Use of Hybrid Stage I to Stratify Between Single Ventricle Palliation and Biventricular Repair.

Background: Hybrid stage I palliation (HS1P) has been utilized for patients with single ventricle (SV) congenital heart disease (CHD). To date, reports on the use of HS1P for other indications including biventricular (BiV) CHD have been limited. Methods: We performed a single-center retrospective cohort study of patients who underwent HS1P with an anticipated physiologic outcome of BiV repair, or with an undetermined SV versus BiV outcome. Patient characteristics and outcomes from birth through definitive repair or palliation were collected and reported with descriptive statistics. Results: Nineteen patients underwent HS1P with anticipated BiV repair. Extracardiac and intracardiac risk factors (ICRF) were common. Ultimately, 13 (68%) patients underwent BiV repair, 1 (5%) underwent SV palliation, and 5 (26%) died prior to further palliation or repair. Resolution of ICRF tracked with BiV outcome (6/6, 100%), persistence of ICRF tracked with SV outcome or death (3/3, 100%). Twenty patients underwent HS1P with an undetermined outcome. Ultimately, 13 (65%) underwent BiV repair, 6 (30%) underwent SV palliation, and 1 (5%) underwent transplant. There were no deaths. Intracardiac risk factors were present in 15 of 20 patients (75%); BiV repair only occurred when all ICRF resolved (67%). Post-HS1P complications and reinterventions occurred frequently in both groups, through all phases of care. Conclusions: Hybrid stage 1 palliation can be used to defer BiV repair and to delay decision between SV palliation and BiV repair. Resolution of ICRF was associated with ultimate outcome. In this high-risk group, complications are common, and mortality especially in the marginal BiV patient is high.

Revisiting the Role of Balloon Atrial Septostomy Prior to the Arterial Switch Operation.

OBJECTIVES: Patients with dextro-transposition of the great arteries (d-TGA) frequently undergo balloon atrial septostomy (BAS) prior to the arterial switch operation (ASO) to promote atrial-level mixing. Balloon atrial septostomy has inherent risks as an invasive procedure and may not always be necessary. This study revisits the routine utilization of BAS prior to ASO. METHODS: Single-center, retrospective review of d-TGA patients undergoing the ASO from July 2018 to March 2023. Preoperative patient characteristics, pulse oximetry oxygen saturations (SpO2), cerebral/renal near-infrared spectroscopy (NIRS) readings along with prostaglandin status at the time of the ASO were analyzed with descriptive and univariate statistics. RESULTS: Thirty patients underwent the ASO. Of these, 7 (23%) were female, 25 (83%) were white, and median weight at ASO was 3.2 kg (range 0.8-4.2). Twenty-two (73%) patients underwent BAS. There were no demographic differences between BAS and no-BAS patients. Of those who underwent BAS, there was a significant increase in SpO2 (median 83% [range 54-92] to median 87% [range 72-95], P = .007); however, there was no change in NIRS from pre-to-post BAS. Six (27%) patients in the BAS group were prostaglandin-free at ASO. Balloon atrial septostomy patients underwent the ASO later compared with no-BAS patients (median 8 [range 3-32] vs 4 [range 2-10] days old, P = .016) and had a longer hospital length of stay (median 13 [range 7-43] vs 10 [range 8-131] days, P = .108). CONCLUSIONS: While BAS is an accepted preoperative procedure in d-TGA patients to improve oxygen saturations, it is also an additional invasive procedure, does not guarantee prostaglandin-free status at the time of ASO, and may increase the interval to ASO. Birth to direct early ASO, with prostaglandin support, should be revisited as an alternative, potentially more expeditious strategy.

An implementation manual for an interprofessional enhanced recovery after surgery protocol in cardiac surgery following international established frameworks.

