RESUMO
BACKGROUND: The Perfusion Measures and Outcomes (PERForm) registry was established in 2010 to advance cardiopulmonary bypass (CPB) practices and outcomes. The registry is maintained through the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative and is the official registry of the American Society of Extracorporeal Technology. METHODS: This first annual PERForm registry report summarizes patient characteristics as well as CPB-related practice patterns in adult (≥18 years of age) patients between 2019 and 2022 from 42 participating hospitals. Data from PERForm are probabilistically matched to institutional surgical registry data. Trends in myocardial protection, glucose, anticoagulation, temperature, anemia (hematocrit), and fluid management are summarized. Additionally, trends in equipment (hardware/disposables) utilization and employed patient safety practices are reported. RESULTS: A total of 40,777 adult patients undergoing CPB were matched to institutional surgical registry data from 42 hospitals. Among these patients, 54.9% underwent a CABG procedure, 71.6% were male, and the median (IQR) age was 66.0 [58.0, 73.0] years. Overall, 33.1% of the CPB procedures utilized a roller pump for the arterial pump device, and a perfusion checklist was employed 99.6% of the time. The use of conventional ultrafiltration decreased over the study period (2019 vs. 2022; 27.1% vs. 24.9%) while the median (IQR) last hematocrit on CPB has remained stable [27.0 (24.0, 30.0) vs. 27.0 (24.0, 30.0)]. Pump sucker termination before protamine administration increased over the study period: (54.8% vs. 75.9%). CONCLUSION: Few robust clinical registries exist to collect data regarding the practice of CPB. Although data submitted to the PERForm registry demonstrate overall compliance with published perfusion evidence-based guidelines, noted opportunities to advance patient safety and outcomes remain.
Assuntos
Ponte Cardiopulmonar , Sistema de Registros , Humanos , Sistema de Registros/estatística & dados numéricos , Masculino , Idoso , Ponte Cardiopulmonar/estatística & dados numéricos , Ponte Cardiopulmonar/instrumentação , Pessoa de Meia-Idade , Feminino , Michigan , AdultoRESUMO
BACKGROUND: Despite several studies comparing off- and on-pump coronary artery bypass grafting (CABG), the effectiveness and outcomes of off-pump CABG still remain uncertain. METHODS: In this registry-based study, we assessed 8163 patients who underwent isolated CABG between 2014 and 2016. Propensity score matching (PSM), inverse probability of weighting (IPW) and covariate adjustment were performed to correct for and minimize selection bias. RESULTS: The overall mean age of the patients was 62 years, and 25.7% were women. Patients who underwent off-pump CABG had shorter length of hospitalization (p < 0.001), intubation time (p = 0.003) and length of ICU admission (p < 0.001). Off-pump CABG was associated with higher risk of 30-days mortality (OR: 1.7; 95% CI 1.09-2.65; p = 0.019) in unadjusted analysis. After covariate adjustment and matching (PSM and IPW), this difference was not statistically significant. After an average of 36.1 months follow-up, risk of MACCE and all-cause mortality didn't have significant differences in both surgical methods by adjusting with IPW (HR: 1.03; 95% CI 0.87-1.24; p = 0.714; HR: 0.91; 95% CI 0.73-1.14; p = 578, respectively). CONCLUSION: Off-pump and on-pump techniques have similar 30-day mortality (adjusted, PSM and IPW). Off-pump surgery is probably more cost-effective in short term; however, mid-term survival and MACCE trends in both surgical methods are comparable.
Assuntos
Ponte Cardiopulmonar/estatística & dados numéricos , Ponte de Artéria Coronária sem Circulação Extracorpórea/estatística & dados numéricos , Ponte de Artéria Coronária/estatística & dados numéricos , Doença da Artéria Coronariana/cirurgia , Modelos Estatísticos , Idoso , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/mortalidade , Pesquisa Comparativa da Efetividade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/mortalidade , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Prospectivos , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The American College of Surgeons Committee on Trauma requires that all level I trauma centers have cardiopulmonary bypass (CPB) capabilities immediately available. Despite this mandate, there are limited data on the utilization and clinical outcomes among trauma patients requiring CPB in the management of injuries. The aim of this study was to evaluate the current use of CPB in the care of trauma patients. METHODS: This is a retrospective analysis of the National Trauma Data Bank from 2010 to 2015. Adult patients sustaining cardiothoracic injuries who underwent surgical repair within the first 24 hours of admission were included. Propensity score matching was used to compare outcomes (in-hospital mortality, hospital length of stay (LOS), intensive care unit LOS, and complications) between patients who underwent CPB within the first 24 hours of admission and those with similar injuries who did not receive CPB. RESULTS: A total of 28,481 patients who met the inclusion criteria were identified, of whom 319 underwent CPB. Three-hundred three CPB patients were matched to 895 comparison patients who did not undergo CPB. Overall in-hospital mortality was 35%. Patients who were not treated with CPB had a significantly higher in-hospital mortality compared with those treated with CBP (odds ratio, 1.57; 95% confidence interval, 1.16-2.12; p = 0.003); however, complications were significantly lower in those who did not receive CPB (odds ratio, 0.63; 95% confidence interval, 0.47-0.86; p = 0.003). Hospital LOS (non-CPB: mean, 13.4 ± 16.3 days; CPB: mean, 14.7 ± 15.1 days; p = 0.23) and intensive care unit LOS (non-CPB: mean, 9.9 ± 10.7 days; CPB: mean, 10.1 ± 9.7 days; p = 0.08) did not differ significantly between groups. CONCLUSION: The use of CPB in the initial management of select cardiothoracic injuries is associated with a survival benefit. Further investigation is required to delineate which specific injuries would benefit the most from the use of CPB. LEVEL OF EVIDENCE: Therapeutic, level IV.
