Hemadsorption treatment for antithrombotic drug removal in emergency cardiac surgery – cost-benefit analysis comparing patient outcomes

Background

Intraoperative hemadsorption is indicated for ticagrelor and rivaroxaban removal in patients undergoing urgent cardiac surgery and has been previously shown to reduce bleeding complications. However, whether this application is cost effective is currently unknown.

Methods

Between June 2017 and June 2021, we evaluated the outcomes of 72 consecutive patients (age 65±11 years) with acute coronary syndrome (ACS) pretreated with ticagrelor who underwent urgent coronary artery bypass grafting (CABG) at our institution. Intraoperative hemoadsorption (IH) was used in all cases (IH-Pat). We estimated the mean cost per patient, and a bootstrap analysis was performed based on individual data from the case series. We compared the results with “historical patients” who were operated under the same conditions between June 2015 and June 2017 but without IH (n=22).

Results

Bilateral internal mammary artery (BIMA) was used in 67.7% of all cases. Use of IH was associated with significantly shorter operation times (277±65 min vs. 320±75 min; P=0.014) and significantly less postoperative 24-hours chest tube drainage (277±65 mL vs. 866±262 mL; P<0.001). Only two rethoracotomies (2.8%) had to be performed. In addition, patients operated without IH required significantly more blood products and had a significantly higher rate of rethoracotomy, resulting in longer ICU stays. The variable that had the highest impact on the level of cost savings was the operation duration. The overall cost saving with IH were calculated at over 4200±1100€ with operation time, ICU stay and blood product costs being the top contributors.

Conclusions

The results suggest that the clinical benefits derived from IH in ticagrelor-treated patients requiring urgent cardiac surgery patients could result in significant cost savings of over 4200±1100 € per patient.

Funding Acknowledgement

Type of funding sources: None.

Effect of rank, group size and number of group changes ante partum on the occurrence of milk ejection disorders in primiparous cows – a field study

Abstract. In the present study causes for the development of milk ejection disorders (MED) in primiparous cows of two herds were investigated. We hypothesised that MED are provoked by social problems within the herd that appear close to calving. Data were collected on 67 heifers of herd A and 60 heifers of herd B. In herd A, heifers were introduced into existing groups of cows 2–4 weeks prior to calving. They were kept in a group housing system with deep bedding. All animals were hornless. In herd B, heifers were kept separated from the cows from 2–4 weeks a.p. in a three-row cubicle barn. In contrast to herd A, all animals had horns. The animals´ reactions regarding the milking process and MED were analysed during the first four milkings p.p. We evaluated the correlation between social rank, group size and frequency of group changes in the antepartal period and the occurrence of MED. 12 % of the animals in herd A and 47 % of the animals in herd B showed MED. In herd A, lowranking heifers had significantly more often MED than higher-ranking heifers. A correlation between low rank, increasing strain due to rank order fights and increasing frequency of MED can be assumed here. In herd B, a correlation between stocking rate and frequency of MED could be observed.

Changes of myocardial function after combined coronary revascularization and mitral valve downsizing in patients with ischemic mitral regurgitation and advanced cardiomyopathy

OBJECTIVE

At present not much data is available on changes in myocardial function after combined coronary artery bypass grafting (CABG) and downsizing of the mitral valve (MV) by restrictive prosthetic ring annuloplasty in patients with chronic ischemic mitral regurgitation (IMR) and advanced cardiomyopathy.

METHODS

63 patients with coronary artery disease, chronic IMR grade 3 - 4+, ischemic cardiomyopathy and reduced left ventricular (LV) function (LV ejection fraction [LVEF] of 30 +/- 9 %; range 12 - 45 %) underwent combined CABG and MV downsizing. Clinical follow-up and serial echocardiographic studies were performed to assess survival, New York Heart Association (NYHA) class, mitral regurgitation (MR), leaflet coaptation height (LCH), left atrial (LA) and LV end-systolic/end-diastolic dimensions/volumes and volume indices (LVESD, -EDD; LVESV, -EDV; LVESVI, -EDVI), fractional shortening (FS) and LVEF to evaluate the changes in myocardial function after surgery.

RESULTS

Early mortality (< 30 days) was 1.6 %, survival at follow-up was 95 % (3 +/- 1 months) and 83 % (2 +/- 1 years), respectively. Functional class improved significantly after surgery; recurrence of relevant MR was absent in all patients. In general, LA/LV dimensions/volumes and volume indices, FS and LVEF improved significantly, even in patients with already severely reduced preoperative LV function (LVEF </= 25 %, n = 23), a significant improvement of myocardial function was observed.

CONCLUSION

Combined MV downsizing and CABG surgery can be performed with low early and late mortality, resulting in a significant improvement of myocardial function and without MR recurrence at short-term and mid-term follow-up.

Permanent Atrial Fibrillation Ablation Surgery in CABG and Aortic Valve Patients is at Least as Effective as in Mitral Valve Disease

BACKGROUND

Data on combined permanent atrial fibrillation (pAF) surgery and coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) are scarce, and the mid- and long-term effects on survival and cardiac rhythm are unknown.