Introduction: Enhanced Recovery After Surgery (ERAS) protocols represent a paradigm shift in perioperative care, aim to optimize patient outcomes and accelerate recovery. This manual presents findings from implementing the INCREASE study, a bicentric prospective randomized controlled trial focusing on ERAS in minimally invasive heart valve surgery. Methods: Utilizing the Consolidated Framework for Implementation Research (CFIR) and the Template for Intervention Description and Replication (TIDieR), the study examined contextual factors, intervention components, and implementation strategies. Results: Key findings from the CFIR analysis revealed critical domains influencing implementation success. These included innovation characteristics, external and internal settings, and individual dynamics. The study showcased ERAS's adaptability to diverse healthcare systems, emphasizing its potential for successful integration across varying contexts. Furthermore, the importance of interprofessional collaboration emerged as a foundation of practical implementation, fostering teamwork, communication, and patient-centered care. Utilizing the TIDieR framework, this manual comprehensively describes ERAS intervention components, detailing preoperative counseling, intraoperative management, and postoperative care strategies. The manual underscored the importance of tailored, patient-centered approaches, highlighting the role of an academic ERAS nurse, early mobilization, and psychosomatic interventions in promoting optimal recovery outcomes. Discussion: In conclusion, the INCREASE study provided valuable insights for creating an implementation manual for ERAS in cardiac surgery, emphasizing adaptability, collaboration, and ongoing evaluation as key drivers of successful implementation. These findings have broad implications for improving patient care outcomes and advancing perioperative practices in cardiac surgery settings.

Association of postoperative delirium with hypotension in critically ill patients after cardiac surgery: a prospective observational study.

BACKGROUND: Postoperative delirium (POD), an acute and variable disturbance in cognitive function, is an intricate and elusive phenomenon that occurs after cardiac surgery. Despite progress in surgical techniques and perioperative management, POD remains a formidable challenge, imposing a significant burden on patients, caregivers, and healthcare systems. METHODS: This prospective observational study involved 307 patients who underwent cardiac surgery. Data on the occurrence of delirium, clinical parameters, and postoperative characteristics were collected. A multivariate analysis was performed to assess the relationship between POH and POD. RESULTS: Sixty-one patients (21%) developed delirium, with an average onset of approximately 5 days postoperatively and a duration of approximately 6 days. On multivariate analysis, POH was significantly associated with POD, and the adjusted odds ratios indicated that patients with POH were more likely to develop delirium (OR, 5.61; p = 0.006). Advanced age (OR, 1.11; p = 0.002), emergency surgery (OR, 8.31; p = 0.001), and on-pump coronary artery bypass grafting were identified as risk factors of POD. Patients who developed delirium were typically older, more likely to be male, and had higher morbidity rates than those who did not. CONCLUSION: POH is significantly associated with delirium in critically ill patients after cardiac surgery. Surgical complexity and advanced age contribute to the risk of developing POD and poor postoperative outcomes.

The implementation of EMI-Heart, a family-tailored early motor intervention in infants with complex congenital heart disease, in practice: a feasibility RCT.