Assuntos
Ponte Cardiopulmonar/estatística & dados numéricos , Traumatismos Torácicos/cirurgia , Lesões do Sistema Vascular/cirurgia , Adulto , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Taxa de Sobrevida , Traumatismos Torácicos/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/cirurgia , Adulto JovemRESUMO
Background Thrombosis is common in infants undergoing staged surgeries for single-ventricle congenital heart disease. The reported incidence and timing of thrombosis varies widely, making it difficult to understand the burden of thrombosis and develop approaches for prevention. We aimed to determine the timing and cumulative incidence of thrombosis following the stage I Norwood procedure and identify clinical characteristics associated with thrombosis. Methods and Results We analyzed data from the Pediatric Heart Network Single Ventricle Reconstruction trial from 2005 to 2009 and identified infants with first-time thrombotic events. In 549 infants, the cumulative incidence of thrombosis was 21.2% (n=57) from stage I through stage II. Most events occurred during stage I (n=35/57, 65%), with a median time to thrombosis of 15 days. We used a Cox proportional hazards model to estimate the association of clinical variables with thrombosis. After adjusting for baseline variables, boys had a higher hazard of thrombosis (adjusted hazard ratio [HR], 2.69; 95% CI, 1.44-5.05; P=0.002), non-hypoplastic left heart syndrome cardiac anatomy was associated with a higher early hazard of thrombosis (adjusted HR, 3.93; 95% CI, 1.89-8.17; P<0.001), and longer cardiopulmonary bypass time was also associated with thrombosis (per 10-minute increase, adjusted HR, 1.07; 95% CI, 1.01-1.12; P=0.02). Lower oxygen saturation after the Norwood procedure increased the hazard for thrombosis in the unadjusted model (HR, 1.08; 95% CI, 1.02-1.14; P=0.011). Conclusions Thrombosis affects 1 in 5 infants through Stage II discharge, with most events occurring during stage I. Male sex, non-hypoplastic left heart syndrome anatomy, longer cardiopulmonary bypass time, and lower stage I oxygen saturation were associated with thrombosis.
Assuntos
Ventrículos do Coração/anormalidades , Síndrome do Coração Esquerdo Hipoplásico/diagnóstico por imagem , Procedimentos de Norwood/efeitos adversos , Trombose/epidemiologia , Ponte Cardiopulmonar/estatística & dados numéricos , Estudos de Casos e Controles , Feminino , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/epidemiologia , Cardiopatias Congênitas/cirurgia , Ventrículos do Coração/cirurgia , Humanos , Síndrome do Coração Esquerdo Hipoplásico/mortalidade , Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Hipóxia/complicações , Incidência , Lactente , Recém-Nascido , Masculino , Procedimentos de Norwood/classificação , Procedimentos de Norwood/métodos , Modelos de Riscos Proporcionais , Procedimentos de Cirurgia Plástica/métodos , Estudos Retrospectivos , Análise de Sobrevida , Trombose/etiologia , Trombose/prevenção & controle , Fatores de TempoRESUMO
OBJECTIVE: There is no clear consensus regarding the definition of low cardiac output syndrome (LCOS) or the follow-up of this patient group. Given this lack of a clinical definition, the aim of this study was to use a LCOS score (LCOSs) similar to the low cardiac output score previously presented in the literature and evaluate the relationship between a high LCOSs and poor clinical outcome. METHODS: A total of 54 patients were prospectively evaluated after cardiac surgery. The LCOSs was used to evaluate the deve-lopment of low cardiac output. Each parameter was scored as 1 point. The score was calculated every hour for 24 hours postoperatively and the highest score was recorded as the peak score (pLOCSs). The LOCSs at the time of admission to the pediatric intensive care unit, at the 4th, 8th, and 16th hour were recorded and a cumulative score (cLOCSs) score was calculated. RESULTS: The mean age of the patients was 49.40±53.15 months and 24.07% had LOCS. In the group with LCOS, the cLOCSs, vasoactive-inotropic score (VIS), lactate mean, aortic clamp time, and the total cardiopulmonary bypass time were significantly higher. In this study, a significant and positive correlation was found between the cLOCSs and pLOCSs and the length of hospital stay, length of stay in the pediatric intensive care unit, VIS, lactate mean, and aortic clamp duration. CONCLUSION: The objective of this study was to draw attention to the potential use of a common language in the care of critical pediatric patients undergoing cardiac surgery with a previously defined scoring method that includes parameters indicating poor perfusion in the patient.
