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Malvindi PG, Bifulco O, Berretta P, Galeazzi M, Alfonsi J, Cefarelli M, Zingaro C, Zahedi HM, Munch C, Di Eusanio M. The Enhanced Recovery after Surgery Approach in Heart Valve Surgery: A Systematic Review of Clinical Studies. J Clin Med 2024; 13:2903. [PMID: 38792445 PMCID: PMC11121940 DOI: 10.3390/jcm13102903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Enhanced recovery after surgery (ERAS) protocols aim to reduce postoperative complications and promote earlier recovery. Although it is well established in noncardiac surgery fields, the ERAS approach has only recently been adopted in cardiac surgery. The aim of this review is to evaluate the status and implementation of ERAS protocols in patients undergoing heart valve surgery and to summarise associated clinical results. Methods: A literature search for the period January 2015 and January 2024 was performed through online databases. Clinical studies (randomised controlled trials and cohort studies) on patients undergoing heart valve surgical procedures and comparing ERAS and conventional approaches were included. The data extracted covered studies and populations characteristics, early outcomes and the features of each ERAS protocol. Results: There were 14 studies that fulfilled the final search criteria and were ultimately included in the review. Overall, 5142 patients were identified in the 14 studies, with 2501 in ERAS groups and 2641 patients who were representative of control groups. Seven experiences exclusively included patients who underwent heart valve surgery. Twelve out of fourteen protocols involved multiple interventions from the preoperative to postoperative phase, while two studies reported actions limited to intraoperative and postoperative care. We found high heterogeneity among the included protocols regarding key actions targeted for improvement and measured outcomes. All the studies showed that ERAS pathways can be safely adopted in cardiac surgery and in most of the experiences were associated with shorter mechanical ventilation time, reduced postoperative opioid use and reduced ICU and hospital stays. Conclusions: As demonstrated in noncardiac surgery, the adoption of structured ERAS protocols has the potential to improve results in patients undergoing heart valve surgery. Further evidence based on larger populations is needed, including more homogenous pathways and reporting further outcomes in terms of patient satisfaction, recovery and quality of life after surgery.
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Affiliation(s)
- Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Olimpia Bifulco
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Michele Galeazzi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Mariano Cefarelli
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Carlo Zingaro
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
| | - Hossein M. Zahedi
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, 60121 Ancona, Italy
| | - Christopher Munch
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, 60121 Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60121 Ancona, Italy
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Schmid ME, Stock S, Girdauskas E. Implementation of an innovative ERAS protocol in cardiac surgery: A qualitative evaluation from patients' perspective. PLoS One 2024; 19:e0303399. [PMID: 38728336 PMCID: PMC11086837 DOI: 10.1371/journal.pone.0303399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 04/15/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE Enhanced recovery after surgery (ERAS) protocols aim to optimize the recovery process for patients after surgical interventions and focus on patient-centered care. In cardiac surgery, the ERAS concept is still in its early stages. Our university hospital has implemented an innovative ERAS protocol for minimally invasive heart valve surgery since 2021. Therefore, our study aimed to comprehensively assess the patient experience within this newly established ERAS protocol and focused on exploring and understanding the nuances of optimal healthcare delivery under the ERAS framework from the unique perspective of the patients undergoing cardiac surgery. METHODS Qualitative research was conducted using semi-structured interviews. Data was analyzed using Kuckartz´s qualitative content analysis. RESULTS The following main themes emerged from the 12 completed patient interviews: 1) information and communication flow, 2) perioperative patient care, and 3) rehabilitation. Patients found the pre-operative patient education and preconditioning very helpful. Patients were satisfied with the flow of information throughout the whole perioperative care process. Most patients expressed a need for more information about the course of surgery. The intensity of care provided by different professions was perceived as optimal. The support and inclusion of relatives in perioperative care were considered crucial. Patients appreciated the direct transfer to the rehabilitation and mainly were able to cope with daily life tasks afterward. CONCLUSION In summary, all patients experienced the ERAS protocol positively, and their healthcare process was well established. Active inclusion and education of patients in their treatment can improve patient empowerment. Two further aspects that deserve major consideration in the healthcare process are the inclusion of relatives and interprofessional cooperation.
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Affiliation(s)
| | - Sina Stock
- Cardiothoracic Surgery, University Hospital Augsburg, Augsburg, Germany
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Hoogma DF, Croonen R, Al Tmimi L, Tournoy J, Verbrugghe P, Fieuws S, Rex S. Association between improved compliance with enhanced recovery after cardiac surgery guidelines and postoperative outcomes: A retrospective study. J Thorac Cardiovasc Surg 2024; 167:1363-1371.e2. [PMID: 35989120 DOI: 10.1016/j.jtcvs.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/23/2022] [Accepted: 07/06/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Enhanced recovery after cardiac surgery is a multidisciplinary clinical care pathway that relies on a bundle of interventions, aiming to reduce the stress response to surgery and promote early recovery of organ function. In 2011, our institution introduced an institutional enhanced recovery after cardiac surgery program focusing on 9 central interventions, which have been expanded during the past decade by additional interventions now considered standard of care. After the recent publication of the enhanced recovery after cardiac surgery guidelines, we evaluated the relation between the compliance with these enhanced recovery after cardiac surgery guidelines and postoperative outcomes. METHODS All patients enrolled in our enhanced recovery after cardiac surgery program in 2019 were included in this retrospective single-center audit. The primary outcome was compliance with 23 enhanced recovery after cardiac surgery guidelines. Secondary outcomes included occurrence of at least 1 postoperative complication and hospital length of stay. RESULTS A total of 356 patients were included in this study. Compliance with the enhanced recovery after cardiac surgery guidelines was 64%. Postoperatively, 51% of the patients experienced at least 1 complication and had a median hospital length of stay of 6 days. Multivariable analysis showed that an increased compliance (per 10%) with the enhanced recovery after cardiac surgery guidelines was associated with a lower risk for any complication (odds ratio, 0.60; 95% confidence interval, 0.46-0.79; P = .0003) and a higher probability of earlier hospital discharge (hazard ratio, 1.25; 95% confidence interval, 1.10-1.43; P = .0008). CONCLUSIONS This audit revealed a correlation between increased compliance with enhanced recovery after cardiac surgery guidelines and a reduction of postoperative complications and hospital length of stay. Future trials are needed to establish evidence-based recommendations for each separate intervention of the enhanced recovery after cardiac surgery guidelines and to create a minimum core-set of enhanced recovery after cardiac surgery interventions.