BACKGROUND: Children with congenital heart disease (CHD) who undergo open-heart surgery are at risk of developmental impairment, including motor delay, which contributes to parental concerns. Additionally, parents experience prolonged stress associated with their child's disease. There is a lack of early motor interventions in infants with CHD accounting for parental burdens. We developed a family-tailored early motor intervention (EMI-Heart), aiming to promote motor development in infants with CHD and family well-being. The primary aim was to evaluate the feasibility of the study design and the intervention. The secondary aim was to evaluate differences between the intervention and the control group in motor outcomes and family well-being at baseline (3-5 months), post-treatment (6-8 months), and at follow-up (12 months). METHOD: In this single-centre feasibility randomized control trial (RCT), infants with CHD after open-heart surgery without genetic or major neurological comorbidities were randomly allocated to EMI-Heart or the control group (standard of care). EMI-Heart's key elements promote postural functional activities and encourage parental sensitivity to infants' motor and behaviour cues. Infants assigned to EMI-Heart received nine sessions of early motor intervention at home, in the hospital, and online for a duration of 3 months by a paediatric physiotherapist. We performed descriptive statistics for feasibility and secondary outcomes. RESULTS: The recruitment rate was 59% (10/17), all participating families completed the study (10/10), and the intervention duration was 3.9 months (± 0.54), including nine intervention sessions per family. Median acceptability to parents was 3.9 (1 = not agree-4 = totally agree, Likert scale). The paediatric physiotherapist considered the intervention as feasible. The comparison of motor outcomes did not show differences between groups. However, we detected improved reliable change scores in family well-being outcomes for families of the intervention group compared to the controls. CONCLUSIONS: Our research indicates that EMI-Heart is a feasible intervention for infants with CHD after open-heart surgery. The intervention was highly acceptable both to parents and to the paediatric physiotherapist. Online treatment sessions offer a valuable alternative to home and hospital visits. This feasibility RCT provides a foundation for a future full trial. TRIAL REGISTRATION: ClinicalTrials.gov, NCTT04666857. Registered 23.11.2020.

Racial Health Disparity Associated With Poor Pediatric Cardiac Surgery Outcomes: A Multicentered, Cross-Sectional Study.

Background: Health disparities are known to play a role in pediatric cardiac surgery outcomes. Objectives: Risk factors associated with poor clinical outcomes were assessed. Methods: Using Pediatric Health Information System Database, pediatric subjects undergoing cardiac surgery using International Classification of Diseases 10th Revision from October 2015 to December 2020 were evaluated. Subjects were categorized by case complexity using the newly validated Risk Adjustment for Congenital Heart Surgery-2 (RACHS-2). Multivariable regression analyses were conducted to ascertain risk factors. Results: A total of 59,856 subjects, median age 7.4 months (IQR: 1.5-61 months) were included; 38,917 (low), 9,833 (medium), and 11,106 (high) RACHS-2. Overall, hospital mortality was 3% and postoperative length of stay (LOS) was 7 days (IQR: 4-18 days), with significant increases in both mortality and postoperative LOS from low to high RACHS-2 scores by multivariable analysis, Kaplan-Meier, and Cox regression. Mechanical ventilation, extracorporeal membrane oxygenation, infection, and surgical complication were most significantly associated with increased mortality by 1.198 to 10.227 times (P < 0.008). After controlling for these significant variables as well as RACHS-2, age at surgery and emergency/urgent admission type, multivariable analysis revealed that non-White race was associated with increased mortality (relative risk: 1.2, 95% CI: 0.729-0.955, P = 0.008) and increased postoperative LOS by 1.04 days (95% CI: 0.95-0.97, P < 0.001). This significant increase in both clinical outcomes was concordant in non-White neonates (mortality relative risk: 1.3, 95% CI: 1.1-1.6, P = 0.003; and postoperative LOS by 2.05 weeks (95% CI: 1.36-3.10, P < 0.001). Conclusions: The influence of racial differences in neonates and children should be further evaluated to mitigate any disparity in those undergoing cardiac surgery.

The Impact of DeBakey Forceps on Cardiac Surgery: Revolutionizing the Surgical Landscape.

The evolution of cardiac surgery has been marked by significant advancements in surgical techniques and tools, leading to improved patient outcomes and safety. A pivotal development in this journey has been the creation of DeBakey forceps, an instrument designed by Dr. Michael DeBakey, a prominent cardiac surgeon and medical innovator. This review explores the impact of a simple, yet effective surgical force invented by Dr. DeBakey, which is not only a cornerstone of cardiac surgery but also finds applications in various other specialties, piquing curiosity about its versatility and unique design that has revolutionized the field of surgery.

Machine Learning Analysis of Predictors for Inhaled Nitric Oxide Therapy Administration Time Post Congenital Heart Disease Surgery: A Single-Center Observational Study.