Assuntos
Baixo Débito Cardíaco/diagnóstico , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Aorta , Baixo Débito Cardíaco/sangue , Baixo Débito Cardíaco/etiologia , Ponte Cardiopulmonar/estatística & dados numéricos , Pré-Escolar , Constrição , Feminino , Humanos , Unidades de Terapia Intensiva Pediátrica , Ácido Láctico/sangue , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Fatores de TempoRESUMO
BACKGROUND: Infants with congenital heart disease (CHD) often require the placement of a gastrostomy button to ensure proper nutrition. Some also require a Nissen fundoplication (NF) to further improve nutrition capabilities in the setting of reflux, however, the clinical and diagnostic imaging characteristics that support NF are variable. The aims of this study were as follows: (1) identify the factors associated with NF in patients with CHD and (2) determine the incidence of NF complications in patients with CHD. METHODS: All patients with CHD who underwent cardiac repair and subsequent creation of a gastrostomy at a single institution between 6/1/2013 and 9/1/2018 were included. We then identified which patients underwent NF. RESULTS: Two-hundred fifty-seven CHD patients who had a gastrostomy button placed after CHD repair, with 17% undergoing a simultaneous NF or an NF at a later time. The presence of acyanotic heart disease, neurologic comorbidities, and vocal cord dysfunction was not univariately associated with a higher likelihood of NF. On multivariable model, only prematurity was significantly associated with NF (P = 0.022). Abnormal findings on imaging studies (upper gastrointestinal series, gastric emptying studies, motility studies, upper endoscopies, swallow studies, and pH probe studies) were not associated with an NF (all P's > 0.05). The overall complication rate was 23%. CONCLUSIONS: Prematurity was the only factor associated with an NF. Surprisingly, cyanotic heart disease, neurologic comorbidities, age at first cardiac surgery, and vocal cord dysfunction were not associated with an NF. We identified an area for quality improvement at our institution given the lack of standardized work-up for the NF in this high-risk population.
Assuntos
Nutrição Enteral/efeitos adversos , Fundoplicatura/efeitos adversos , Refluxo Gastroesofágico/terapia , Gastrostomia/efeitos adversos , Cardiopatias Congênitas/terapia , Complicações Pós-Operatórias/epidemiologia , Ponte Cardiopulmonar/estatística & dados numéricos , Nutrição Enteral/instrumentação , Nutrição Enteral/métodos , Nutrição Enteral/estatística & dados numéricos , Feminino , Fundoplicatura/estatística & dados numéricos , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/etiologia , Gastrostomia/estatística & dados numéricos , Idade Gestacional , Cardiopatias Congênitas/complicações , Humanos , Incidência , Recém-Nascido , Recém-Nascido Prematuro , Intubação Gastrointestinal/efeitos adversos , Intubação Gastrointestinal/métodos , Intubação Gastrointestinal/estatística & dados numéricos , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco/estatística & dados numéricos , Fatores de RiscoRESUMO
To evaluate the effectiveness of retrograde autologous priming (RAP) based on miniaturized cardiopulmonary bypass (CPB) circuit in children undergoing open heart surgery.We performed a retrospective analysis of all patients (≤15âkg) who underwent open heart surgery with CPB in our center from January 1, 2017, to July 31, 2019. Propensity score matching was used to adjust for significant covariates, and multivariable stratified analysis was used to assess the association of the RAP technique with clinical outcomes.A total of 1111 patients were analyzed. There were 355 (32.0%) children who underwent RAP, and 756 (68.0%) were in the non-RAP group. After propensity score matching, there were a total of 638 patients, with 319 patients in each group. The bloodless priming rate was significantly higher (Pâ=â.013), and the ultrafiltration rate was significantly lower (Pâ=â.003) in the RAP group than in the non-RAP group. Compared with patients in the non-RAP group, patients in the RAP group had a shorter postoperative mechanical ventilation time (Pâ<â.001) and shorter lengths of stay in the intensive care unit (ICU) (Pâ<â.001) and the hospital (Pâ<â.001). No differences were noted in postoperative hematocrit (Pâ=â.920), postoperative 24-hour blood loss (Pâ=â.435), and hospital mortality (Pâ=â.563). In the stratified analysis, the difference remained statistically significant (Pâ<â.05) when the patient weight was >4âkg or the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery (STAT) category was <3. However, when the patient weight was ≤4âkg or the STAT category was ≥3, there was no significant difference between the 2 groups in terms of bloodless priming, ultrafiltration, postoperative mechanical ventilation time, or length of stay in the ICU or the hospital (Pâ>â.05).The RAP technique based on miniaturized CPB system was safe and effective for children who underwent congenital heart surgery. The RAP technique can significantly reduce the priming volume, improve the rate of bloodless priming, and reduce blood product application. It was also associated with a shorter postoperative mechanical ventilation time and shorter lengths of stay in the ICU and the hospital.