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Affiliation(s)
- Danny Feike Hoogma
- Department of Anesthesiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, University Leuven, Biomedical Sciences Group, KU Leuven, Leuven, Belgium.
| | - Roel Croonen
- Department of Anesthesiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Layth Al Tmimi
- Department of Anesthesiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, University Leuven, Biomedical Sciences Group, KU Leuven, Leuven, Belgium
| | - Jos Tournoy
- Geriatric Medicine and Department of Public Health and Primary Care, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiovascular Sciences, University Leuven, Biomedical Sciences Group, KU Leuven, Leuven, Belgium; Department of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Steffen Fieuws
- University Leuven, Biomedical Sciences Group, Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), KU Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, University Leuven, Biomedical Sciences Group, KU Leuven, Leuven, Belgium
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Grant MC, Crisafi C, Alvarez A, Arora RC, Brindle ME, Chatterjee S, Ender J, Fletcher N, Gregory AJ, Gunaydin S, Jahangiri M, Ljungqvist O, Lobdell KW, Morton V, Reddy VS, Salenger R, Sander M, Zarbock A, Engelman DT. Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS). Ann Thorac Surg 2024; 117:669-689. [PMID: 38284956 DOI: 10.1016/j.athoracsur.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Cheryl Crisafi
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Adrian Alvarez
- Department of Anesthesia, Hospital Italiano, Buenos Aires, Argentina
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mary E Brindle
- Departments of Surgery and Community Health Services, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joerg Ender
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom; St George's University Hospital, London, United Kingdom
| | - Alexander J Gregory
- Department of Anesthesia, Perioperative and Pain Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Marjan Jahangiri
- Department of Cardiac Surgery, St George's Hospital, London, United Kingdom
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Kevin W Lobdell
- Regional Cardiovascular and Thoracic Quality, Education, and Research, Atrium Health, Charlotte, North Carolina
| | - Vicki Morton
- Clinical and Quality Outcomes, Providence Anesthesiology Associates, Charlotte, North Carolina
| | - V Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
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Malvindi PG, Bifulco O, Berretta P, Galeazzi M, Zingaro C, D'Alfonso A, Zahedi HM, Munch C, Di Eusanio M. On-table extubation is associated with reduced intensive care unit stay and hospitalization after trans-axillary minimally invasive mitral valve surgery. Eur J Cardiothorac Surg 2024; 65:ezae010. [PMID: 38230801 DOI: 10.1093/ejcts/ezae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/15/2023] [Accepted: 01/15/2024] [Indexed: 01/18/2024] Open
Abstract
OBJECTIVES Few data are available regarding early extubation after mitral valve surgery. We sought to assess the impact of an enhanced recovery after surgery-based protocol-ultra-fast-track protocol-in patients undergoing minimally invasive transaxillary mitral valve surgery. METHODS Data of patients who underwent transaxillary mitral valve surgery associated with ultra-fast-track protocol between 2018 and 2023 were reviewed. We compared preoperative, intraoperative and postoperative data of patients who had fast-track extubation (≤6 h since the end of the procedure) and non-fast-track extubation (>6 h) and, within the fast-track group, patients who underwent on-table extubation and patients who were extubated in intensive care unit within 6 h. Multivariable logistic regression was used to study the association of extubation timing and intensive care unit stay, postoperative stay and discharge home. RESULTS Three hundred fifty-six patients were included in the study. Two hundred eighty-two patients underwent fast-track extubation (79%) and 160 were extubated on table (45%). We found no difference in terms of mortality and occurrence of major complications (overall mortality and cerebral stroke 0.3%) according to the extubation timing. Fast-track extubation was associated with shorter intensive care unit stay, discharge home and discharge home within postoperative day 7 when compared to non-fast-track extubation. Within the fast-track group, on-table extubation was associated with intensive care unit stay ≤1 day and discharge home within postoperative day 7. CONCLUSIONS Fast-track extubation was achievable in most of the patients undergoing transaxillary minimally invasive mitral valve surgery and was associated with higher rates of day 1 intensive care unit discharge and discharge home. On-table extubation was associated with further reduced intensive care unit stay and hospitalization.