Background Congenital heart disease (CHD) is a structural deformity of the heart present at birth. Pulmonary hypertension (PH) may arise from increased blood flow to the lungs, persistent pulmonary arterial pressure elevation, or the use of cardiopulmonary bypass (CPB) during surgical repair. Inhaled nitric oxide (iNO) selectively reduces high blood pressure in the pulmonary vessels without lowering systemic blood pressure, making it useful for treating children with postoperative PH due to heart disease. However, reducing or stopping iNO can exacerbate postoperative PH and hypoxemia, necessitating long-term administration and careful tapering. This study aimed to evaluate, using machine learning (ML), factors that predict the need for long-term iNO administration after open heart surgery in CHD patients in the postoperative ICU, primarily for PH management. Methods We used an ML approach to establish an algorithm to predict 'patients with long-term use of iNO' and validate its accuracy in 34 pediatric postoperative open heart surgery patients who survived and were discharged from the ICU at Kagoshima University Hospital between April 2016 and March 2019. All patients were started on iNO therapy upon ICU admission. Overall, 16 features reflecting patient and surgical characteristics were utilized to predict the patients who needed iNO for over 168 hours using ML analysis with AutoGluon. The dataset was randomly classified into training and test cohorts, comprising 80% and 20% of the data, respectively. In the training cohort, the ML model was constructed using the important features selected by the decrease in Gini impurity and a synthetic oversampling technique. In the testing cohort, the prediction performance of the ML model was evaluated by calculating the area under the receiver operating characteristics curve (AUC) and accuracy. Results Among 28 patients in the training cohort, five needed iNO for over 168 hours; among six patients in the testing cohort, one needed iNO for over 168 hours. CPB, aortic clamp time, in-out balance, and lactate were the four most important features for predicting the need for iNO for over 168 hours. In the training cohorts, the ML model achieved perfect classification with an AUC of 1.00. In the testing cohort, the ML model also achieved perfect classification with an AUC of 1.00 and an accuracy of 1.00. Conclusion The ML approach identified that four factors (CPB, in-out balance, aortic cross-clamp time, and lactate) are strongly associated with the need for long-term iNO administration after open heart surgery in CHD patients. By understanding the outcomes of this study, we can more effectively manage iNO administration in postoperative open heart surgery in CHD patients with PH, potentially preventing the recurrence of postoperative PH and hypoxemia, thereby contributing to safer patient management.

Comparison of Blalock-Taussig-Thomas Shunts With Patent Ductus Arteriosus Ligated Versus Left Open.

BACKGROUND: The optimal approach to patent ductus arteriosus management during systemic-to-pulmonary artery shunt placement is currently unknown. The purpose of this study is to examine the outcomes of variable strategies for patent ductus arteriosus management during Blalock-Taussig-Thomas shunt surgery. METHODS: A retrospective cohort study of infants who underwent shunt placement was performed, comparing those who had the ductus ligated with those who had the ductus left open. Indicators of low cardiac output syndrome, development of necrotizing enterocolitis, and secondary outcomes such as resuscitation events were examined. RESULTS: Thirty-six infants were included all of whom had their shunt placed via median sternotomy. Twenty infants had their ductus ligated at the time of the shunt, and they were compared with 16 infants whose ductus was left open. There was no statistical difference in preoperative baseline characteristics, including corrected gestational age, age in days, weight, mechanical ventilation, vasoactive use, heterotaxy, and gastrointestinal anomalies. There was also no statistical difference in postoperative indicators of low cardiac output, including urine production, total fluids given, renal injury, maximum lactate, and vasoactive-inotropic score. Three patients had postoperative renal injury, and all were in the ligated duct group. There was also no statistical difference in any secondary outcomes, including the development of necrotizing eneterocolitis, resuscitation events, reinterventions, length of intubation, total length of stay, and mortality. CONCLUSIONS: This study provides evidence that variable management of the ductus during shunt placement does not significantly impact outcomes. Leaving the ductus open allows for a potential rescue source of pulmonary blood flow and does not appear to increase the risk of postoperative low cardiac output.