MATERIAL AND METHODS

In a prospective analysis 125 patients (Group I: CABG and/or AVR, n = 50; Group II: mitral valve [MV] surgery, n = 75) with pAF (> or = 6 months) underwent either concomitant monopolar (Group I: n = 20; Group II: n = 75) or bipolar (Group I: n = 30) radiofrequency (RF) ablation procedures. Group I patients had a significantly smaller left atrial (LA) size than Group II patients (LA-diameter: 47.7 +/- 4.6 vs. 58.2 +/- 6.1 mm; p < 0.01). Regular follow-up was performed from 3 to 36 months after surgery to assess survival, NYHA-class, and conversion rate to stable sinus rhythm (SR).

RESULTS

Early mortality (< 30 days) of Group I patients was 0% (Group II: 2.7%), cumulative survival at long-term follow-up was 0.95 vs. 0.82 (p = 0.31) and NYHA-class improved significantly in both groups, particularly in cases with stable SR. At follow-up 80% of Group I patients had SR (Group II: 70%). In Group I patients the bipolar approach was associated with significantly shorter ablation procedure times compared to the monopolar procedure (12.1 +/- 3.4 vs. 18.9 +/- 1.6 min; p < 0.05).

CONCLUSIONS

Concomitant pAF ablation surgery in CABG and/or AVR is safe and at least as effective as in MV surgery, presumably because severe LA enlargement is exceptionally rare in this group.

Abdominal complications following cardiac surgery

Type and frequency of abdominal complications after open heart surgery are described. Out of 3,312 patients, 48 patients (1.4%) developed early postoperative abdominal complications with a mortality rate of 14.5%. Paralytic ileus, erosive gastritis and gastrointestinal hemorrhage were the most frequent complications, whilst intestinal ischemia, acute cholecystitis and acute pancreatitis were less frequently observed. The comparison of the frequency of abdominal complications in cardiac surgery patients with the same complications in other operated patients showed no significant difference (hi-square test), with the exception of COLD which was more frequent in the group with abdominal complications. No association was found between perioperative treatment with aprotinine and the development of abdominal complications.

[Abdominal complications after heart surgery interventions]

OBJECTIVE

Risk factors of abdominal complications after cardiac surgery are largely unknown. We undertook this study to determine different types of abdominal complications after cardiac surgery and to identify patients at risk.

PATIENTS AND METHODS

3312 adult patients were operated between Jan. 91 and Oct. 95 (2352 males, 960 females, 62.6 +/- 0.18y). We included all patients who suffered from abdominal complications within 30 days postoperatively.

RESULTS

Abdominal complications are rare after cardiac surgery using cardiopulmonary bypass (CPB) (1.4%), but they are associated with high mortality (14.5%) in our department. Abdominal complications like paralytic ileus (43.8%), erosive gastritis (22.9%) and gastrointestinal bleeding (18.8%) are more often, compared with acute cholecystitis (14.5%), acute pancreatitis (8.3%) and intestinal ischemia (19.5%). Patients with intestinal ischemia are at high risk and do have a high mortality (83%). Abdominal complications can be found more often in connection with prolonged myocardial ischemia and valve replacement or combined operations. Prediction of complications on the basis of anamnestic data alone was not possible.

CONCLUSION

Abdominal complications after cardiac surgery, especially intestinal ischaemia, are life-threatening. Prediction of abdominal complications is impossible. We have to concentrate on an early diagnosis and therapeutic intervention to lower mortality. A close cooperation between cardiac and general surgeons is mandatory for a successful treatment of life-threatening abdominal complications such as intestinal ischemia.

[Cardiomyopathy after osteosarcoma treatment: a contribution to the cardiotoxicity of adriamycin]

The frequency and severity of clinical and subclinical heart damage were studied in patients who had been treated with adriamycin (ADR) as part of the Cooperative Osteosarcoma Studies (COSS). The study charts of 785 patients from 63 participating institutions were reviewed: The overall incidence of drug-induced congestive heart failure was 2.2% (17 cases, 5 fatal). Late left ventricular function was studied in 29 tumor free survivors 81 +/- 41 month after treatment with 342 +/- 113 mg/m2 ADR. A detailed history and physical exam for signs of overt heart disease were obtained. M-mode echocardiography (ECHO, 29 cases) with evaluation of the fractional shortening rate (FS) and radionuclide ventriculography (RNV, 18 cases) with determination of the systolic ejection fraction at rest (EF) were used to screen for subclinical cardiac disease. Impaired cardiac function leading to pathological values was documented in close to one half of these patients. The frequency and severity of clinical and subclinical heart damage increased with cumulative adriamycin and time since cessation of anthracycline therapy.

Respiratory behavior in near-miss sudden infant death syndrome

Seventeen infants with unexplained prolonged apnea that has been designated near-miss sudden infant death syndrome were monitored for sleep and cardiorespiratory variables during a 12-hour, all-night recording session. Infants were matched for gestational age, sex, and age at recording with control infants. Respiratory variables studied included respiratory rate, respiratory variability, apnea duration, apnea density, and periodic breathing. No statistically significant differences were found in sleep state or respiratory variables between near-miss and control infants. Eight infants (47%) had no recurrence of prolonged apnea, whereas three (17.6%) had recurrent apneic episodes for six weeks to eight months following the original episode. No clinical or polygraphic finding predicted which infant would exhibit recurrent apnea. None of the infants was monitored at home. All infants were developing normally when examined at 1 to 2 years of age.