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Affiliation(s)
- Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Olimpia Bifulco
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Michele Galeazzi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Carlo Zingaro
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Alessandro D'Alfonso
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Hossein M Zahedi
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Christopher Munch
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
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Bifulco O, Malvindi PG, Berretta P, Brugiatelli L, Cefarelli M, Alfonsi J, D’Alfonso A, Zingaro C, Di Eusanio M. Minimally Invasive Trans-Axillary versus Full Sternotomy Mitral Valve Repair: A Propensity Score-Matched Analysis on Mid-Term Outcomes. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:29. [PMID: 38256290 PMCID: PMC10821199 DOI: 10.3390/medicina60010029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/15/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Minimally invasive cardiac surgery is an established approach for the treatment of heart valve pathologies and is associated with excellent technical and early postoperative outcomes. Data from medium- and long-term longitudinal evaluation of patients who underwent mitral valve repair (MVr) through transaxillary approach (TAxA) are still lacking. The aim of this study is to investigate mid-term results in patients who underwent TAxA MVr. Materials and Methods: Prospectively collected data of patients who underwent first-time MVr for MV regurgitation between 2017 and 2022, were reviewed. A total of 308 patients received TAxA, while in 220 cases, traditional full sternotomy (FS) was performed. Concomitant aortic and coronary artery bypass grafting (CABG) procedures, infective endocarditis or urgent operations were excluded. A propensity match (PS) analysis was used to overcome preoperative differences between the populations. Follow-up data were retrieved from outpatients' clinic, telephone calls and municipal administration records. Results: After PS-matching, two well-balanced cohorts of 171 patients were analysed. The overall 30-day mortality rate was 0.6% in both cohorts. No statistical difference in postoperative complications was reported. TAxA cohort experienced earlier postoperative extubation (p < 0.001) with a higher rate of extubation performed in the operating theatre (p < 0.001), shorter intensive care unit (ICU) stay (p < 0.001), and reduced hospitalization with 51% of patients discharged home (p < 0.001). Estimated survival at 5 years was 98.8% in TAxA vs. 93.6% in FS cohort (Log rank p = 0.15). The cumulative incidence of reoperation was 2.6% and 4.4% at 5 years, respectively, in TAxA and FS cohorts (Gray test p = 0.49). Conclusions: TAxA approach for MVr was associated with low rates of in-hospital mortality and major postoperative complications being furthermore associated with shorter mechanical ventilation time, shorter ICU stay and reduced hospitalization with a higher rate of patients able to be discharged home. At mid-term, TAxA was associated with excellent survival and low rate of MV reoperation.
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Affiliation(s)
| | - Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, 60126 Ancona, Italy (M.D.E.)
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Laraia KN, Pepe RJ, Sabatino ME, Dewan KC, Yoo J, Yang NK, Chao JC, Takebe M, Sunagawa G, Ikegami H, Lemaire A, Russo MJ, Lee LY. Ambulatory Electrocardiography Monitoring for Early Discharge After Minimally Invasive Valve Surgery. J Surg Res 2023; 292:182-189. [PMID: 37633247 DOI: 10.1016/j.jss.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 08/28/2023]
Abstract
INTRODUCTION We sought to compare outcomes after early discharge in patients with and without predischarge diagnosis of arrhythmia following minimally invasive valve surgery (MIVS). MATERIALS AND METHODS We retrospectively reviewed ambulatory electrocardiography (AECG) datasheets and medical records of patients discharged with 14-d AECG monitoring from our facility between October 2019 and March 2022 ≤ 3 d after MIVS. Baseline and clinical characteristics, arrhythmias during AECG monitoring, and 30-d adverse outcomes were reported for the population and stratified by presence or absence of predischarge arrhythmia. RESULTS Of 41 patients discharged ≤3 d postoperatively of MIVS, 17 (41.5%) experienced predischarge arrhythmias and 24 (58.5%) did not. The population was predominantly male and White with a median age of 62 y [57, 70]. Baseline and clinical characteristics did not differ between subgroups. Most patients (92.7% [n = 38]) experienced one or more tachyarrhythmias during the AECG monitoring period. There were similar proportions of patients experiencing atrial fibrillation in both groups, but patients with predischarge arrhythmias had higher burden of atrial fibrillation on AECG monitoring (27.60% [6.57%, 100%] versus 1.65% [0.76%, 4.32%]; P = 0.004). The predischarge arrhythmia subgroup had higher proportions of patients experiencing nonsustained ventricular tachycardia but lower proportions experiencing supraventricular tachycardia. There were no mortalities within 30 d of surgery. Six (14.6%) patients were readmitted within 30 d with equal proportions of readmissions between subgroups (P = 0.662). CONCLUSIONS Early discharge timelines and noninvasive monitoring techniques can allow patients to return to their normal activities quicker in the comfort of their own home with no increased risk of morbidity or mortality.
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Affiliation(s)
- Kayla N Laraia
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Russell J Pepe
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Marlena E Sabatino
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Krish C Dewan
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jin Yoo
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - NaYoung K Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Joshua C Chao
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Manabu Takebe
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Gengo Sunagawa
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Hirohisa Ikegami
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Anthony Lemaire
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Mark J Russo
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Leonard Y Lee
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey.