Outcomes of Patients Undergoing the Kawashima Procedure at an Early Age: A Single Center Experience.

BACKGROUND: Previous reports have demonstrated the safety and efficacy of performing early Kawashima procedure (KP). Despite this, more recent studies have shown that the average age at the time of operation remains greater than one year of age. We report our experience with performing KP at an earlier age than previously reported. METHODS: A retrospective review was completed of patients undergoing KP at a single center (January 2000 to June 2020). Clinical outcomes were examined. RESULTS: Initial palliation was performed in 11 out of 12 patients. Age and weight at time of KP were 8.25 months (6.4-9.7) and 7.7 kg (6.5-8.6). Intensive care unit stay was 3.16 days (1-12), overall length of stay was 9.5 days (3-22). There was one unplanned reoperation, and no mortality in the cohort. Discharge oxygen saturation was 88% (80%-98%). Seven patients developed pulmonary arteriovenous malformations (PAVMs) with six proceeding to hepatic vein incorporation (HVI). Interval time to development of PAVMs was 42.3 months (16-121). Four of the 12 patients were left with antegrade pulmonary blood flow (PBF) and three (75%) remain without PAVMs. Median follow-up was 10 years (1.5-22) with 11 of 12 (91.67%) survival for the cohort. CONCLUSIONS: The KP can be done at a younger age than previously reported with adequate early and late results. Most patients will go on to develop PAVMs and require HVI but leaving patients with some antegrade PBF is likely protective but will need further investigation to show definitive benefit.

Systematic review and meta-analysis of left atrial appendage closure's influence on early and long-term mortality and stroke.

Objective: Left atrial appendage closure (LAAC) concomitant to heart surgery in patients with underlying atrial fibrillation (AF) has gained attention because of long-term reduction of thromboembolic complications. As of mortality benefits in the setting of non-AF, data from both observational studies and randomized controlled trials are conflicting. Methods: On-line databases were screened for studies comparing LAAC versus no LAAC concomitant to other heart surgery. End points assessed were all-cause mortality and stroke at early and longest-available follow-up. Subgroup analyses stratified on preoperative AF were performed. Risk ratios (RR) with 95% CIs served as primary statistics. Results: Electronic search yielded 25 studies (N = 660 [158 patients]). There was no difference between LAAC and no LAAC in terms of early mortality. In the overall population analysis, LAAC reduced long-term mortality (RR, 0.86; 95% CI, 0.74-1.00; P = .05; I 2 = 88%), reduced early stroke risk by 19% (RR, 0.81; 95% CI, 0.72-0.93; P = .002; I 2 = 57%), and reduced late stroke risk by 13% (RR, 0.87; 95% CI, 0.84-0.90; P < .001; I 2 = 58%). Subgroup analysis showed lower mortality (RR, 0.85; 95% CI, 0.72-1.01; P = .06; I 2 = 91%), short-, and long-term stroke risk reduction only in patients with preoperative AF (RR, 0.81; 95% CI, 0.71-0.93; P = .003; I 2 = 71% and RR, 0.87; 95% CI, 0.84-0.91; P < .001; I 2 = 70%, respectively). No benefit of LAAC in patients without AF was found. Conclusions: Concomitant LAAC was associated with reduced stroke rates at early and long-term and possibly reduced all-cause mortality at the long-term follow-up but the benefits were limited to patients with preoperative AF. There is not enough evidence to support routine concomitant LAAC in non-AF settings.

A Shot Through the Heart.

We present the case of a patient who was shot through the heart with an air rifle and presented in a stable condition at our emergency department. At the time of presentation, the bullet was still present within the myocardium. Imaging, management, and outcome are discussed in this report.

Impact of nitric oxide via cardiopulmonary bypass on pediatric heart surgery: a meta-analysis of randomized controlled trials.