Assuntos
Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Ponte Cardiopulmonar/métodos , Ponte Cardiopulmonar/estatística & dados numéricos , Feminino , Cardiopatias Congênitas/cirurgia , Humanos , Lactente , Masculino , Estudos RetrospectivosRESUMO
The use of extracorporeal membrane oxygenator instead of standard cardiopulmonary bypass during lung transplantation is debatable. Moreover, recently, the concept of prolonged postoperative extracorporeal membrane oxygenator (ECMO) support has been introduced in many transplant centers to prevent primary graft dysfunction (PGD) and improve early and long-term results. The objective of this study was to review the results of our extracorporeal life support strategy during and after bilateral sequential lung transplantation (BSLT) for pulmonary artery hypertension. We review retrospectively our experience in BSLT for pulmonary artery hypertension between January 2010 and August 2018. A total of 38 patients were identified. Nine patients were transplanted using cardiopulmonary bypass (CPB), in eight cases CPB was followed by a prolonged ECMO (pECMO) support, 14 patients were transplanted on central ECMO support, and seven patients were transplanted with central ECMO support followed by a pECMO assistance. The effects of different support strategies were evaluated, in particular in-hospital morbidity, mortality, incidence of PGD, and long-term follow-up. The use of CPB was associated with poor postoperative results and worse long-term survival compared with ECMO-supported patients. Predictive preoperative factors for the need of intraoperative CPB instead of ECMO were identified. The pECMO strategy had a favorable effect to mitigate postoperative morbidity and mortality, not only in intraoperative ECMO-supported patients, but even in CPB-supported cases. In our experience, ECMO may be considered as the first choice circulatory support for lung transplantation. Sometimes, in very complex cases, CBP is still necessary. The pECMO strategy is very effective to reduce incidence of PGD even in CPB-supported patients.
Assuntos
Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Cuidados Intraoperatórios/métodos , Transplante de Pulmão/efeitos adversos , Cuidados Pós-Operatórios/métodos , Disfunção Primária do Enxerto/epidemiologia , Hipertensão Arterial Pulmonar/cirurgia , Adulto , Ponte Cardiopulmonar/estatística & dados numéricos , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Incidência , Cuidados Intraoperatórios/estatística & dados numéricos , Transplante de Pulmão/métodos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/estatística & dados numéricos , Disfunção Primária do Enxerto/etiologia , Disfunção Primária do Enxerto/prevenção & controle , Hipertensão Arterial Pulmonar/mortalidade , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: To report the early and mid-term results of patients who underwent minimally invasive aortic valve replacement (MI-AVR) with a sutureless prosthesis from an international prospective registry. METHODS: Between March 2011 and September 2018, among 957 patients included in the prospective observational SURE-AVR (Sorin Universal REgistry on Aortic Valve Replacement) registry, 480 patients underwent MI-AVR with self-expandable Perceval aortic bioprosthesis (LivaNova PLC, London, UK) in 29 international institutions through either minithoracotomy (n = 266) or ministernotomy (n = 214). Postoperative, follow-up, and echocardiographic outcomes were analyzed for all patients. RESULTS: Patient age was 76.1 ± 7.1 years; 64.4% were female. Median EuroSCORE I was 7.9% (interquartile range [IQR], 4.8 to 10.9). Median cardiopulmonary bypass and cross-clamp times were 81 minutes (IQR 64 to 100) and 51 minutes (IQR 40 to 63). First successful implantation was achieved in 97.9% of cases. Two in-hospital deaths occurred, 1 for noncardiovascular causes and 1 following a disabling stroke. In the early (≤30 days) period, stroke rate was 1.4%. Three early explants were reported: 2 due to nonstructural valve dysfunction (NSVD) and 1 for malpositioning. One mild and 1 moderate paravalvular leak were reported. In 16 patients (3.3%) pacemaker implantation was needed. Mean follow-up was 2.4 years (maximum = 7 years). During follow-up 5 explants were reported, 3 due to endocarditis and 2 due to NSVD. Follow-up stroke rate was 2.5%. Three structural valve deteriorations not requiring reintervention were reported. Five-year survival was 91.45%. CONCLUSIONS: In this large prospective international registry, MI-AVR with Perceval valve confirmed to be safe, reproducible, and effective in an intermediate-risk population, providing excellent clinical recovery both in early and mid-term follow-up.
Assuntos
Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos sem Sutura/métodos , Idoso , Idoso de 80 Anos ou mais , Bioprótese , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/estatística & dados numéricos , Ecocardiografia/métodos , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Humanos , Masculino , Estudos Prospectivos , Desenho de Prótese/tendências , Sistema de Registros , Procedimentos Cirúrgicos sem Sutura/estatística & dados numéricos , Resultado do TratamentoRESUMO
BACKGROUND: The outcome of open-heart surgery for patients with liver cirrhosis (LC) varies widely, indicating multifactorial influences on liver injury after cardiopulmonary bypass (CPB). METHODS: This observational single center study evaluated adult LC patients receiving open heart surgery with CPB during 2007 and 2017. The primary endpoint was post-operative hypoxic hepatitis (POHH), defined by post-operative serum glutamate oxaloacetate transaminase and glutamate pyruvate transaminase more than 10 times the pre-operative value. RESULTS: In total, 61 patients were included in the study, of whom 14 (18.7%) developed POHH. Hospital mortality of non-POHH group (4.3%) was similar to that estimated using Euroscore II (4.0%), but that of the POHH group (21.4%) was 2.7 times as that estimated using Euroscore II (8.0%). Model for End-Stage Liver Disease (MELD) score and CPB duration were found as independent risk factors for POHH by multivariate logistic regression. POHH incidence was 0.0% if MELD <5 and 80.0% of MELD >20 regardless of CPB duration. For those with MELD between 5 and 20, POHH incidence increases as CPB duration increases. CONCLUSION: For LC patients undergoing cardiac surgery with CPB, the incidence of POHH is highly associated with MELD score and CPB duration. To prevent POHH, the CPB duration should be shortened for those with MELD score between 5 and 20, and CPB be avoid for those with MELD >20.