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Haunschild J, van Kampen A, Misfeld M, Von Aspern K, Ender J, Zakhary W, Borger MA, Etz CD. Is perioperative fast-track management the future of proximal aortic repair? EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2023; 63:6947988. [PMID: 36538944 DOI: 10.1093/ejcts/ezac578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/18/2022] [Accepted: 12/19/2022] [Indexed: 02/11/2023]
Abstract
OBJECTIVES The Bentall procedure is the gold standard for patients with combined aortic root dilation and valve dysfunction. Over the past decade, fast-track (FT) perioperative anaesthetic management protocols have progressively evolved. We reviewed our results for selected patients undergoing Bentall surgery under an FT protocol. METHODS We retrospectively analysed a consecutive cohort of patients who underwent elective Bentall procedures at our institution between 2000 and 2018. Complex aortic root repair (i.e. David and Ross procedure, redo surgery, major concomitant procedures, emergency repair for acute dissections) was excluded. Patients who underwent conventional perioperative treatment and those treated according to our institutional FT concept were compared following 1:1 propensity score matching. RESULTS Of 772 patients who fit the in- and exclusion criteria, 565 were treated conventionally post-surgery, while 207 were treated using the FT protocol. Propensity score matching resulted in 197 pairs, with no differences in baseline characteristics after matching. In-house mortality, 30-day mortality and overall all-cause long-term mortality were comparable between the FT and the conventionally treated cohort. Postoperative anaesthetic care unit/intensive care unit length-of-stay (6.2 vs 20.6 h, P = 0.03) and postoperative ventilation times (158.9 vs 465.5 min, P < 0.001) were significantly shorter in the FT cohort. There were no differences in rates of postoperative adverse events. CONCLUSIONS In centres with experienced anaesthesiologists, perioperative FT management is non-inferior to conventionally treated patients undergoing elective Bentall procedures without compromising patient safety.
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Affiliation(s)
- Josephina Haunschild
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Antonia van Kampen
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Martin Misfeld
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Institute of Academic Surgery, RPAH, Sydney, NSW, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, NSW, Australia
| | | | - Jörg Ender
- Department of Anaesthesiology and Intensive care Medicine, Leipzig Heart Center, Leipzig, Germany
| | - Waseem Zakhary
- Department of Anaesthesiology and Intensive care Medicine, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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9
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El-Andari R, Fialka NM, Nagendran J. Enhanced recovery after cardiac surgery: The next step towards optimized care. Int J Cardiol 2023; 372:48-49. [PMID: 36493928 DOI: 10.1016/j.ijcard.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/04/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Ryaan El-Andari
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada.
| | - Nicholas M Fialka
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada.
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Berretta P, De Angelis V, Alfonsi J, Pierri MD, Malvindi PG, Zahedi HM, Munch C, Di Eusanio M. Enhanced recovery after minimally invasive heart valve surgery: Early and midterm outcomes. Int J Cardiol 2023; 370:98-104. [PMID: 36375597 DOI: 10.1016/j.ijcard.2022.11.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Although the use of protocols for "enhanced recovery after surgery" (ERAS) have been associated with improved results in different surgical specialties, only a few data are available for ERAS in cardiac surgery. This study aimed to compare 30-day outcomes of patients undergoing ultra-fast-track minimally invasive valve surgery (UFT-MIVS) versus conventional MIVS (c-MIVS). METHODS The key features of UFT-MIVS approach involves: 1) less invasive valve surgery techniques, 2) normothermic cardiopulmonary bypass management, 3) UFT-anesthesia with table extubation, 4) immediate rehabilitation therapy and patient-family contact. Five-hundred and seventy-six consecutive patients who underwent aortic or mitral MIVS were analyzed (2016-2020). Treatment selection bias (UFT-MIVS vs. c-MIVS) was addressed by the use of propensity score (PS) matching. After PS-matching 2 well-balanced groups of 152 patients each were created. RESULTS In the matched cohort, the overall 30-day mortality and stroke rates were 0.3% and 0.7%, respectively, with no difference between groups. UFT-MIVS resulted in lower rates of respiratory insufficiency and agitation/delirium compared with c-MIVS. Patients receiving UFT-MIVS were associated with significantly shorter intensive care unit length of stay and hospital stay. CONCLUSIONS Our study confirms that MIVS is associated with excellent results in terms of early mortality and major postoperative complications rates. The implementation of UFT-MIVS protocol showed to be safe and was associated with improved clinical outcomes in regard to respiratory insufficiency, delirium and lengths of stay.
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Affiliation(s)
- Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Via Conca 71, 60126 Ancona, Italy.
| | - Veronica De Angelis
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
| | - Michele D Pierri
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
| | - Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
| | - Hossein M Zahedi
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Via Conca 71, 60126 Ancona, Italy
| | - Christopher Munch
- Cardiac Anaesthesia and Intensive Care Unit, Lancisi Cardiovascular Center, Via Conca 71, 60126 Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Via Conca 71, 60126 Ancona, Italy
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11
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Van Praet KM, Kofler M, Hirsch S, Akansel S, Hommel M, Sündermann SH, Meyer A, Jacobs S, Falk V, Kempfert J. Factors associated with an unsuccessful Fast-Track course following Minimally Invasive Surgical Mitral Valve Repair. Eur J Cardiothorac Surg 2022; 62:6693624. [PMID: 36069638 DOI: 10.1093/ejcts/ezac451] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 08/26/2022] [Accepted: 09/06/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Analyses of fast-track processes demonstrated that low-risk cardiac surgical patients require minimal intensive care, with a low incidence of mortality or morbidity. We investigated perioperative factors and their association with fast-track failure in a retrospective cohort study of patients undergoing minimally invasive mitral valve surgery. METHODS Patients undergoing minimally invasive surgical mitral valve repair for Carpentier type I or type II mitral regurgitation between 2014 and 2020 were included in the study. The definition of fast-track failure consisted of > 10 hours mechanical ventilation, >24 hours intensive care unit stay, re-intubation after extubation and re-admission to the intensive care unit. Multivariable logistic regression analysis enabled the identification of factors associated with fast-track failure. RESULTS In total, 491 patients were included in the study and were analysed. Two-hundred and thirty-seven patients (48.3%) failed the fast-track protocol. Multivariable logistic regression analysis showed that a New York Heart Association classification ≥3 (OR 2.05; CI 1.38-3.08; p < 0.001, pre-existing chronic kidney disease (OR 2.03; CI 1.14-3.70; p = 0.018), coronary artery disease (OR 1.90; CI 1.13-3.23; p = 0.016), postoperative bleeding requiring surgical revision (OR 8.36; CI 2.81-36.01; p < 0.001) and procedure time (OR 1.01; CI 1.01-1.01; p < 0.001) were independently associated with fast-track failure. CONCLUSIONS Factors associated with fast-track failure in patients with Carpentier type I and II pathologies undergoing minimally invasive mitral valve repair are a New York Heart Association classification III-IV at baseline, pre-existing chronic kidney disease and coronary artery disease. Postoperative bleeding requiring rethoracotomy and procedure time were also identified as important factors associated with failed fast-track. CLINICAL REGISTRATION NUMBER The corresponding local ethics committee (Charité Medical School, Berlin, Germany) approved the present study which complies with the Declaration of Helsinki (ethics approval number: EA2/175/20).