OBJECTIVE: The impact of nitric oxide (NO) administered via cardiopulmonary bypass (CPB) on pediatric heart surgery remains controversial. The objective of this study is to conduct a comprehensive systematic review and meta-analysis to examine the impact of NO administered via CPB on pediatric heart surgery. METHODS: This study searched 7 electronic databases to identify Randomized Controlled Trials (RCTs) on the impact of NO administration during CPB on postoperative outcomes in pediatric heart surgery. The searched databases included Embase, Medline (though PubMed), Cochrane Library, Web of Science, Wan Fang database, China National Knowledge Infrastructure (CNKI), and ClinicalTrials.gov from their inception to November 2, 2022. The included RCTs compared NO administration during CPB with standard CPB procedures or placebo gas treatment in pediatric heart surgery. fixed-effects models and/or random-effects models were used to estimate the effect size with 95% confidence interval (CI). Heterogeneity among studies was indicated by p-values and I2. All analyses were performed using Review Manager software (version 5.4) in this study. RESULTS: A total of 6 RCTs including 1,739 children were identified in this study. The primary outcome was duration of postoperative mechanical ventilation, with the length of hospital and intensive care unit (ICU) stay as the second outcomes. Through a pooled analysis, we found that exogenous NO administered via CPB for pediatric heart surgery could not shorten the duration of postoperative mechanical ventilation when compared with the control group (standardized mean difference (SMD) -0.07, CI [-0.16, 0.02], I2 = 45%, P = 0.15). Additionally, there were also no difference between the two groups in terms of length of hospital stay (mean difference (MD) -0.29, CI [-1.03, 0.46], I2 = 32%, P = 0.45) and length of ICU stay (MD -0.22, CI [-0.49 to 0.05], I2 = 72%, P = 0.10). CONCLUSIONS: This meta-analysis showed that exogenous NO administration via CBP had no benefits on the duration of mechanical ventilation, the length of postoperative hospital, and ICU stay after pediatric heart surgery.

Concomitant Tricuspid Valve Ring Annuloplasty During Mitral Valve Surgery Versus Mitral Valve Surgery Alone: A Systematic Review and Meta-Analysis.

AIM: Although current guidelines recommend concomitant tricuspid annuloplasty for moderate or greater tricuspid regurgitation (TR) and/or dilated annulus, there remains significant variation in undertaking concomitant tricuspid valve surgery (TVA) across different centres. This meta-analysis aimed to compare the clinical outcomes of concomitant tricuspid valve surgery for patients with moderate or greater TR and/or dilated annulus at the time of mitral valve (MV) surgery. METHOD: A systematic review of the literature using six databases. Eligible studies include comparative studies on TVA concomitant with MV surgery versus MV surgery alone. A meta-analysis was performed on studies reporting outcomes of interest to quantify the effects of concomitant tricuspid ring annuloplasty. RESULTS: Two randomised controlled trials and six cohort studies were included in the analysis. 1,941 patients were included in the analysis, of whom, 1,090 underwent concomitant TVA and 851 underwent MV surgery alone. Pooled analysis demonstrated that there was less progression of moderate/severe TR in the concomitant group (3.0% vs 9.6%; odds ratio [OR] 0.29; 95% confidence interval [CI] 0.13-0.55; p=0.0001). There was no significant difference in in-hospital mortality (3.0% vs 3.8%; OR 0.79; 95% CI 0.47-1.34; p=0.38). The rate of permanent pacemaker implantation was higher in the concomitant group although this did not reach statistical significance (7.6% vs 5.3%; OR 1.30; 95% CI 0.85-1.98; p=0.23). Cardiopulmonary bypass was longer in the concomitant TVA group by 20 minutes (mean difference 13.9-26.0; p<0.00001). CONCLUSIONS: Our study demonstrated that concomitant tricuspid ring annuloplasty at the time of MV surgery is associated with a significantly lower rate of TR progression without increasing the operative mortality. There is a trend towards a higher permanent pacemaker implantation rate although this did not reach statistical significance.

