Outcomes of Chylothorax Nonoperative Management After Cardiothoracic Surgery: A Systematic Review and Meta-Analysis

INTRODUCTION

Chylothorax after thoracic surgery is a severe complication with high morbidity and mortality rate of 0.10 (95% confidence interval [CI] 0.06 - 0.02). There is no agreement on whether nonoperative treatment or early reoperation should be the initial intervention. This systematic review and meta-analysis aimed to evaluate the outcomes of the conservative approach to treat chyle leakage after cardiothoracic surgeries.

METHODS

A systematic review was conducted in PubMed®, Embase, Cochrane Library Central, and LILACS (Biblioteca Virtual em Saúde) databases; a manual search of references was also done. The inclusion criteria were patients who underwent cardiothoracic surgery, patients who received any nonoperative treatment (e.g., total parenteral nutrition, low-fat diet, medium chain triglycerides), and studies that evaluated chylothorax resolution, length of hospital stay, postoperative complications, infection, morbidity, and mortality.

CENTRAL MESSAGE

Nonoperative treatment for chylothorax after cardiothoracic procedures has significant hospital stay, morbidity, mortality, and reoperation rates.

RESULTS

Twenty-two articles were selected. Pulmonary complications, infections, and arrhythmia were the most common complications after surgical procedures. The incidence of chylothorax in cardiothoracic surgery was 1.8% (95% CI 1.7 - 2%). The mean time of maintenance of the chest tube was 16.08 days (95% CI 12.54 - 19.63), and the length of hospital stay was 23.74 days (95% CI 16.08 - 31.42) in patients with chylothorax receiving nonoperative treatment. Among patients that received conservative treatment, the morbidity event was 0.40 (95% CI 0.23 - 0.59), and reoperation rate was 0.37 (95% CI 0.27 - 0.49). Mortality rate was 0.10 (95% CI 0.06 - 0.02).

CONCLUSION

Nonoperative treatment for chylothorax after cardiothoracic procedures has significant hospital stay, morbidity, mortality, and reoperation rates.

Comparison of Single-Dose Cardioplegia in Valvular Heart Surgery: Lactated Ringer's-Based del Nido vs. Histidine-Tryptophan-Ketoglutarate Cardioplegia Solution

INTRODUCTION

This study evaluated myocardial protection and clinical outcomes when using lactated Ringer's solution as the base solution for del Nido cardioplegia compared with histidine-tryptophan-ketoglutarate (HTK) solution in valvular surgery.

METHODS

From January 2017 to May 2018, 71 adult patients who underwent valvular surgery with del Nido cardioplegia (n=37) or HTK cardioplegia (n=34) were retrospectively analyzed.

RESULTS

Patients' characteristics were comparable between groups. Postoperative peak troponin T levels were similar. The del Nido group had a decreased incidence of ventricular fibrillation after aortic cross-clamp removal (13.51 vs. 55.88%; P<0.001), lower total volume of cardioplegia administered (1,000 [1,000, 1,250] vs. 1,800 [1,500, 2,000] mL; P<0.001), shorter hospital stay (6 [5, 8] vs. 7 [6, 10] days; P=0.03), and less postoperative red cell transfusion (34.29 vs. 61.11%; P=0.024). There is no difference in aortic cross-clamping time, postoperative change in left ventricular ejection fraction, intensive care unit stay, duration of inotropic support, new onset of atrial fibrillation, in-hospital mortality, complications, and three-year overall survival rate.

CONCLUSION

Lactated Ringer's-based del Nido cardioplegia can be safely used for valvular surgery with acceptable clinical outcomes compared to HTK cardioplegia.

Cardiovascular Events and All-Cause Mortality in Patients With Chronic Obstructive Pulmonary Disease Using Olodaterol and Other Long-Acting Beta2-Agonists

PURPOSE

We examined the effect of olodaterol on the risk of myocardial ischaemia, cardiac arrhythmia, and all-cause mortality compared with use of other long-acting beta2-agonists (LABAs). Channelling bias was also explored.

METHODS

This Danish population-based cohort study used data linked from registries of hospital diagnoses, outpatient dispensings, and deaths. It included patients (aged ≥40 years) with a diagnosis of chronic obstructive pulmonary disease (COPD) who initiated olodaterol or another LABA. Using matching and propensity score (PS) stratification, we calculated adjusted incidence rate ratios (IRRs) using Poisson regression, followed by several additional analyses to evaluate and control channelling bias.