Assuntos
Ponte Cardiopulmonar/estatística & dados numéricos , Doença Hepática Terminal/mortalidade , Cardiopatias/cirurgia , Hepatite/etiologia , Cirrose Hepática/mortalidade , Adulto , Idoso , Ponte Cardiopulmonar/efeitos adversos , Doença Hepática Terminal/diagnóstico , Feminino , Cardiopatias/complicações , Cardiopatias/mortalidade , Mortalidade Hospitalar , Humanos , Cirrose Hepática/complicações , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Taiwan , Resultado do TratamentoRESUMO
OBJECTIVE: Malnutrition is known to affect postoperative outcomes, but only a limited number of assessment methods are available for evaluating nutritional status before cardiac surgery. The purpose of this study was to investigate the clinical significance of the prognostic nutritional index for adult patients undergoing cardiac surgery. METHODS: We retrospectively reviewed the medical records of 374 patients aged more than 18 years who underwent cardiac surgery with cardiopulmonary bypass. Patients were divided into 2 groups based on the cutoff prognostic nutritional index, and these groups were compared with respect to early morbidity and mortality rates, intensive care unit stays, and long-term outcomes. Logistic regression analyses were performed to identify the risk factors of early outcomes. RESULTS: The calculated cutoff value of the prognostic nutritional index was 46.13. Early mortality and morbidity were significantly more common in the high-risk group (9.0% vs 2.9%: P = .02, 58.0% vs 42.0%: P = .01). The median duration of mechanical ventilation support (18.0 vs 16.0 hours: P < .01) and intensive care unit stays (3.0 vs 2.0 days: P < .01) were also longer in the high-risk group. However, no significant intergroup difference was observed for the long-term clinical outcomes. Multivariate analysis showed that the prognostic nutritional index, age, cardiopulmonary bypass time, and aortic crossclamp time independently predicted early outcomes. Of these, only the prognostic nutritional index and age were significant preoperative variables (P = .01 and P < .01). CONCLUSIONS: The prognostic nutritional index may be a useful preoperative nutrition screening tool for predicting the early clinical outcomes of adult patients after cardiac surgery using cardiopulmonary bypass.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Estado Nutricional/fisiologia , Adulto , Idoso , Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Ponte Cardiopulmonar/mortalidade , Ponte Cardiopulmonar/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Thrombocytopenia is a risk factor for morbidity and mortality in critically ill patients, and is common after cardiopulmonary bypass (CPB). In this study, we evaluate whether thrombocytopenia after CPB is an independent risk factor for postoperative morbidity and mortality. METHODS: We retrospectively evaluated 1364 patients requiring CPB at the University of Colorado Hospital between January 2011 and May 2016. Platelet nadir, absolute change in platelets, and percent change in platelets were modeled as continuous variables. Patients with postoperative thrombocytopenia (defined a nadir <75 × 103/µL within 72 hours) were also compared with patients without thrombocytopenia in a propensity-matched model. The primary outcome was in-hospital mortality, and secondary outcomes included postoperative infection, postoperative acute kidney injury (AKI), postoperative stroke, and prolonged intensive care unit (ICU) and hospital lengths of stay (LOS). RESULTS: Postoperative thrombocytopenia occurred in 356 (26.0%) patients. In multivariable analysis, platelet nadir was significantly inversely associated with mortality (odds ratio [OR], 0.955; 95% confidence interval [CI], 0.934-0.975; P < .001), postoperative infection (OR, 0.992; 95% CI, 0.986-0.999; P = .03), AKI (all stage) (OR, 0.993; 95% CI, 0.988-0.998; P = .01), AKI (stage 3) (OR, 0.966; 95% CI, 0.951-0.982; P < .001), postoperative stroke (OR, 0.974; 95% CI, 0.956-0.992; P = .006), prolonged ICU stay (OR, 0.986; 95% CI, 0.981-0.991; P < .001), and hospital LOS (OR, 0.998; 95% CI, 0.997-0.999; P = .001). Percent change in platelets from baseline was also significantly associated with all primary and secondary outcomes. CONCLUSIONS: Postoperative thrombocytopenia is independently associated with postoperative mortality, AKI, infection, stroke, and prolonged ICU and hospital LOS. Serial platelet monitoring may help identify patients at higher risk of postoperative complications. Further studies investigating strategies to reduce postoperative thrombocytopenia, including reducing CPB time, are needed.
