inside the patient, beneath the level of the diaphragm, after cardiac surgery in 2018. This foreign body slowly migrated across the diaphragm, towards the mediastinum, finally lodging inside the heart, after a period of 3 years. The patient was referred to cardiac surgery for foreign body retrieval.

Discussion

We describe an unusual case of cardiac perforation caused by a needle used to fix these wires to the skin, which migrated across subcutaneous tissues and finally lodged inside the basal interventricular septum and left atria. Full compliance with standardized surgical care bundles, as well as the implementation of a structured incident reporting system, is of upmost importance to prevent postoperative complications and improve surgical care.

Definition and Classification of Postoperative Complications After Cardiac Surgery: A Pilot Delphi Study (Preprint)

Background

Postoperative complications following cardiac surgery are common and represent a serious burden to health services and society. However, there is a lack of consensus among experts on what events should be considered as a “complication” and how to assess their severity.

Objective

This study aimed to consult domain experts to pilot the development of a definition and classification system for complications following cardiac surgery with the goal to allow the progression of standardized clinical processes and systems in cardiac surgery.

Methods

We conducted a Delphi study, which is a well-established method to reach expert consensus on complex topics. We sent 2 rounds of surveys to domain experts, including cardiac surgeons and anesthetists, to define and classify postoperative complications following cardiac surgery. The responses to open-ended questions were analyzed using a thematic analysis framework.

Results

In total, 71 and 37 experts’ opinions were included in the analysis in Round 1 and Round 2 of the study, respectively. Cardiac anesthetists and cardiac critical care specialists took part in the study. Cardiac surgeons did not participate. Experts agreed that a classification for postoperative complications for cardiac surgery is useful, and consensus was reached for the generic definition of a postoperative complication in cardiac surgery. Consensus was also reached on classification of complications according to the following 4 levels: “Mild,” “Moderate,” “Severe,” and “Death.” Consensus was also reached on definitions for “Mild” and “Severe” categories of complications.

Conclusions

Domain experts agreed on the definition and classification of complications in cardiac surgery for “Mild” and “Severe” complications. The standardization of complication identification, recording, and reporting in cardiac surgery should help the development of quality benchmarks, clinical audit, care quality assessment, resource planning, risk management, communication, and research.

Elevated Blood Urea Nitrogen to Serum Albumin Ratio Is an Adverse Prognostic Predictor for Patients Undergoing Cardiac Surgery

Background

Elevated blood urea nitrogen (BUN) and reduced albumin have been prominently correlated with unfavorable outcomes in patients with cardiovascular diseases. However, whether combination BUN and albumin levels could predict the adverse outcomes of cardiac surgery patients remains to be confirmed. Here, we investigated the prognostic effect of the preoperative BUN to serum albumin ratio (BAR) in cardiac surgery patients.

Methods

Data were obtained from the Medical Information Mart for Intensive Care (MIMIC) III and eICU databases and classified into a training cohort and validation cohort. The BAR (mg/g) was calculated by initial BUN (mg/dl)/serum albumin (g/dl). The primary outcome was in-hospital mortality. Secondary outcomes were 1-year mortality, prolonged length at intensive care unit, and duration of hospital stay. The associations of BAR with outcomes were explored by multivariate regression analysis and subgroup analyses. Then, C statistics were performed to assess the added prognostic impact of BAR beyond a baseline risk model.

Results

Patients with in-hospital death had significantly higher levels of BAR. Multivariate regression analysis identified BAR, as a categorical or continuous variable, as an independent factor for adverse outcomes of cardiac surgery (all p < 0.05). Subgroup analyses demonstrated a significant relationship between elevated BAR and in-hospital mortality in different subclasses. The addition of BAR to a baseline model provided additional prognostic information benefits for assessing primary outcome. Results were concordant in the external validation cohort.

Conclusions

Increased preoperative BAR is a potent predictor of unfavorable outcomes in patients undergoing cardiac surgery.