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Affiliation(s)
- Karel M Van Praet
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Solveig Hirsch
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Serdar Akansel
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Matthias Hommel
- Institute for Anesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Simon H Sündermann
- Department of Cardiovascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health
| | - Alexander Meyer
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Stephan Jacobs
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany.,Department of Cardiovascular Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health.,Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH) Zurich
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Germany
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12
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Kubitz JC, Schubert AM, Schulte-Uentrop L. [Enhanced recovery after surgery (ERAS®) in cardiac anesthesia]. DIE ANAESTHESIOLOGIE 2022; 71:663-673. [PMID: 35987897 DOI: 10.1007/s00101-022-01190-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 06/15/2023]
Abstract
Enhanced Recovery After Cardiac Surgery (ERACS) is a multidisciplinary and multiprofessional treatment approach in cardiac surgery. Recently, a transfer and adaptation of enhanced recovery after surgery (ERAS) protocols from other disciplines, such as colorectal surgery, to cardiac surgery has been performed in different settings. First, prehabilitation programs have been established and investigated to improve patients' physical, psychological and nutritional status including treatment of preoperative anemia. Second, intraoperative therapeutic steps are described, such as infection reduction bundles, rigid sternal closure and guidance of perioperative anesthesia. For this, the use of short-acting agents, goal-directed fluid management and multimodal anesthesia are among the important measures. Third, early recovery and restoration of patient autonomy are achieved with early extubation and mobilization, efficient postoperative analgesia and diagnosis and treatment of delirium.The introduction of an ERACS protocol is a team effort requiring a protocol adapted to the institutional conditions and a willingness to perform a shift of culture in perioperative care. So far, the successful establishment of ERACS protocols in minimally invasive cardiac surgery has been reported and encourages the development of protocols of specific patient groups, such as pediatric cardiac surgery or left ventricular assist device implantation.
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Affiliation(s)
- J C Kubitz
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Nürnberg und Krankenhäuser Nürnberger Land GmbH, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Prof. Ernst Nathan Str. 1, 90419, Nürnberg, Deutschland.
| | - A-M Schubert
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - L Schulte-Uentrop
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
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13
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Sabatino ME, Okoh AK, Chao JC, Soto C, Baxi J, Salgueiro LA, Olds A, Ikegami H, Lemaire A, Russo MJ, Lee LY. Early Discharge After Minimally Invasive Aortic and Mitral Valve Surgery. Ann Thorac Surg 2022; 114:91-97. [PMID: 34419437 PMCID: PMC10893855 DOI: 10.1016/j.athoracsur.2021.07.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 06/07/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND We investigated patient outcomes in relation to their postoperative length of stay after minimally invasive valve surgery. METHODS All adults who survived elective, uncomplicated minimally invasive aortic or mitral valve surgery at a single center between 2012 and 2019 were classified by postoperative length of stay: early discharge (≤3 days) or late discharge (>3 days). The trend in early discharge was investigated over the study period, predictors of early discharge were identified using multivariate logistic regression modeling, and 1:1 propensity score matching was used to determine which patients in the late-discharge cohort had similar health to patients discharged early. Adjusted outcomes of 30-day mortality, readmission, and direct costs were analyzed. RESULTS Among 1262 consecutive patients undergoing minimally invasive valve surgery, 618 were elective and uncomplicated, 25% (n = 162) of whom were discharged early. The proportion of early-discharge patients increased over time (P for trend < .05). A history of congestive heart failure, stroke, or smoking and higher Society of Thoracic Surgeons predictive risk of mortality score negatively predicted early discharge (P < .05). Propensity score matching identified 101 (22%) late-discharge patients comparable with early-discharge patients. Adjusted 30-day mortality and readmission rates were comparable between cohorts. The median direct costs per patient ($20,046 vs $22,124, P < .05) were significantly lower in the early-discharge cohort. CONCLUSIONS In well-selected patients early discharge after minimally invasive valve surgery was associated with lower costs but comparable postoperative outcomes. About one-fifth of patients who remain in the hospital beyond postoperative day 3 may be candidates for earlier discharge.
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Affiliation(s)
- Marlena E Sabatino
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Alexis K Okoh
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Joshua C Chao
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Cassandra Soto
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jigesh Baxi
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Lauren A Salgueiro
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Anna Olds
- Department of Surgery, Division of Cardiac Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Hirohisa Ikegami
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Anthony Lemaire
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Mark J Russo
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Leonard Y Lee
- Department of Surgery, Division of Cardiothoracic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Robert Wood Johnson University Hospital, New Brunswick, New Jersey.