Assuntos
Ponte Cardiopulmonar , Mortalidade Hospitalar , Complicações Pós-Operatórias/epidemiologia , Trombocitopenia/epidemiologia , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Distribuição por Idade , Idoso , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Ponte Cardiopulmonar/estatística & dados numéricos , Comorbidade , Diabetes Mellitus/epidemiologia , Feminino , Insuficiência Cardíaca/epidemiologia , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Distribuição por Sexo , Fumar/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Abuso de Substâncias por Via Intravenosa/epidemiologia , Trombocitopenia/etiologiaRESUMO
Risk-averse behavior has been reported among physicians and facilities treating cardiogenic shock in states with public reporting. Our objective was to evaluate if public reporting leads to a lower use of mechanical circulatory support in cardiogenic shock. We conducted a retrospective study with the use of the National Inpatient Sample from 2005 to 2011. Hospitalizations of patients ≥18 years old with a diagnosis of cardiogenic shock were included. A regional comparison was performed to identify differences between reporting and nonreporting states. The main outcome of interest was the use of mechanical circulatory support. A total of 13043 hospitalizations for cardiogenic shock were identified of which 9664 occurred in reporting and 3379 in nonreporting states (age 69.9 ± 0.4 years, 56.8% men). Use of mechanical circulatory support was 32.8% in this high-risk population. Odds of receiving mechanical circulatory support were lower (OR 0.50; 95% CI 0.43-0.57; p < 0.01) and in-hospital mortality higher (OR 1.19; 95% CI 1.06-1.34; p < 0.01) in reporting states. Use of mechanical circulatory support was also lower in the subgroup of patients with acute myocardial infarction and cardiogenic shock in reporting states (OR 0.61; 95% CI 0.51-0.72; p < 0.01). In conclusion, patients with cardiogenic shock in reporting states are less likely to receive mechanical circulatory support than patients in nonreporting states.
Assuntos
Circulação Assistida/estatística & dados numéricos , Ponte Cardiopulmonar/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Registros Públicos de Dados de Cuidados de Saúde , Choque Cardiogênico/terapia , Idoso , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Masculino , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Estudos Retrospectivos , Choque Cardiogênico/mortalidade , Estados Unidos/epidemiologiaRESUMO
Background The presence of a durable left ventricular assist device (LVAD) is associated with increased risk of vasoplegia in the early postoperative period following heart transplantation (HT). However, preoperative predictors of vasoplegia and its impact on survival after HT are unknown. We sought to examine predictors and outcomes of patients who develop vasoplegia after HT following bridging therapy with an LVAD. Methods and Results We identified 94 patients who underwent HT after bridging with continuous-flow LVAD from 2008 to 2018 at a single institution. Vasoplegia was defined as persistent low vascular resistance requiring ≥2 intravenous vasopressors within 48 hours after HT for >24 hours to maintain mean arterial pressure >70 mm Hg. Overall, 44 patients (46.8%) developed vasoplegia after HT. Patients with and without vasoplegia had similar preoperative LVAD, echocardiographic, and hemodynamic parameters. Patients with vasoplegia were significantly older; had longer LVAD support, higher preoperative creatinine, longer cardiopulmonary bypass time, and higher Charlson comorbidity index; and more often underwent combined organ transplantation. In a multivariate logistic regression model, older age (odds ratio: 1.08 per year; P=0.010), longer LVAD support (odds ratio: 1.06 per month; P=0.007), higher creatinine (odds ratio: 3.9 per 1 mg/dL; P=0.039), and longer cardiopulmonary bypass time (odds ratio: 1.83 per hour; P=0.044) were independent predictors of vasoplegia. After mean follow-up of 4.0 years after HT, vasoplegia was associated with increased risk of all-cause mortality (hazard ratio: 5.20; 95% CI, 1.71-19.28; P=0.003). Conclusions Older age, longer LVAD support, impaired renal function, and prolonged intraoperative CPB time are independent predictors of vasoplegia in patients undergoing HT after LVAD bridging. Vasoplegia is associated with worse prognosis; therefore, detailed assessment of these predictors can be clinically important.