Factors Determining the Functional State of Cardiac Surgery Patients with Complicated Postoperative Period

The purpose of this work was to study the factors determining the functional state of cardiac surgery patients with a complicated postoperative period upon discharge from the hospital. This observational study included 60 patients who underwent cardiac surgery with a complicated postoperative course and with a prolonged intensive care unit stay of more than 72 h. We assessed handgrip and lower-extremity muscle strength and the six-minute walk test (6MWT) distance 3 days after the surgery and at discharge from the hospital. Some patients (53%) additionally underwent a course of neuromuscular electrostimulation (NMES). Two groups of patients were formed: first (6MWT distance at discharge of more than 300 m) and second groups (6MWT distance of 300 m or less). The patients of the second group had less lower-extremity muscle strength and handgrip strength on the third postoperative day, a longer aortic clamping time and a longer stay in the intensive care unit. Independent predictors of decreased exercise tolerance at discharge were body mass index, foot extensor strength and baseline 6MWT distance in the general group, duration of cardiopulmonary bypass in the NMES group and in the general group, and age in the NMES group. Thus, the muscle status on the third postoperative day was one of the independent factors associated with the 6MWT distance at discharge in the general group, but not in patients who received NMES. It is advisable to use these results in patients with complications after cardiac surgery with the use of NMES rehabilitation.

The effects of preoperative supplementation with a combination of beta-hydroxy-beta-methylbutyrate, arginine, and glutamine on inflammatory and hematological markers of patients with heart surgery: a randomized controlled trial

Background

Cardiac surgery is associated with a widespread inflammatory response, by an additional release of free radicals. Due to the importance of these patient’s nutritional status, the present study was designed to evaluate the effectiveness of supplementation with a combination of glutamine, β-hydroxy-β-methylbutyrate (HMB) and arginine in patients undergoing to the heart surgery.

Methods

The experiment was performed in 1 month (30 days) before cardiac surgery. patients were asked to take 2 sachets of Heallagen® (a combination of 7 g l-arginine, 7 g l-glutamine, and 1.5 g daily HMB) or placebo with identical appearance and taste (maltodextrin) with 120 cc of water. Clinical and biochemical factors were evaluated in the baseline and end of the study.

Results

Totally, 60 preoperative patients (30 interventions and 30 placeboes) with a mean age of 53.13 ± 14.35 years participated in the study. Subjects in Heallagen® group had a lower serum levels of interleukin-6 (P = 0.023), erythrocyte sedimentation rate (P < 0.01), high sensitivity C-reactive protein (P < 0.01), and lymphocyte number (P = 0.007) compared to the placebo, at end of the study.

Conclusion

In the patients undergoing heart surgery, Heallagen® significantly improved some of the inflammatory factors and hematological parameters. These results need to be confirmed in a larger trial.

Trial registration: The protocol of the study was registered in the IRCT.ir with registration no. IRCT20120913010826N31 at 13/10/2020.

Lung injury after cardiopulmonary bypass: Alternative treatment prospects

Although the lung injury caused by cardiopulmonary bypass (CPB) has been extensively investigated, the incidence and mortality of lung injury after CPB remain a prominent clinical problem. The poor outcome has been attributed to multifactorial etiology, including the systemic inflammatory response and ischemia reperfusion (I/R) injury during CPB. Lung injury after CPB is a complex pathophysiological process and has many clinical manifestations of mild to severe disease. Which is associated with prognosis. To alleviate this lung injury, interventions that address the pathogenesis are particularly important. This review summarizes the pathogenesis, mechanism and treatment options of lung injury after CPB, such as lung protection with intralipid.

Prolonged mechanical ventilation after cardiac surgery: substudy of the Transfusion Requirements in Cardiac Surgery III trial

PURPOSE

Prolonged mechanical ventilation (MV) is a major complication following cardiac surgery. We conducted a secondary analysis of the Transfusion Requirements in Cardiac Surgery (TRICTS) III trial to describe MV duration, identify factors associated with prolonged MV, and examine associations of prolonged MV with mortality and complications.

METHODS

Four thousand, eight hundred and nine participants undergoing cardiac surgery at 71 hospitals worldwide were included. Prolonged MV was defined based on the Society of Thoracic Surgeons definition as MV lasting 24 hr or longer. Adjusted associations of patient and surgical factors with prolonged MV were examined using multivariable logistic regression. Associations of prolonged MV with complications were assessed using odds ratios, and adjusted associations between prolonged MV and mortality were evaluated using multinomial regression. Associations of shorter durations of MV with survival and complications were explored.

RESULTS

Prolonged MV occurred in 15% (725/4,809) of participants. Prolonged MV was associated with surgical factors indicative of complexity, such as previous cardiac surgery, cardiopulmonary bypass duration, and separation attempts; and patient factors such as critical preoperative state, left ventricular impairment, renal failure, and pulmonary hypertension. Prolonged MV was associated with perioperative but not long-term complications. After risk adjustment, prolonged MV was associated with perioperative mortality; its association with long-term mortality among survivors was weaker. Shorter durations of MV were not associated with increased risk of mortality or complications.

