Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review

There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery.

Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management

Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.

Pulmonary prehabilitation and smoking cessation

PURPOSE OF REVIEW

This review aims to summarize the current literature on pulmonary prehabilitation programs, their effects on postoperative pulmonary complications, and the financial implications of implementing these programs. Additionally, this review has discussed the current trends in pulmonary prehabilitation programs, techniques for improving rates of perioperative smoking cessation, and the optimal timing of these interventions.

RECENT FINDINGS

Prehabilitation is a series of personalized multimodal interventions tailored to individual needs, including lifestyle and behavioral measures. Pulmonary prehabilitation has shown to reduce postoperative pulmonary complications (PPCs).

SUMMARY

The implications of clinical practice and research findings regarding PPCs are an increased burden of postoperative complications and financial cost to both patients and hospital systems. There is convincing evidence that pulmonary prehabilitation based on endurance training should be started 8-12 weeks prior to major surgery; however, similar rates of improved postoperative outcomes are observed with high-intensity interval training (HIIT) for 1-2 weeks. This shorter interval of prehabilitation may be more appropriate for patients awaiting thoracic surgery, especially for cancer resection. Additionally, costs associated with creating and maintaining a prehabilitation program are mitigated by shortened lengths of stay and reduced PPCs. Please see Video Abstract, http://links.lww.com/COAN/A90.

Formation of an Anesthesiology Residency Mentoring Program Using a Mentee-Driven Approach

Mentorship is crucial to career development and advancement in academic medicine with valuable benefits to residents realized during training and beyond. The primary aims of this program are to train faculty members to provide quality mentorship to every resident in our department and to reduce gender and racial disparities in access to mentorship. We piloted a new mentorship program that combines mentor self-nomination, mentor training with mentee-driven mentor selection. This report details the program design and early observations.

Aorto-Left Atrial Fistula as Sequela of Endocarditis

Aortoatrial fistula formation is a rare complication of bacterial endocarditis. Fistulous tracts may form between the aorta and either atrium. Clinical presentation varies from an insignificant murmur to refractory congestive heart failure. Most clinically relevant fistula manifests with acute and severe symptoms. Transesophageal echocardiography (TEE) is more sensitive than transthoracic echocardiography (TTE) in diagnosing intracardiac shunts, and invaluable in guiding intraoperative surgical repair. Definitive therapy involves closure of the fistula either through an open surgical approach or percutaneously with an occluder device.

Mechanisms of Self-Inflicted Injuries at an Urban City Hospital

BACKGROUND

Suicide is a major public health issue with root causes including psychological, economical, and societal factors.

METHODS

Retrospective review identified self-inflicted traumatic injuries (SITIs) at Grady Health System between 2009 and 2017. Patients were categorized by penetrating or blunt mechanism of injury (MOI). Outcomes included hospital length of stay (HLOS) and ventilator duration, mortality, and location of death.

RESULTS

678 patients in total were identified. Penetrating MOI was most prevalent (n = 474). Patients with a blunt MOI were significantly younger (32 Y vs. 37 Y; P < .0001). Psychiatric illness was equally common between MOI at more than 50%. Penetrating traumas required longer ventilator times (1 D vs. 0 D; P < .0001) but shorter overall HLOS (4 D vs. 6 D; P = .0013). Mortality was twice as high in the penetrating group (29.8% vs. 11.8%; P < .0001).

CONCLUSION

Self-inflicted traumatic injuries occurred most often among younger adults and those with history of psychiatric illness. Penetrating traumas result in worse outcomes. Self-inflicted traumatic injuries carry high morbidity and mortality. Improved prevention strategies targeting high-risk groups are needed.

Traumatic Ventricular Septal Defect After Stab Wound to the Chest Missed by Transthoracic Echocardiography: A Case Report

Traumatic ventral septal defect may be sustained after either blunt force or penetrating trauma to the chest. Severity ranges from asymptomatic to acute decompensated heart failure. Our patient suffered a stab wound to the chest and was initially taken to the operating room for repair of a lacerated right ventricle. Subsequent postoperative hemodynamic deterioration prompted a bedside transthoracic echocardiogram, which failed to identify causal factors. A transesophageal echocardiogram performed immediately after ventral septal defect was demonstrated. This case serves to highlight the gaps in current standard practice and encourages the use of transesophageal echocardiogram as a screening tool in patients after penetrating cardiac injuries.