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14
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Klotz SGR, Ketels G, Behrendt CA, König HH, Kohlmann S, Löwe B, Petersen J, Stock S, Vettorazzi E, Zapf A, Zastrow I, Zöllner C, Reichenspurner H, Girdauskas E. Interdisciplinary and cross-sectoral perioperative care model in cardiac surgery: implementation in the setting of minimally invasive heart valve surgery (INCREASE)-study protocol for a randomized controlled trial. Trials 2022; 23:528. [PMID: 35739541 PMCID: PMC9229105 DOI: 10.1186/s13063-022-06455-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background Valvular heart diseases are frequent and increasing in prevalence. Minimally invasive heart valve surgery embedded in an interdisciplinary enhanced recovery after surgery (ERAS) program may have potential benefits with regard to reduced length of stay and improved patient reported outcomes. However, no prospective randomized data exist regarding the superiority of ERAS program for the patients’ outcome. Methods We aim to randomize (1:1) a total of 186 eligible patients with minimally invasive heart valve surgery to an ERAS program vs. standard treatment at two centers including the University Medical Center Hamburg-Eppendorf, Germany, and the University Hospital Augsburg, Germany. The intervention is composed out of pre-, peri-, and postoperative components. The preoperative protocol aims at better preparation for the operation with regard to physical activity, nutrition, and psychological preparedness. Intraoperative anesthesiologic and surgical management are trimmed to enable an early extubation. Patients will be transferred to a specialized postoperative anesthesia care unit, where first mobilization occurs 3 h after surgery. Transfer to low care ward will be at the next day and discharge at the fifth day. Participants in the control group will receive treatment as usual. Primary endpoints include functional discharge at discharge and duration of in-hospital care during the first 12 months after index surgery. Secondary outcomes include health-related quality of life, health literacy, and level of physical activity. Discussion This is the first randomized controlled trial evaluating the effectiveness of an ERAS process after minimally invasive heart valve surgery. Interprofessional approach is the key factor of the ERAS process and includes in particular surgical, anesthesiological, physiotherapeutic, advanced nursing, and psychosocial components. A clinical implication guideline will be developed facilitating the adoption of ERAS model in other heart teams. Trial registration The study has been registered in ClinicalTrials.gov (NCT04977362 assigned July 27, 2021).
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Affiliation(s)
- Susanne G R Klotz
- Department of Physiotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Gesche Ketels
- Department of Physiotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christian A Behrendt
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Sebastian Kohlmann
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Johannes Petersen
- Department of Cardiovascular Surgery, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Sina Stock
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Antonia Zapf
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Inke Zastrow
- Department of Patient and Care Management, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christian Zöllner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
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15
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Sherazee EA, Chen SA, Li D, Li D, Frank P, Kiaii B. Pain Management Strategies for Minimally Invasive Cardiothoracic Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:167-176. [PMID: 35521910 DOI: 10.1177/15569845221091779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Elan A Sherazee
- Department of Surgery, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - Sarah A Chen
- Division of Cardiac Surgery, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - David Li
- Department of Anesthesiology and Pain Medicine, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - David Li
- Department of Pharmacy Services, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - Paul Frank
- Department of Anesthesiology and Pain Medicine, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - Bob Kiaii
- Division of Cardiac Surgery, 8789UC Davis Medical Center, Sacramento, CA, USA
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16
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Turner E, Piccinini F. Tratamiento moderno de la estenosis aórtica: reemplazo valvular aórtico 2022. REVISTA MÉDICA CLÍNICA LAS CONDES 2022. [DOI: 10.1016/j.rmclc.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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17
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Toscano A, Barbero C, Capuano P, Costamagna A, Pocar M, Trompeo A, Pasero D, Rinaldi M, Brazzi L. Chronic postsurgical pain and quality of life after right minithoracotomy mitral valve operations. J Card Surg 2022; 37:1585-1590. [PMID: 35274774 DOI: 10.1111/jocs.16400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/09/2022] [Accepted: 02/17/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Chronic postsurgical pain (CPSP) is a relatively common complication after cardio-thoracic operations with well-known consequences in terms of return to normal activities and quality of life. Little is known about the prevalence and severity of CPSP after minimally invasive cardiac surgery. The aim of this study was to measure the rate of CPSP in patients undergoing right minithoracotomy mitral valve (MV) surgery and to compare the effectiveness of different approaches to pain control. METHODS A prospective observational study was conducted between March 2019 and September 2020. All patients undergoing right minithoracotomy MV surgery treated with morphine, continuous serratus anterior plane block (SAPB), or continuous erector spinae plane block (ESPB) were included. The Brief Pain Inventory questionnaire was used to evaluate 6-month CPSP and quality of life. RESULTS A total of 100 patients were enrolled: postoperative pain control was obtained with morphine in 26 cases, with SAPB in 37 cases, and with ESPB in 37 cases. Median intensive care unit and hospital length of stay were 1 day and 6 days, respectively. Pain severity index was lower than 10 in 81 patients, and no differences were recorded between groups (p = .59). No patients reported chronic use of medications for pain management or severe pain interference in daily activities at follow-up. DISCUSSION Right minithoracotomy approach is not burdened by a high incidence of CPSP: pain severity index was lower than 10 in more than 90% of patients. Then, in our experience, chronic pain seems not to be related to the type of perioperative analgesia adopted.