CONCLUSION

In this substudy of the TRICS III trial, prolonged MV was common after cardiac surgery and was associated with patient and surgical risk factors. Although prolonged MV showed strong associations with perioperative complications and mortality, it was not associated with long-term complications and had weaker association with long-term mortality among survivors.

STUDY REGISTRATION

www.

CLINICALTRIALS

gov (NCT02042898); registered 23 January 2014. This is a substudy of the Transfusion Requirements in Cardiac Surgery (TRICS) III trial.

Efficacy of Early and Enhanced Respiratory Physiotherapy and Mobilization after On-Pump Cardiac Surgery: A Prospective Randomized Controlled Trial

Background: This randomized controlled trial aimed to investigate the influence of physical activity and respiratory physiotherapy on zero postoperative day on clinical, hemodynamic and respiratory parameters of patients undergoing cardiac surgeries under extracorporeal circulation. Methods: 78 patients undergoing coronary artery bypass graft (CABG) or/and valvular heart disease surgeries were randomly assigned into an early and enhanced physiotherapy care group (EEPC group; n = 39) and a conventional physiotherapy care group (CPC group; n = 39). Treatment protocol for the EEPC group included ≤3 Mets of physical activity and respiratory physiotherapy on zero post-operative day and an extra physiotherapy session during the first three post-operative days, whereas the CPC group was treated with usual physiotherapy care after the first post-operative day. The length of hospital and intensive care unit (ICU) stay were set as the primary study outcomes, while pre- and post-intervention measurements were also performed to assess the oxymetric and hemodynamic influence of early mobilization and physiotherapy. Results: Participants’ mean age was 51.9 ± 13.8 years. Of them 48 (61.5%) underwent CABG. Baseline and peri-procedural characteristics did not differ between the two groups. The total duration of hospital and ICU stay were significantly higher in the CPC group compared to the EEPC group (8.1 ± 0.4 days versus 8.9 ± 0.6 days and 25.4 ± 3 h versus 23.2 ± 0.6 h, p < 0.001, respectively). Statistically significant differences in pre-intervention oxygen saturation, and post-intervention PO2 and lactate levels were also observed between the two groups (p = 0.022, 0.027 and 0.001, respectively). Conclusion: In on-pump cardiac surgery, early and enhanced post-procedural physical activity (≤3 METS) can prevent a prolonged ICU stay and decrease the duration of hospitalization while ameliorating post-operative hemodynamic and oxymetric parameters.

Mathematical and Computational Modeling of Device-Induced Thrombosis

Given the extensive and routine use of cardiovascular devices, a major limiting factor to their success is the thrombotic rate that occurs. This both poses direct risk to the patient and requires counterbalancing with anticoagulation and other treatment strategies, contributing additional risks. Developing a better understanding of the mechanisms of device-induced thrombosis to aid in device design and medical management of patients is critical to advance the ubiquitous use and durability. Thus, mathematical and computational modelling of device-induced thrombosis has received significant attention recently, but challenges remain. Additional areas that need to be explored include microscopic/macroscopic approaches, reconciling physical and numerical timescales, immune/inflammatory responses, experimental validation, and incorporating pathologies and blood conditions. Addressing these areas will provide engineers and clinicians the tools to provide safe and effective cardiovascular devices.

Superior Vena Cava Syndrome due to pericardial hematoma: A case report and mini-review of literature

Superior vena cava syndrome is a life-threatening condition. Typically, the clinical presentations are gradual; hence, the diagnosis is often delayed until critical compression or obstruction has occurred. Pericardial hematoma is a rare condition that could occur after cardiac surgery. An asymptomatic, 25-year-old female, who underwent surgical atrial septal defect closure 5 days ago, was sent for routine echocardiography examination before discharge. An intrapericardiac hematoma was detected at the right atrium’s free wall without any intracardiac hemodynamic consequences. The patient was discharged and planned for monthly evaluation. During follow-up, the intrapericardiac hematoma was expanding. In the third month’s follow-up, the patient complained of shortness of breath, headaches, and coughs. Echocardiography evaluation revealed enlarged pericardial hematoma, which compressed the right atrium and superior vena cava orifice, without echo’ sign of cardiac tamponade. Computed tomography scan revealed superior vena cava compression by the pericardial hematoma and appearance of the collateral vessel. The patient was diagnosed with superior vena cava syndrome and sent for surgical evacuation. Pericardial hematoma after cardiac surgery should be evaluated meticulously. Chronic expanding hematoma could cause superior vena cava syndrome, which is fatal. Early diagnosis and appropriate treatment are essential in managing this condition.