Assuntos
Insuficiência Cardíaca/terapia , Transplante de Coração , Coração Auxiliar , Complicações Pós-Operatórias/epidemiologia , Vasoplegia/epidemiologia , Adulto , Fatores Etários , Idoso , Cardiomiopatia Dilatada/complicações , Ponte Cardiopulmonar/estatística & dados numéricos , Causas de Morte , Comorbidade , Creatinina/sangue , Feminino , Cardiopatias Congênitas/complicações , Insuficiência Cardíaca/etiologia , Humanos , Transplante de Rim/estatística & dados numéricos , Transplante de Fígado/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Mortalidade , Análise Multivariada , Isquemia Miocárdica/complicações , Duração da Cirurgia , Modelos de Riscos Proporcionais , Fatores de Risco , Taxa de Sobrevida , Doenças da Glândula Tireoide/epidemiologia , Fatores de TempoRESUMO
PURPOSE: Data on the benefit or or harmful effects of oxygen level on ischemic reperfusion injuries in cardiac surgery are insufficient. We hypothesized that hyperoxia during cardiopulmonary bypass decreases the incidence of postoperative atrial fibrillation (POAF) and ventricular fibrillation, and therefore decreases cardiovascular morbidity (CARDIOX study). METHODS: An open-label, randomized clinical trial including adults undergoing elective cardiac surgery, i.e. cardiopulmonary bypass (CPB) randomized 1:1 to an intervention group or standard group at two French University Hospitals from June 2016 to October 2018. The intervention consisted in delivering of an inspired fraction of oxygen of one to one during CPB. The standard care consisted in delivering oxygen to achieve a partial arterial blood pressure less than 150 mmHg. The primary endpoint was the occurrence of POAF and/or ventricular tachycardia/ventricular fibrillation (VT/VF) within the 15 days following cardiac surgery. The secondary endpoint was the occurrence of major adverse cardiovascular events (MACCE: in-hospital mortality, stroke, cardiac arrest, acute kidney injury, and mesenteric ischemia). RESULTS: 330 patients were randomly assigned to either the intervention group (n = 161) or the standard group (n = 163). Mean PaO2 was 447 ± 98 mmHg and 161 ± 60 mmHg during CPB, for the intervention and standard group (p < 0.0001) respectively. The incidence of POAF or VT/VF were similar in the intervention group and the standard group (30% [49 of 161 patients] and 30% [49 of 163 patients], absolute risk reduction 0.4%; 95% CI, - 9.6-10.4; p = 0.94). MACCE was similar between groups with, an occurrence of 24% and 21% for the intervention group and the standard groups (absolute risk reduction 3.4%; 95% CI, - 5.7-12.5; p = 0.47) respectively. After adjustment, the primary and secondary endpoints remained similar for both groups. CONCLUSION: Hyperoxia did not decrease POAF and cardiovascular morbidity following cardiac surgery with CPB. CLINICALTRIAL. GOV IDENTIFIER: NCT02819739.
Assuntos
Ponte Cardiopulmonar/normas , Doenças Cardiovasculares/etiologia , Hiperóxia/complicações , Idoso , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/etiologia , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/métodos , Ponte Cardiopulmonar/estatística & dados numéricos , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/cirurgia , Feminino , França/epidemiologia , Humanos , Hiperóxia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Oxigênio/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Período Pós-OperatórioRESUMO
OBJECTIVE: To delineate the efficacy and safety of transthoracic cannulation to the ascending aorta through a right pleural cavity during minimally invasive cardiac surgery (MICS). METHODS: We retrospectively assessed the records of 104 patients who underwent MICS in our institution between December 2011 and December 2018. Procedures included mitral valve repair (88 patients), aortic valve replacement (8 patients), atrial septal defect closure (6 patients), and myxoma resection (2 patients). Aortic valve replacements were performed through the third intercostal space (ICS), whereas the other procedures were mainly performed through the fourth ICS. The femoral group comprised 60 patients in whom an artificial graft was anastomosed to the femoral artery and 4 who underwent cannulation into the femoral artery. The aorta group comprised 40 patients in whom transthoracic cannulation was performed through the second or third ICS, separate from the main skin incision. RESULTS: No mortality or critical complications were associated with cardiopulmonary bypass. Perfusion pressure measured at outflow of the artificial lung (224 ± 43 vs. 190 ± 42; P < 0.001) and pump pressure measured at the outflow of the pump (293 ± 50 vs. 255 ± 57; P < 0.001) were significantly higher in the femoral group than in the aorta group. The skin incision lengths were similar (56.9 ± 6.9 vs. 55.1 ± 6.0 mm; P = 0.107). CONCLUSIONS: Transthoracic cannulation into the ascending aorta is reliable and can be safely performed. The possible risks associated with peripheral cannulation and retrograde perfusion can be avoided thereafter.
Assuntos
Aorta/cirurgia , Procedimentos Cirúrgicos Cardíacos/instrumentação , Cateterismo/métodos , Artéria Femoral/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Idoso , Ponte Cardiopulmonar/métodos , Ponte Cardiopulmonar/estatística & dados numéricos , Cateterismo/efeitos adversos , Feminino , Átrios do Coração/cirurgia , Neoplasias Cardíacas/cirurgia , Comunicação Interatrial/cirurgia , Próteses Valvulares Cardíacas/efeitos adversos , Valvas Cardíacas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Mixoma/cirurgia , Perfusão/métodos , Perfusão/tendências , Pressão/efeitos adversos , Estudos Retrospectivos , Segurança , Ferida Cirúrgica/epidemiologia , Resultado do TratamentoRESUMO
OBJECTIVES: To study the incidence of acute kidney injury (AKI) in the postoperative period of cardiac surgery in patients without preoperative renal insufficiency who underwent cardiac surgery with cardiopulmonary bypass (CPB), and to explore the association between the incidence of AKI and predictors related to CPB. METHODS: Observational, cross-sectional study. Participants were divided in two groups, those who developed AKI in the postoperative period and those who did not develop AKI. Kidney Disease: Improving Global Outcomes - Clinical Practice Guideline for Acute Kidney Injury (KDIGO) classification was used to characterize AKI. The analysis included preoperative variables (anthropometric data, cardiovascular risk factors and blood parameters), as well as the type of surgery, intraoperative variables related to CPB, and postoperative creatinine variation. Association between variables was studied with binary logistic regression. RESULTS: We have included 329 patients, of which 62 (19%), developed AKI. There were statistically significant differences between the groups in age (p<0.001; OR (95%)-1.075 (1.037-1.114)), duration of CPB (p=0.011; 1.008 (1.002-1.014)), urine output during CPB (p=0.038; 0.998 (0.996-0.999)), mannitol and furosemide administration during CPB, (respectively, p=0.032; 2.293 (1.075-4.890) and p=0.013; 2.535 (1.214-5.296)). CONCLUSIONS: A significant number of patients developed AKI in the postoperative period of cardiac surgery and this incidence was influenced by factors related to CPB, namely: age, duration of CPB, urine output during CPB, mannitol and furosemide administration during CPB.