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Affiliation(s)
- Antonio Toscano
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Cristina Barbero
- Department of Cardiovascular and Thoracic surgery, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Paolo Capuano
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, UPMC, Palermo, Italy
| | - Andrea Costamagna
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Marco Pocar
- Department of Cardiovascular and Thoracic surgery, Città della Salute e della Scienza Hospital, Turin, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Anna Trompeo
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Daniela Pasero
- Department of Medical, Surgical and Experimental Science, University of Sassari, Sassari, Italy
| | - Mauro Rinaldi
- Department of Cardiovascular and Thoracic surgery, Città della Salute e della Scienza Hospital, Turin, Italy.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Luca Brazzi
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy.,Department of Surgical Sciences, University of Turin, Turin, Italy
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18
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Tian B, Ma C, Su JW, Luo J, Sun HX, Su J, Ning ZP. Left atrial appendage occlusion in a mirror-image dextrocardia: A case report and review of literature. World J Clin Cases 2022; 10:1357-1365. [PMID: 35211570 PMCID: PMC8855170 DOI: 10.12998/wjcc.v10.i4.1357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/05/2021] [Accepted: 12/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In mirror-image dextrocardia, the anterior-posterior position of the cardiac chambers and great vessels is maintained, but the left-right orientation of the abdominal organs is reversed. The abnormal anatomy of the heart poses surgical challenges and problems in dealing with surgical risk and monitoring complications. There are few reports on closure of the left atrial appendage (LAA) in dextrocardia and no reports on the application of enhanced recovery after surgery (ERAS) following LAA occlusion (LAAO) procedures.
CASE SUMMARY The objective for this case was to ensure perioperative safety and accelerate postoperative recovery from LAAO in a patient with mirror-image dextrocardia. ERAS was guided by the theory and practice of nursing care. Atrial fibrillation was diagnosed in a 77-year-old male patient, in whom LAAO was performed. The 2019 guidelines for perioperative care after cardiac surgery recommend that the clinical nursing procedures for patients with LAAO should be optimized to reduce the incidence of perioperative complications and ensure patient safety. Music therapy can be used throughout perioperative treatment and nursing to improve the anxiety symptoms of patients.
CONCLUSION The procedure was uneventful and proceeded without complications. Anxiety symptoms were improved.
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Affiliation(s)
- Bei Tian
- Zhoupu Hospital Shanghai University of Medicine & Health Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China
| | - Chuang Ma
- Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China
| | - Jin-Wen Su
- Zhoupu Hospital Shanghai University of Medicine & Health Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China
| | - Jun Luo
- Zhoupu Hospital Shanghai University of Medicine & Health Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China
| | - Hong-Xia Sun
- Zhoupu Hospital Shanghai University of Medicine & Health Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China
| | - Jie Su
- Shache County People's Hospital, Kashgar 200437, Xinjiang Uygur Autonomous Region, China
| | - Zhong-Ping Ning
- Zhoupu Hospital Shanghai University of Medicine & Health Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China
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19
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Heim C, Müller PP, Massoudy P, Harig F, Nooh E, Weyand M, Czesla M. Pass On What You Have Learned: A Structured Mentor-Mentee Concept for the Implementation of a Minimally Invasive Mitral Valve Surgery Program. Eur Surg Res 2021; 63:98-104. [PMID: 34852340 DOI: 10.1159/000520431] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/21/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Starting a minimally invasive cardiac surgery (MICS) for mitral valve repair (MVR) program is challenging as it requires a new learning curve, but compromising surgical results at the same time is not acceptable. Here, we describe our surgical educational experience of starting a new MICS program at a university heart center in Germany. METHODS A dedicated team for the new MICS program including 2 cardiac surgeons, 1 cardiac anesthetist, 1 perfusionist, and 1 scrub nurse was chosen. The use of long shafted instruments was trained in a low-cost self-assembled MICS simulator, and the EACTS endoscopic dry lab course was visited. Thereafter, 1 MICS center was visited for direct observation and peer-to-peer education for 6 weeks. The mentor observed the first 10 cases performed by the mentee. The surgical mitral valve expertise of 1 single cardiac surgeon was retrospectively analyzed between April 2016 and April 2021. RESULTS Before the implementation of the MICS-MVR program, 18 mitral valve operations have been performed through sternotomy between April 2016 and October 2018 including 12 replacements and 6 ring annuloplasties. After starting the MICS-MVR program, 73 mitral operations have been performed by the same surgeon of which 53 video-assisted through minithoracotomy (72.6%). 83.1% of the MICS procedures included complex repair (n = 38) and ring annuloplasty (n = 6). Open heart MV surgery was necessary in 20 patients due to concomitant procedures (n = 8), redo procedures (n = 2), severe endocarditis (n = 4), or contraindication for MICS such as PAD (n = 6). There have been no deaths, 1 stroke, and 1 cardiac vascular (RCX) complication. Two patients required conversion to sternotomy and one pericardiocentesis in the long term. CONCLUSION Typically, excellent exposure and high repair rates of the MV has led us offer MICS approach to a majority of patients with isolated MV disease. Careful planning and a strict mentor-mentee concept facilitated a safe startup of an MICS program in a busy university heart center.