The effects of cardiovascular and orthopaedic surgery on vitamin concentrations: a narrative review of the literature and mechanisms of action

Given the rise in worldwide chronic diseases, supplemented by an aging population, the volume of global major surgeries, encompassing cardiac and orthopedic procedures is anticipated to surge significantly. Surgical trauma can be accompanied by numerous postoperative complications and metabolic changes. The present review summarized the results from studies assessing the effects of orthopedic and cardiovascular surgery on vitamin concentrations, in addition to exploring the possible mechanisms associated with changes in concentrations. Studies have revealed a potentially severe depletion in plasma/serum concentrations of numerous vitamins following these surgeries acutely. Vitamins C, D and B1 appear particularly vulnerable to significant depletions, with vitamin C and D depletions consistently transpiring into inadequate and deficient concentrations, respectively. The possible multifactorial mechanisms impacting postoperative vitamin concentrations include changes in hemodilution and vitamin utilization, redistribution, circulatory transport and absorption. For a majority of vitamins, there has been a lack of investigation into the effects of both, cardiac and orthopedic surgery. Additionally, studies were predominantly restricted to short-term postoperative investigations, primarily performed within the first postoperative week of surgery. Overall, results indicated that further examination is necessary to determine the severity and clinical significance of the possible depletions in vitamin concentrations that ensue cardiovascular and orthopedic surgery.

Transfixing heart injury by stab wound: Case report

Cardiac impalement is a rare and usually fatal injury. Immediate recognition and surgical intervention are decisive factors for patient survival. This is a reported case of cardiac impalement with left ventricular transfixation, whose prehospital management, surgical treatment and postoperative care were successful.

Associations Between Expiratory Flow Limitation and Postoperative Pulmonary Complications in Patients Undergoing Cardiac Surgery

OBJECTIVES

To determine whether driving pressure and expiratory flow limitation are associated with the development of postoperative pulmonary complications (PPCs) in cardiac surgery patients.

DESIGN

Prospective cohort study.

SETTING

University Hospital San Raffaele, Milan, Italy.

PARTICIPANTS

Patients undergoing elective cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was the occurrence of a predefined composite of PPCs. The authors determined the association among PPCs and intraoperative ventilation parameters, mechanical power and energy load, and occurrence of expiratory flow limitation (EFL) assessed with the positive end-expiratory pressure test. Two hundred patients were enrolled, of whom 78 (39%) developed one or more PPCs. Patients with PPCs, compared with those without PPCs, had similar driving pressure (mean difference [MD] -0.1 [95% confidence interval (CI), -1.0 to 0.7] cmH₂O, p = 0.561), mechanical power (MD 0.5 [95% CI, -0.3 to 1.1] J/m, p = 0.364), and total energy load (MD 95 [95% CI, -78 to 263] J, p = 0.293), but they had a higher incidence of EFL (51% v 38%, p = 0.005). Only EFL was associated independently with the development of PPCs (odds ratio 2.46 [95% CI, 1.28-4.80], p = 0.007).

CONCLUSIONS

PPCs occurred frequently in this patient population undergoing cardiac surgery. PPCs were associated independently with the presence of EFL but not with driving pressure, total energy load, or mechanical power.

The association between advanced practice nursing roles and outcomes in adults following cardiac surgery: A systematic review of randomized controlled trials

BACKGROUND

Empirical findings have shown significant and non-significant effects of advanced practice nursing roles within postoperative cardiac settings. The inconsistencies of the current literature preclude the identification of a significant effect of advanced practice nursing roles on patient and organizational outcomes.

OBJECTIVE

1) identify patient and organizational outcomes of advanced practice nursing roles in postoperative cardiac surgery and 2) synthesize the evidence of current roles of advanced practice nurses in postoperative cardiac surgery to provide the best quality of care for patients.