RESULTS

The IRRs of cardiac arrhythmias or myocardial ischaemia among users of olodaterol (n=14,239) compared to users of other LABA (n=51,167) ranged from 0.96 to 1.65 in various analyses, although some estimates had low precision. Initial analysis suggested an increased risk for death with olodaterol compared with other LABAs (IRR, 1.63; 95% CI, 1.44-1.84). Because olodaterol prescribing was associated with COPD severity, the mortality association was attenuated by using different methods of tighter confounding control: the IRRs were 1.26 (95% CI, 0.97-1.64) among LABA-naïve LABA/LAMA users without recent COPD hospitalisation; 1.27 (95% CI, 1.03-1.57) in a population with additional trimming from the tails of the PS distribution; and 1.32 (95% CI, 1.19-1.48) after applying overlap-weights analysis.

CONCLUSIONS

Olodaterol users had a similar risk for cardiac arrhythmias or myocardial ischaemia as other LABA users. The observed excess all-cause mortality associated with olodaterol use could be due to uncontrolled channelling bias.

Development of a Risk Score for QT Prolongation in the Intensive Care Unit Using Time-Series Electrocardiogram Data and Electronic Medical Records

Objective

Drug-induced QT prolongation can lead to life-threatening arrhythmia. In the intensive care unit (ICU), various drugs are administered concurrently, which can increase the risk of QT prolongation. However, no well-validated method to evaluate the risk of QT prolongation in real-world clinical practice has been established. We developed a risk scoring model to continuously evaluate the quantitative risk of QT prolongation in real-world clinical practice in the ICU.

Methods

Continuous electrocardiogram (ECG) signals measured by patient monitoring devices and Electronic Medical Records data were collected for ICU patients. QT and RR intervals were measured from raw ECG data, and a corrected QT interval (QTc) was calculated by Bazett's formula. A case-crossover study design was adopted. A case was defined as an occurrence of QT prolongation ≥12 hours after any previous QT prolongation. The patients served as their own controls. Conditional logistic regression was conducted to analyze prescription, surgical history, and laboratory test data. Based on the regression analysis, a QTc prolongation risk scoring model was established.

RESULTS

In total, 811 ICU patients who experienced QT prolongation were included in this study. Prescription information for 13 drugs was included in the risk scoring model. In the validation dataset, the high-risk group showed a higher rate of QT prolongation than the low-and low moderate-risk groups.

Conclusions

Our proposed model may facilitate risk stratification for QT prolongation during ICU care as well as the selection of appropriate drugs to prevent QT prolongation.

Introduction of Wearable Device in Cardiovascular Field for Monitoring Arrhythmia

There has been increasing adoption of wearable smart devices in health care field and they enable non-invasive continuous monitoring of various cardiac parameters. Lots of studies have demonstrated that ambulatory monitoring devices were able to provide data for reliable diagnostics for arrhythmia. Distinguishing features of wearables such as ubiquitous continuous monitoring make it a convincing alternative to traditional diagnostic devices. Additionally, this revolutionary technology does not only enhance the diagnostic utility of wearable devices, but has also facilitated remote health care using IOT (internet of things) capability. In this review, the authors aim to present the state of current technologic development of smart wearables for detection of arrhythmia and comment on future perspectives with reviewing recent studies focused on clinical utility.

QT interval and P wave dispersion in slow coronary flow phenomenon

BACKGROUND

Slow coronary flow (SCF) phenomenon is an angiographic finding which is defined as slow contrast passage through coronary arteries which may predispose patients to serious cardiac complications such as fatal arrhythmias. P-wave and QT-interval dispersion are electrocardiographic findings which are related to atrial fibrillation and ventricular tachyarrhythmias. In the present study, the relation between SCF and presence of P-wave and QT-interval dispersion in electrocardiography has been evaluated.

METHODS

47 patients with normal coronary arteries and SCF and 40 patients with normal coronary artery flow without SCF were enrolled in this case control study. Standard electrocardiogram (ECG) was analyzed for P-wave and QT-interval dispersion. SCF was identified in normal coronary vessels by use of Thrombolysis in Myocardial Infarction (TIMI) frame count (TFC) method (TFC > 27). Corrected TIMI frame count (CTFC) of coronary vessels as well as mean CTFC along with QT-interval and P-wave dispersion were compared between 2 groups. The study data were analyzed by SPSS software and P value less than 0.050 was considered to be significant.

RESULTS

QT-interval [76.17 (35.23) ms versus 39.25 (19.26) ms] and P-wave [39.74 (17.48) ms versus 19.50 (8.54) ms] dispersion were significantly higher among patients with SCF phenomenon (P < 0.050). In addition, there was a positive significant linear correlation between TFC and P-wave and QT-dispersion (r = 0.857, r = 0.861, respectively, P < 0.050).

