The role of methadone in cardiac surgery for management of postoperative pain

Background

This retrospective study evaluated the efficacy and safety of intraoperative methadone compared with short-acting opioids.

Methods

Patients undergoing cardiac surgery with cardiopulmonary bypass (n=11 967) from 2018 to 2023 from a single health system were categorised into groups based on intraoperative opioid administration: no methadone (Group O), methadone plus other opioids (Group M+O), and methadone only (Group M).

Results

Patients in Groups M and M+O had lower mean pain scores until postoperative day (POD) 7 compared with Group O after adjusting for covariates (P<0.01). Both Groups M and M+O had lower total opioid administered compared with Group O for all days POD0-POD6 (all P<0.001). The median number of hours until initial postoperative opioid after surgery was 2.55 (inter-quartile range [IQR]=1.07-5.12), 6.82 (IQR=3.52-12.98), and 7.0 (IQR=3.82-12.95) for Group O, Group M+O, and Group M, respectively. The incidence of postoperative complications did not differ between groups.

Conclusions

Intraoperative administration of methadone was associated with better pain control without significant side-effects after cardiac surgery.

Trends and Disparities in Valvular Heart Disease Mortality in the United States From 1999 to 2020

BACKGROUND

Percutaneous heart valve procedures have been increasingly performed over the past decade, yet real-world mortality data on valvular heart disease (VHD) in the United States remain limited.

METHODS AND RESULTS

We queried the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database among patients ≥15 years old from 1999 to 2020. VHD and its subtypes were listed as the underlying cause of death. We calculated age-adjusted mortality rate (AAMR) per 100 000 individuals and determined overall trends by estimating the average annual percent change using the Joinpoint regression program. Subgroup analyses were performed based on demographic and geographic factors. In the 22-year study, there were 446 096 VHD deaths, accounting for 0.80% of all-cause mortality (56 014 102 people) and 2.38% of the total cardiovascular mortality (18 759 451 people). Aortic stenosis recorded the highest mortality of VHD-related death in both male (109 529, 61.74%) and female (166 930, 62.13%) populations. The AAMR of VHD has declined from 8.4 (95% CI, 8.2-8.5) to 6.6 (95% CI, 6.5-6.7) per 100 000 population. Similar decreasing AAMR trends were also seen for the VHD subtypes. Men recorded higher AAMR for aortic stenosis and aortic regurgitation, whereas women had higher AAMR for mitral stenosis and mitral regurgitation. Mitral regurgitation had the highest change in average annual percent change in AAMR.

CONCLUSIONS

The mortality rate of VHD among the US population has declined over the past 2 decades. This highlights the likely efficacy of increasing surveillance and advancement in the management of VHD, resulting in improved outcomes.

Days Alive and Out of the Hospital After Heart Transplantation: A Retrospective Cohort Study

OBJECTIVE

Evaluate days alive and out of the hospital (DAOH) as an outcome measure after orthotopic heart transplantation in patients with mechanical circulatory support (MCS) as a bridge to transplant compared to those patients without prior MCS.

DESIGN

A retrospective observational study of adult patients who underwent cardiac transplantation between January 1, 2015, and January 1, 2020. The primary outcome was DAOH at 365 days (DAOH365) after an orthotopic heart transplant. A Poisson regression model was fitted to detect the association between independent variables and DAOH365.

SETTING

An academic tertiary referral center.

PARTICIPANTS

A total of 235 heart transplant patients were included-103 MCS as a bridge to transplant patients, and 132 direct orthotopic heart transplants without prior MCS.

MEASUREMENTS AND MAIN RESULTS

The median DAOH365 for the entire cohort was 348 days (IQR 335.0-354.0). There was no difference in DAOH365 between the MCS patients and patients without MCS (347.0 days [IQR 336.0-353.0] v 348.0 days [IQR 334.0-354.0], p = 0.43). Multivariate analysis identified patients who underwent a transplant after the 2018 heart transplant allocation change, pretransplant pulmonary hypertension, and increased total ischemic time as predictors of reduced DAOH365.