METHOD

A systematic review of randomized controlled trials was conducted in six electronic databases, including Medline, CINHAL, Embase, Cochrane Database, Joanna Briggs Database and Web of Science, and the grey literature. Randomized controlled trials published after 1999 were included if they examined advanced practice nursing roles and recruited patients who underwent cardiac surgery. The study selection was performed by two independent reviewers, and consensus was achieved with a third reviewer. Data extraction was conducted by one reviewer and revised by a second reviewer. The methodological quality of the included studies was assessed with the Evidence Project risk of bias tool by two independent reviewers and revised by a third reviewer. A narrative synthesis of the available evidence was completed. No meta-analysis technique was attempted because of the high heterogeneity of the included studies.

RESULTS

Among 4,448 retrieved papers, ten randomized controlled trials and three secondary analyses were included in this review. The methodological quality of the included studies was moderate. All studies included a comparison group and the majority of the studies collected data using a blinded researcher. However, all studies were based on small sample sizes and failed to randomly recruit participants. Five studies implemented nurse practitioner roles and five studies implemented clinical nurse specialist roles. The advanced practice nursing care included health condition management, lifestyle promotion and coping strategies with patients. A total of 22 outcomes were identified, including 13 patient outcomes (e.g., depressive symptoms) and nine organizational outcomes (e.g., rehospitalization after discharge). Each outcome was examined in one to five studies. All of the included outcomes were associated with inconsistent findings.

CONCLUSION

The findings from existing literature remain inconsistent. The high risk of bias and the small sample sizes could potentially explain the non-significant findings. Avenues for future research should focus on the development of methodologically high-quality studies with larger sample sizes to enhance our understanding of the effectiveness of advanced practice nursing roles.

Association between the weekday on which coronary artery bypass graft surgery is performed and the 30-day mortality: A nationwide cohort study in South Korea

BACKGROUND

Postoperative mortality associated with elective coronary artery bypass graft (CABG) surgery may reportedly increase as the weekday of surgery approaches the weekend. We aimed to investigate the potential effect of the weekday of CABG surgery on the 30-day mortality.

METHODS

This population-based cohort study analyzed data obtained from the South Korea national health insurance service database. The cohort included all adult patients diagnosed with ischemic heart disease (International Classification of Diseases-10 codes I20*-I25*) who underwent isolated and elective CABG surgery from January 2012 to December 2017.

RESULTS

Of the 13,556 patients included in the analysis, 595 (4.4%) died within 30 days after CABG surgery. In a multivariable Cox model, the 30-day mortality of patients who underwent CABG surgery later in the week (Wednesday-Friday) was not significantly associated with the weekday of surgery as similar to those who underwent surgery early in the week (Monday-Tuesday) (hazard ratio [HR]: 1.14, 95% confidence interval [CI]: 0.97-1.34; p = .109). Multivariable sensitivity analysis revealed that CABG surgery on Friday was associated with a 1.40-fold higher hazard of 30-day mortality (HR: 1.40; 95% CI: 1.09-1.80; p = .008) than CABG surgery on Monday.

CONCLUSIONS

This South Korean population-based cohort study revealed that relative to surgery early in the week (Monday-Tuesday), CABG surgery later in the week (Wednesday-Friday) was not associated with higher 30-day mortality. However, using surgery on Monday as a reference, CABG surgery on Friday was associated with higher 30-day mortality. Future studies must confirm these findings.

Postoperative Cardiac Arrest in Cardiac Surgery-How to Improve the Outcome?

Background

In the early postoperative period after cardiac surgery the heart may be temporarily dysfunctional and prone to arrhythmias due to the phenomenon of myocardial stunning, vasoplegic syndrome, systemic inflammatory response syndrome (SIRS), electrolyte disturbances, operative trauma and myocardial edema. Most cases of cardiac arrest after cardiac surgery are reversible.

Objective

To analyse the factors that may influence the outcome of cardiac arrest after adult and pediatric cardiac surgery.

Methods

Retrospective analysis that included cardiac surgical procedures (886 adult and 749 pediatric patients) performed during the 18 month period of this study at Queen Alia Heart Institute/ Amman, Jordan. All cardiac arrest events were recorded and analysed. Data was collected on Utstein style templates designed for the purpose of this study. The outcome of cardiac arrest is examined as an early outcome (ROSC or lethal outcome) and late outcome (full recovery, recovery with complications, or in-hospital mortality). Factors that may influence the outcome of cardiac arrest were recorded and statistically analysed. Ethical committee approval obtained.