CONCLUSION

According to the results, increasing TFC among patients with SCF will result in P wave and QT interval dispersion and therefore this finding can be considered as an indicative marker for cardiac events.

Interactive Multimodal Curriculum on Use and Interpretation of Inpatient Telemetry

INTRODUCTION

Inpatient telemetry monitoring is a commonly used technology designed to detect and monitor life-threatening arrhythmias. However, residents are rarely educated in the proper use and interpretation of telemetry monitoring.

METHODS

We developed a training module containing an educational video, PowerPoint presentation, and hands-on interactive learning session with a telemetry expert. The module highlights proper use of telemetry monitoring, recognition of telemetry artifact, and interrogation of telemetry to identify clinically significant arrhythmias. Learners completed pre- and postcurriculum knowledge-based assessments and a postcurriculum survey on their experience with the module. In total, the educational curriculum had three 60-minute sessions.

RESULTS

Thirty-two residents participated in the training module. Residents scored higher on the posttest (77% ± 12%) than on the pretest (70% ± 12%), t(31) = -4.3, p < .001. Wilcoxon signed rank tests indicated PGY-3s performed better on the posttest (Mdn = 0.86) than on the pretest (Mdn = 0.72), z = -2.19, p = .031. PGY-2s also performed better on the posttest (Mdn = 0.86) than on the pretest (Mdn = 0.76), z = -2.04, p = .042. There was no difference between pretest (Mdn = 0.66) and posttest (Mdn = 0.71) scores for PGY-1s, z = -1.50, p = .142. The majority of residents reported that the telemetry curriculum boosted their self-confidence, helped prepare them to analyze telemetry on their patients, and should be a required component of the residency.

DISCUSSION

This module represents a new paradigm for teaching residents how to successfully and confidently interpret and use inpatient telemetry.

Multi-arrhythmias detection with an XML rule-based system from 12-Lead Electrocardiogram

Background

The computer-aided detection of cardiac arrhythmias stills a crucial application in medical technologies. The rule based systems RBS ensure a high level of transparency and interpretability of the obtained results.

Aim

To facilitate the diagnosis of the cardiologists and to reduce the uncertainty made in this diagnosis.

Methods

In this research article, we have realized a classification and automatic recognition of cardiac arrhythmias, by using XML rules that represent the cardiologist knowledge. Thirteen experiments with different knowledge bases were realized for improving the performance of the used method in the detection of 13 cardiac arrhythmias. In the first 12 experiments, we have designed a specialized knowledge base for each cardiac arrhythmia, which contains just one arrhythmia detection rule. In the last experiment, we applied the knowledge base which contains rules of 12 arrhythmias. We used, for the experiments, an international data set with 279 features and 452 records characterizing 12 leads of ECG signal and social information of patients. The data sets were constructed and published at Bilkent University of Ankara, Turkey. In addition, the second version of the self-developed software “XMLRULE” was used; the software can infer more than one class and facilitate the interpretability of the obtained results.

Results

The 12 first experiments give 82.80% of correct detection as the mean of all experiments, the results were between 19% and 100% with a low rate in just one experiment. The last experiment in which all arrhythmias are considered, the results of correct detection was 38.33% with 90.55% of sensibility and 46.24% of specificity. It was clearly show that in these results the good choice of the classification model is very beneficial in terms of performance. The obtained results were better than the published results with other computational methods for the mono class detection, but it was less in multi-class detection.

Conclusion

The RBS is the most transparent method for cardiac arrhythmias detection and multi arrhythmias detection. It improves an exceptional recognition of arrhythmias, but due to conflicts between rules, multi-arrhythmias and uncertainty of measures, the rate of correct classification was less than the other methods.

Inherited Ventricular Arrhythmias: The Role of the Multi-Subunit Structure of the L-Type Calcium Channel Complex

The normal heartbeat is conditioned by transient increases in the intracellular free Ca²⁺ concentration. Ca²⁺ influx in cardiomyocytes is regulated by the activity of the heteromeric L-type voltage-activated Ca_V1.2 channel. A complex network of interactions between the different proteins forming the ion channel supports the kinetics and the activation gating of the Ca²⁺ influx. Alterations in the biophysical and biochemical properties or in the biogenesis in any of these proteins can lead to serious disturbances in the cardiac rhythm. The multi-subunit nature of the channel complex is better comprehended by examining the high-resolution three-dimensional structure of the closely related Ca_V1.1 channel. The architectural map identifies precise interaction loci between the different subunits and paves the way for elucidating the mechanistic basis for the regulation of Ca²⁺ balance in cardiac myocytes under physiological and pathological conditions.