CONCLUSIONS

In this analysis of patients undergoing orthotopic heart transplantation, there was no significant difference in DAOH365 in patients with prior MCS as a bridge to transplant compared to those without MCS. Incorporating days alive and out of the hospital into the pre-transplant evaluation may improve understanding and conceptualization of the post-transplantation patient experience and aid in shared decision-making with clinicians.

Chest Pain and Dyspnea After a Minimally Invasive Repair of Pectus Excavatum

Although infrequent, damage to cardiovascular structures can occur during or following a minimally invasive repair of pectus excavatum. We present a case of right ventricular outflow tract compression caused by a displaced intrathoracic bar. Removal of the bar resulted in an improvement in symptoms and hemodynamics. (Level of Difficulty: Advanced.)

Transcatheter aortic valve replacement outcomes in solid organ transplant recipients

BACKGROUND AND AIMS

Transcatheter aortic valve replacement (TAVR) has become the primary treatment for severe symptomatic aortic stenosis in patients >65 years with volumes exceeding surgical aortic valve replacements (SAVR) since 2019. As a less invasive procedure with lower complication rates, TAVR is preferable in most patient populations, particularly those with increased surgical risk. One such population is patients who have undergone solid organ transplant (SOT). We aimed to evaluate periprocedural outcomes and complication rates following TAVR in SOT recipients as compared to the general TAVR population.

METHODS

The 2016-2018 National Inpatient Sample (NIS) was queried by ICD-10 PCS codes to identify TAVR cases; hospitalizations were subsequently stratified by SOT history. Multivariate analyses were completed to evaluate complication rates, length of stay (LOS), and cost of stay (COS).

RESULTS

No significant difference was observed in mortality rates or post-procedural complications between SOT recipients (n = 223) and those without transplant history undergoing TAVR (n = 29,448) except for increased thromboembolic events captured in transplant patients (p < .001). There was no significant variation in LOS or COS between the two populations; female sex and Black or Hispanic race were predictors of increased inpatient time.

CONCLUSIONS

SOT recipients have no increased risk of mortality or periprocedural complications when undergoing TAVR. Though the rate of thromboembolic events was higher in SOT recipients, observation size was small (n = 27 TAVR, n = 4 TAVR + SOT) thus external validity is limited. Based on these data, transplant recipients experience no difference in outcomes following TAVR as compared to patients without a history of organ transplant.

Transcarotid Versus Transaxillary/Subclavian Transcatheter Aortic Valve Replacement (TAVR): Analysis of Outcomes

Transcatheter aortic valve replacement (TAVR) has revolutionized the percutaneous management of valvular heart disease and has evolved to progressively minimalist techniques over the past decade. This review discusses the impact of minimalist TAVR, explores the alternative approaches when transfemoral (TF) TAVR is not possible, and analyzes the current outcomes of transcarotid (TC) versus transaxillary/subclavian (TAx) TAVR, which are the two leading nonfemoral (NF) approaches emerging as the preferred alternatives to TF TAVR.

Practical Considerations for and Outcomes of Interfacility ECMO Transfer of Patients With COVID-19 During a Pandemic: Mayo Clinic Experience

Interfacility transport of a critically ill patient with acute respiratory distress syndrome (ARDS) may be necessary for a higher level of care or initiation of extracorporeal membrane oxygenation (ECMO). During the COVID-19 pandemic, ECMO has been used for patients with severe ARDS with successful results. Transporting a patient after ECMO cannulation by the receiving facility brings forth logistic challenges, including availability of adequate personal protective equipment for the transport team and hospital capacity management issues. We report our designated ECMO transport team's experience of 5 patients with COVID-19-associated severe ARDS after cannulation at the referring facility. Focusing on transport-associated logistics, creation of checklists, and collaboration with emergency medical services partners is necessary for safe and good outcomes for patients while maintaining team safety.