Results

The overall mortality rate was 3.3%. Cardiac arrest occurred in 114 patients (6.97%). The age of patients ranged from 5 days to 82 years and constituted 66 pediatric and 48 adult patients. Most pediatric cardiac arrests manifested as non-shockable rhythms (77%). Most in-hospital cardiac arrests occurred in the intensive care unit (86.5%). The majority of patients were mechanically ventilated at the time of occurrence of arrest (62.5% and 54.5% in adult and pediatric patients, respectively). Average time of cardiopulmonary resuscitation was 32.24 minutes. Overall, CA survival was 20% higher in the paediatric sub-group (full recovery rate of 51.5%). Neurological injury was slightly lower in pediatric than adult cardiac arrest survivals. (2% vs. 3%).

Conclusion

Shockable rhythms are more common in adult cardiac arrest, while non-shockable rhythms are more frequent in the pediatric sub-population. Hemodynamic monitoring, witnessed-type of cardiac arrest, non-interrupted cardiac massage, and early recognition of cardiac tamponade are the factors associated with higher rates of survival.

Role of Anaesthetic Choice in Improving Outcome after Cardiac Surgery

Clinical background

Volatile anaesthetics (VAs) have been shown to protect cardiomyocytes against ischaemia and reperfusion injury in cardiac surgery.

Clinical problems

VAs have been shown in multiple trials and meta-analyses to be associated with better outcomes when compared to intravenous anaesthesia in cardiac surgery. However, recent data from a large randomised controlled trial do not confirm the superiority of VA as compared to total intravenous anaesthesia in this population.

Review objectives

This mini review presents the VA cardioprotective effects, their clinical use in cardiac surgery and the most recent evidence that compares VA to intravenous anaesthesia for reducing perioperative morbidity. At present, there is no clear superiority of VA over intravenous anaesthesia in improving the outcome after cardiac surgery.

Effect of preparative rehabilitation on recovery after cardiac surgery: A systematic review

BACKGROUND

Physical prehabilitation (preparative rehabilitation) programs may have beneficial effects on enhancing physical strength and functional status before surgery, but their effects on postoperative recovery are unclear.

OBJECTIVES

This systematic review investigated the effectiveness of physical prehabilitation programs before cardiac surgery on postoperative recovery and other perioperative outcomes.

METHODS

We searched for reports of randomised controlled trials of any prehabilitation programs that included physical activity or an exercise training component in adults undergoing elective cardiac surgery, published in any language, from six bibliographic databases (last search on June 20, 2019). We assessed trials for risk of bias, overall certainty of evidence and quality of intervention reporting using the Cochrane Risk of Bias Assessment Tool, GRADE system and the Template for Intervention Description and Replication checklist and guide, respectively.

RESULTS

All 7 studies (726 participants) were at high risk of bias because of lack of blinding. The quality of prehabilitation reporting was moderate because program adherence was rarely assessed. The timing of prehabilitation ranged from 5 days to 16 weeks before surgery and from face-to-face exercise prescription to telephone counselling and monitoring. We found uncertain effects of prehabilitation on postoperative clinical outcomes (among the many outcomes assessed): perioperative mortality (Peto odds ratio 1.30, 95% confidence interval [CI] 0.28 to 5.95; I²=0%; low-certainty evidence) and postoperative atrial fibrillation (relative risk 0.75, 95% CI 0.38 to 1.46; I²=50%; very low-certainty evidence). However, prehabilitation may improve postoperative functional capacity and slightly shorten the hospital stay (mean difference -0.66 days, 95% CI -1.29 to -0.03; I²=45%; low-certainty evidence).

CONCLUSION

Despite the high heterogeneity among physical prehabilitation trials and the uncertainty regarding robust clinical outcomes, physical prehabilitation before cardiac surgery seems to enhance selected postoperative functional performance measures and slightly reduce the hospital length of stay after cardiac surgery.