External validation of a clinical mathematical model estimating post-operative urine output following cardiac surgery in children.

BACKGROUND: This study aims to externally validate a clinical mathematical model designed to predict urine output (UOP) during the initial post-operative period in pediatric patients who underwent cardiac surgery with cardiopulmonary bypass (CPB). METHODS: Children aged 0-18 years admitted to the pediatric cardiac intensive care unit at Cleveland Clinic Children's from April 2018 to April 2023, who underwent cardiac surgery with CPB were included. Patients were excluded if they had pre-operative kidney failure requiring kidney replacement therapy (KRT), re-operation or extracorporeal membrane oxygenation or KRT requirement within the first 32 post-operative hours or had indwelling urinary catheter for fewer than the initial 32 post-operative hours, or had vasoactive-inotrope score of 0, or those with missing data in the electronic health records. RESULTS: A total of 213 encounters were analyzed; median age (days): 172 (IQR 25-75th%: 51-1655), weight (kg): 6.1 (IQR 25-75th%: 3.8-15.5), median UOP ml/kg/hr in the first 32 post-operative hours: 2.59 (IQR 25-75th%: 1.93-3.26) and post-operative 30-day mortality: 1, (0.4%). The mathematical model achieved the following metrics in the entire dataset: mean absolute error (95th% Confidence Interval (CI)): 0.70 (0.67-0.73), median absolute error (95th% CI): 0.54 (0.52-0.56), mean squared error (95th% CI): 0.97 (0.89-1.05), root mean squared error (95th% CI): 0.99 (0.95-1.03) and R2 Score (95th% CI): 0.29 (0.24-0.34). CONCLUSIONS: This study provides encouraging external validation results of a mathematical model predicting post-operative UOP in pediatric cardiac surgery patients. Further multicenter studies must explore its broader applicability.

Effect of Preoperative Recombinant Human Erythropoietin on the Need for Blood Transfusion and Surgical Outcomes in Adult Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis with Trial Sequential Analysis.

This study aimed to examine the value of preoperative recombinant human erythropoietin (rhEPO) administration to adults undergoing elective cardiac surgery. Databases were searched for randomized controlled trials (RCTs) comparing rhEPO plus standard treatment versus standard treatment only. Primary outcomes were the need for and volume of homologous blood transfusion (HBT). Secondary outcomes were the lengths of intensive care unit (ICU) and hospital stay and the incidence of major adverse events. There was very low certainty that rhEPO is associated with a reduction in the need for HBT, with a number needed to treat of 5.6 (95% confidence interval [CI], 3.9-12.5), and low certainty that it is associated with a moderate reduction in HBT volume (Hedges g = -0.55; 95% CI, -0.79 to -0.32). Meta-regression revealed that studies with a higher proportion of females or older patients demonstrated less benefit of rhEPO in terms of reduced consumption of HBT. Trial sequential analysis showed that rhEPO was superior to standard treatment only for reducing the need for and volume of HBT. Regarding secondary outcomes, there was moderate certainty that rhEPO is associated with a limited reduction in the length of ICU (Hedges g = -0.10; 95% CI, -0.19 to -0.01) and hospital stay (Hedges g = -0.13; 95% CI = -0.25 to -0.02), and low certainty for increased risk of myocardial infarction, with a number needed to harm of 36.1 (95% CI, 17.9-127.4). More well-designed, adequately powered RCTs are needed to draw conclusions regarding the value of rhEPO.

Psychometric Properties of the Persian Version of the Intensive Care Experience Questionnaire (ICE-Q).