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Affiliation(s)
- Christian Heim
- University of Erlangen-Nuremberg, Cardiac Surgery, Erlangen, Germany
| | - Philipp P Müller
- University of Erlangen-Nuremberg, Cardiac Surgery, Erlangen, Germany
| | - Parwis Massoudy
- Department of Cardiac Surgery, Klinikum Passau, Passau, Germany
| | - Frank Harig
- University of Erlangen-Nuremberg, Cardiac Surgery, Erlangen, Germany
| | - Ehab Nooh
- University of Erlangen-Nuremberg, Cardiac Surgery, Erlangen, Germany
| | - Michael Weyand
- University of Erlangen-Nuremberg, Cardiac Surgery, Erlangen, Germany
| | - Markus Czesla
- Department of Cardiac Surgery, Klinikum Passau, Passau, Germany
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Fuchs A, Heinisch PP, Luedi MM, Reid CS. Pain after cardiac surgery: Time to include multimodal pain management concepts in ERAS protocols. J Clin Anesth 2021; 76:110583. [PMID: 34768206 DOI: 10.1016/j.jclinane.2021.110583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Paul Philipp Heinisch
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Catherine S Reid
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Gebauer A, Petersen J, Konertz J, Brickwedel J, Schulte-Uentrop L, Reichenspurner H, Girdauskas E. Enhanced Recovery After Cardiac Surgery: Where Do We Stand? CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00455-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Abstract
Purpose of Review
Enhanced recovery after surgery (ERAS) protocols are multimodal and multi-professional strategies to enhance postoperative convalescence and thereby reduce the length of hospital stay and hospital-associated complications. This review provides an up-to-date overview about basic principles of enhanced recovery after surgery protocols, their transfer into cardiac surgery, and their current state of evidence. It is supposed to offer clinical implications for further adaptations and implementations of such protocols in cardiac surgery.
Recent Findings
ERAS protocols are a story of success in numerous surgical disciplines and led to a paradigm shift in perioperative care and the establishment of ERAS Cardiac Society, a non-profit organization that provides evidence-based guidelines and recommendations for further development of enhanced recovery protocols, trying to harmonize the many existing efforts of individual approaches for cardiac surgery.
Summary
Promising results from comprehensive ERAS protocols in cardiac surgery emerged. Nevertheless, there is a paucity of high-quality data about holistic approaches in cardiac surgery and further efforts need to be promoted.
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Maj G, Regesta T, Campanella A, Cavozza C, Parodi G, Audo A. Optimal Management of Patients Treated With Minimally Invasive Cardiac Surgery in the Era of Enhanced Recovery After Surgery and Fast-Track Protocols: A Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:766-775. [PMID: 33840614 DOI: 10.1053/j.jvca.2021.02.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Use of minimally invasive cardiac surgery (MICS) is increasing, but to exert its maximum effect on patient outcomes, MICS must be coupled with improved perioperative management, including the Enhanced Recovery after Surgery (ERAS) and fast-track protocols. This study aimed to evaluate the impact of ERAS and fast track in this context. DESIGN NARRATIVE REVIEW: The authors performed a narrative review that included patients treated with MICS and patients treated with the ERAS/fast-track protocols in the MEDLINE/PubMed database. The keywords ERAS and fast-track were combined with the following key words: minimally invasive cardiac surgery OR robotic cardiac surgery OR minimally invasive mitral surgery OR minimally invasive aortic surgery. RESULTS Overall, the authors selected six studies in which either the ERAS or fast-track protocol was applied. The reported adherence to ERAS protocols was high, and neither protocol-related complications nor in-hospital mortality occurred. Patients managed based on ERAS had significantly lower postoperative pain scores, fewer rates of blood transfusions, and shorter hospital and intensive care unit stays compared with those who received standard management. All ERAS patients were managed safely, with early extubation. Similarly, fast-track cardiac surgery, with immediate postprocedure extubation and early transfer to the ward, was shown to be safe, with no increased morbidity or mortality. CONCLUSION Use of standardized ERAS and fast-track protocols seems to be feasible and safe in the context of MICS, with improved outcomes. Both ERAS and fast track allow for a faster return to full functional status while minimizing perioperative complications.
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Affiliation(s)
- Giulia Maj
- Department of Anesthesia and Intensive Care, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy.
| | - Tommaso Regesta
- Department of Cardiac Surgery, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Antonio Campanella
- Department of Cardiac Surgery, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Corrado Cavozza
- Department of Cardiac Surgery, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Giovanni Parodi
- Department of Anesthesia and Intensive Care, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Andrea Audo
- Department of Cardiac Surgery, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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23
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Zaouter C, Damphousse R, Moore A, Stevens LM, Gauthier A, Carrier FM. Elements not Graded in the Cardiac Enhanced Recovery After Surgery Guidelines Might Improve Postoperative Outcome: A Comprehensive Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:746-765. [PMID: 33589344 DOI: 10.1053/j.jvca.2021.01.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
Enhanced Recovery Programs (ERPs) are protocols involving the whole patient surgical journey. These protocols are based on multimodal, multidisciplinary, evidence-based, and patient-centered approaches aimed at improving patient recovery after a surgical intervention. Such programs have shown striking positive results in different surgical specialties. However, only a few research groups have incorporated preoperative, intraoperative, and postoperative evidence-based interventions in bundles used to standardize care and build cardiac surgery ERPs. The Enhanced Recovery After Surgery Society recently published evidence-based recommendations for perioperative care in cardiac surgery. Their recommendations included 22 perioperative interventions that may be part of any cardiac ERP. However, various components integrated in already-published cardiac ERPs were neither graded nor reported in these recommendations. The goals of the current review are to present published cardiac ERPs and their effects on patient outcomes and reported components incorporated into these ERPs and to discuss the objectives and scope of cardiac ERPs.
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Affiliation(s)
- Cédrick Zaouter
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada.
| | - Remy Damphousse
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Alex Moore
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Louis-Mathieu Stevens
- Department of Surgery, Division of Cardiac surgery, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Alain Gauthier
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - François Martin Carrier
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Medicine, Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
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