Effect of Early Mobilization on Physical Function in Patients after Cardiac Surgery: A Systematic Review and Meta-Analysis

The objective effects of early mobilization on physical function in patients after cardiac surgery remain unknown. The purpose of the present study was to clarify the effects of early mobilization on physical function in patients after cardiac surgery through meta-analysis. Four electronic databases were searched on 2 August 2019. We used search keywords related to “early mobilization”, “cardiac surgery”, and “randomized controlled trials”. All randomized controlled trials conducting early mobilization after cardiac surgery were included. We defined early mobilization as the application of physical activity within the first five postoperative days. Citations and data extraction were independently screened in duplicate by two authors. The meta-analysis was conducted using random-effects modeling with EZR software. The primary outcome was the distance walked during the six-minute walking test at hospital discharge. Six randomized controlled trials comprising 391 patients were included following screening of 591 studies. All studies included coronary artery bypass grafting as the cardiac surgery conducted. Early mobilization started on postoperative days 1–2 and was conducting twice daily. Early mobilization showed a trend of being combined with respiratory exercise or psychoeducation. The meta-analysis showed that the distance walked during the 6-min walking test improved by 54 m (95% confidence interval, 31.1–76.9; I² = 52%) at hospital discharge. The present study suggested that early mobilization after cardiac surgery may improve physical function at discharge.

Transcatheter and Surgical Aortic Valve Replacement Outcomes for Patients with Chronic Heart Failure

OBJECTIVES

To determine in-hospital outcomes and assess high-risk groups among chronic heart failure (CHF) patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).

DESIGN

A retrospective analysis of the Nationwide Inpatient Sample database from January 2012 to September 2015 was performed.

SETTING

Hospitals across the United States that offer TAVRs or SAVRs.

PARTICIPANTS

Adults with a diagnosis of CHF and AS.

INTERVENTIONS

The patients underwent either TAVR or SAVR.

MEASUREMENTS AND MAIN RESULTS

Totals of 5,871 and 4,008 CHF patients underwent TAVR and SAVR, respectively. TAVR patients were significantly older, more were female, and had a higher comorbidity burden. No significant differences in in-hospital mortality were noted between TAVR and SAVR. However, mean length of stay was significantly longer by 3.5 days in the SAVR group, as was the mean total cost. With the exception of complete heart block, permanent pacemaker implantation, and vascular complications, the majority of postoperative events were higher among the SAVR group. Multivariate regression analysis identified postoperative cardiac, respiratory and renal complications as significant predictors of in-hospital mortality for both groups. Additionally, age ≥75 years and vascular complications were significant predictors of mortality for patients undergoing TAVR.

CONCLUSIONS

Among CHF patients with symptomatic AS, TAVR had similar in-hospital mortality rate compared with SAVR despite higher comorbidity burden. TAVR patients are at a lower risk of cardiovascular, respiratory, and renal complications and might lead to reduced length of hospital stay and cost. Hence, TAVR may be a safer option in this population.

Use of Smart Technology for the Early Diagnosis of Complications After Cardiac Surgery: The Box 2.0 Study Protocol

BACKGROUND

Atrial fibrillation (AF), sternal wound infection, and cardiac decompensation are complications that can occur after cardiac surgery. Early detection of these complications is clinically relevant, as early treatment is associated with better clinical outcomes. Remote monitoring with the use of a smartphone (mobile health [mHealth]) might improve the early detection of complications after cardiac surgery.

OBJECTIVE

The primary aim of this study is to compare the detection rate of AF diagnosed with an mHealth solution to the detection rate of AF diagnosed with standard care. Secondary objectives include detection of sternal wound infection and cardiac decompensation, as well as assessment of quality of life, patient satisfaction, and cost-effectiveness.

METHODS

The Box 2.0 is a study with a prospective intervention group and a historical control group for comparison. Patients undergoing cardiac surgery at Leiden University Medical Center are eligible for enrollment. In this study, 365 historical patients will be used as controls and 365 other participants will be asked to receive either The Box 2.0 intervention consisting of seven home measurement devices along with a video consultation 2 weeks after discharge or standard cardiac care for 3 months. Patient information will be analyzed according to the intention-to-treat principle. The Box 2.0 devices include a blood pressure monitor, thermometer, weight scale, step count watch, single-lead electrocardiogram (ECG) device, 12-lead ECG device, and pulse oximeter.

RESULTS

The study started in November 2018. The primary outcome of this study is the detection rate of AF in both groups. Quality of life is measured with the five-level EuroQol five-dimension (EQ-5D-5L) questionnaire. Cost-effectiveness is calculated from a society perspective using prices from Dutch costing guidelines and quality of life data from the study. In the historical cohort, 93.9% (336/358) completed the EQ-5D-5L and patient satisfaction questionnaires 3 months after cardiac surgery.

CONCLUSIONS

The rationale and design of a study to investigate mHealth devices in postoperative cardiac surgery patients are presented. The first results are expected in September 2020.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03690492; http://clinicaltrials.gov/show/NCT03690492.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/16326.