Background and Purpose: It is important to assess the experience of patients who have been admitted to an intensive care unit to provide the best treatment and nursing care possible. Therefore, a valid and reliable tool is necessary for measurement. This study aimed to determine the psychometric properties of the Persian version of the Intensive Care Experience Questionnaire (ICEQ) for open-heart surgery patients. Methods: The study was conducted in four steps: translation, face and content validity, confirmatory factor analysis, and reliability assessment. The adapted questionnaire was administered to 200 Iranian cardiac surgery patients who had received treatment in an intensive care unit within the past month. Results: In the final Persian version of ICEQ, there are 4 factors and 21 items. Following the translation and cultural adaptation process, the content validity was evaluated. Three items had content validity ratio < 0.6, so they were deleted. Scale-level content validity index/Average was 0.81 and more than 0.7 for each item on the scale. This scale was validated through confirmatory factor analysis using fit indicators (comparative fit index, normalized fit index, root mean square error of approximation, and chi-square). There was Cronbach's alpha of 0.71-0.85, and intraclass correlation coefficients were 0.82-0.93 for subscales. Conclusions: The Persian version of ICEQ showed appropriate psychometric properties. This scale may be useful to inform the development of effective interventions to improve subsequent outcomes for Iranian open-heart surgery patients.

ARISCAT and LAS VEGAS risk scores for predicting postoperative pulmonary complications after cardiac surgery: a cohort study.

Background: Postoperative pulmonary complications (PPCs) could lead to morbidity, mortality, and prolonged hospital stay. Different risk-scoring systems are used to predict the identification of patients at risk of developing PPCs. The diagnostic accuracies of the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) and Local Assessment of Ventilatory Management During General Anaesthesia for Surgery (LAS VEGAS) risk scores are compared in prediction of PPCs taking pulmonary complication as the gold standard in cardiac surgery. Materials and methods: A prospective cohort study with consecutive sampling technique. A total of 181 patients were included. Quantitative data is presented as simple descriptive statistics giving mean and standard deviation, and qualitative variables are presented as frequency and percentages. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracies are also calculated. Results: Total 181 post-cardiac surgery patients were analyzed. The median [interquartile range] of age, height, weight, and BMI were 60.0 [52.0-67.0] years, 163.0 [156.0-168.0] cm, 71.0 [65.0-80.0] kg and 27.3 [24.2-30.4] kg/m2. 127 (70.2%) were male, and 54 (29.8%) were female. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of ARISCAT for the prediction of PPCs were (94.9%, 4.65%, 76.1%, 22.9% and 73.4%), whereas LAS VEGAS were (97.1%, 4.65%, 76.5%, 33.3% and 75.1%), respectively. Conclusion: Both the ARISCAT and LAS VEGAS risk scores are of limited value in cardiac surgery patients for the prediction of postoperative pulmonary complications, based on the predicted scores in this study.

Early Impressions and Adoption of the AtriAmp for Managing Arrhythmias Following Congenital Heart Surgery.

AtriAmp is a new medical device that displays a continuous real-time atrial electrogram on telemetry using temporary atrial pacing leads. Our objective was to evaluate early adoption of this device into patient care within our pediatric intensive care unit (PICU). This is a qualitative study using inductive analysis of semi-structured interviews to identify dominant themes. The study was conducted in a single-center, tertiary, academic 21-bed mixed PICU. The subjects were PICU multidisciplinary team members (Pediatric Cardiac Intensivists, PICU Nurse Practitioners, PICU nurses and Pediatric Cardiologists) who were early adopters of the AtriAmp (n = 14). Three prominent themes emerged: (1) Accelerated time from arrhythmia event to diagnosis and treatment; (2) Increased confidence in the accuracy of providers' arrhythmia diagnosis; and (3) Improvement in the ability to educate providers about post-operative arrhythmias. Providers also noted some learning curves, but none compromised medical care or clinical workflow. Insights from early adopters of AtriAmp signal the need for simplicity and fidelity in new PICU technologies. Our research suggests that such technologies can be pivotal to the support and growth of multi-disciplinary teams, even among those who do not participate in early implementation. Further research is needed to understand when and why novel technology adoption becomes widespread in high-stakes settings.