Association of plasma-soluble ST2 and galectin-3 with cardiovascular events and mortality following cardiac surgery

BACKGROUND

Cardiac surgery induces hemodynamic stress on the myocardium, and this process can be associated with significant post-operative morbidity and mortality. Soluble suppression of tumorigenicity 2 (sST2) and galectin-3 (gal-3) are biomarkers of myocardial remodeling and fibrosis; however, their potential association with post-operative changes is unknown.

METHODS

We measured peri-operative plasma sST2 and gal-3 levels in two prospective cohorts (TRIBE-AKI and NNE) of over 1800 patients who underwent cardiac surgery. sST2 and gal-3 levels were evaluated for association with a composite primary outcome of cardiovascular event or mortality over median follow-up periods of 3.4 and 6.0 years, respectively, for the two cohorts. Meta-analysis of hazard ratio estimates from the cohorts was performed using random effects models.

RESULTS

Cohorts demonstrated event rates of 70.2 and 66.8 per 1000 person-years for the primary composite outcome. After adjustment for clinical covariates, higher post-operative sST2 and gal-3 levels were significantly associated with cardiovascular event or mortality [pooled estimate HRs: sST2 1.29 (95% CI 1.16, 1.44); gal-3 1.26 (95% CI 1.09, 1.46)]. These associations were not significantly modified by pre-operative congestive heart failure or AKI.

CONCLUSIONS

Higher post-operative sST2 and gal-3 values were associated with increased incidence of cardiovascular event or mortality. These two biomarkers should be further studied for potential clinical utility for patients undergoing cardiac surgery.

Trajectory and mortality of preserved ratio impaired spirometry: the Rotterdam Study

Preserved ratio impaired spirometry (PRISm) is a heterogeneous condition but its course and disease progression remain to be elucidated. We aimed to examine its prevalence, trajectories and prognosis in the general population.In the Rotterdam Study (population-based prospective cohort) we examined prevalence, trajectories and prognosis of subjects with normal spirometry (controls; forced expiratory volume in 1 s (FEV₁)/forced vital capacity (FVC) ≥0.7, FEV₁  ≥80%), PRISm (FEV₁/FVC ≥0.7, FEV₁ <80%) and chronic obstructive pulmonary disease (COPD) (FEV₁/FVC <0.7) at two study visits. Hazard ratios with 95% confidence intervals for mortality (until December 30, 2018) were adjusted for age, sex, body mass index, current smoking and pack-years.Of 5487 subjects (age 69.1±8.9 years; 7.1% PRISm), 1603 were re-examined after 4.5 years. Of the re-examined PRISm subjects, 15.7% transitioned to normal spirometry and 49.4% to COPD. Median lung function decline was highest in subjects with incident PRISm (FEV₁ -92.8 mL·year^-1, interquartile range (IQR) -131.9- -65.8 mL·year^-1; FVC -93.3 mL·year^-1, IQR -159.8- -49.1 mL·year^-1), but similar in persistent PRISm (FEV₁ -30.2 mL·year^-1, IQR -67.9- -7.5 mL·year^-1; FVC -20.1 mL·year^-1, IQR -47.7-21.7 mL·year^-1) and persistent controls (FEV₁ -39.6 mL·year^-1, IQR -64.3--12.7 mL·year^-1; FVC -20.0 mL·year^-1, IQR -55.4-18.8 mL·year^-1). Of 5459 subjects with informed consent for follow-up, 692 (12.7%) died during 9.3 years (maximum) follow-up: 10.3% of controls, 18.7% of PRISm subjects and 20.8% of COPD subjects. Relative to controls, subjects with PRISm and COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2-4 had increased all-cause mortality (PRISm: HR 1.6, 95% CI 1.2-2.0; COPD GOLD 2-4: HR 1.7, 95% CI 1.4-2.1) and cardiovascular mortality (PRISm: HR 2.8, 95% CI 1.5-5.1; COPD 2-4: HR 2.1, 95% CI 1.2-3.6). Mortality within <1 year was highest in PRISm, with patients often having cardiovascular comorbidities (heart failure or coronary heart disease; 70.0%).PRISm is associated with increased mortality and this population encompasses at least three distinct subsets: one that develops COPD during follow-up, a second with high cardiovascular burden and early mortality, and a third with persistent PRISm and normal age-related lung function decline.