Assuntos
Injúria Renal Aguda/etiologia , Ponte Cardiopulmonar/efeitos adversos , Injúria Renal Aguda/epidemiologia , Ponte Cardiopulmonar/estatística & dados numéricos , Estudos Transversais , Humanos , Incidência , Prognóstico , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Acute kidney injury (AKI) following open aortic arch surgery is a frequent complication associated with increased morbidity and mortality. The primary purpose of this study was to evaluate risk factors for postoperative AKI in patients who underwent open aortic arch surgery utilizing hypothermic circulatory arrest (HCA). MATERIALS AND METHODS: Included were 295 patients undergoing surgery between January 2011 and March 2018. AKI was defined according to Kidney Disease: Improving Global Outcomes guidelines. Preoperative and intraoperative variables were stratified by no AKI versus any AKI, and bivariate analysis was performed. Multivariable logistic regression analysis used statistically and clinically significant characteristics from the bivariate analysis. RESULTS: Of the 295 patients, 93 (32%) developed AKI. In the bivariate analysis, significant predictors of AKI included the following: history of hypertension (P < 0.001), diabetes (P = 0.03), operative urgency (P = 0.009), cardiopulmonary bypass (CPB) time (P < 0.0001), HCA time (0.02), total intraoperative transfusions (P = 0.002), and concomitant procedures (coronary artery bypass grafting, or mitral/tricuspid interventions, P = 0.0009). In the multivariable analysis, significant predictors of AKI were history of hypertension (P = 0.03) and CPB time (P = 0.02). Age, operative urgency, circulatory arrest time, and any intraoperative transfusion were not significant in the multivariable analysis. CONCLUSION: In conclusion, given that CPB time is the only modifiable risk factor identified in the analysis, approaches to reducing bypass time should continue to be the focus of decreasing risk for postoperative AKI in HCA cases.
Assuntos
Injúria Renal Aguda/diagnóstico , Aorta Torácica/cirurgia , Ponte Cardiopulmonar/efeitos adversos , Parada Circulatória Induzida por Hipotermia Profunda/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Adulto , Idoso , Transfusão de Sangue/estatística & dados numéricos , Ponte Cardiopulmonar/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Prognóstico , Estudos Retrospectivos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Central venous catheter (CVC) use is common in the management of critically ill children, especially those with congenital heart disease. CVCs are known to augment the risk of deep vein thrombosis (DVT), but data on CVC-associated DVTs in the pediatric cardiac intensive care unit (CICU) are limited. In this study, we aim to identify the incidence of and risk factors for CVC-related DVT in this high-risk population, as its complications are highly morbid. MATERIALS AND METHODS: The PC4 database and a radiologic imaging database were retrospectively reviewed for the demographics and outcomes of patients admitted to the Texas Children's Hospital CICU requiring CVC placement, as well as the incidence of DVT and its complications. RESULTS: Between January 2017 and December 2017, 1215 central lines were placed over 851 admissions. DVT was diagnosed in 8% of admissions with a CVC, 29% of which demonstrated thrombus in the inferior vena cava. The risk factors significantly associated with DVT included the presence of >1 line, higher total line hours, longer intubation times, and extended CICU stay. A diagnosis of low cardiac output syndrome, sepsis, central line-associated bloodstream infection, and cardiac catheterization were also significant risk factors. Interestingly, cardiac surgery with cardiopulmonary bypass appeared to be protective of clot development. DVT was a highly significant risk factor for mortality in these patients. CONCLUSIONS: CVC-related DVTs in critically ill children with congenital heart disease are associated with higher risks of morbidity and mortality, highlighting the need for well-designed studies to determine the best preventative and treatment strategies and to establish guidelines for appropriate monitoring and follow-up of these patients.
Assuntos
Cateterismo Venoso Central/efeitos adversos , Cardiopatias Congênitas/cirurgia , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Trombose Venosa/epidemiologia , Ponte Cardiopulmonar/estatística & dados numéricos , Cateterismo Venoso Central/instrumentação , Cateterismo Venoso Central/métodos , Cateteres Venosos Centrais/efeitos adversos , Criança , Pré-Escolar , Feminino , Cardiopatias Congênitas/mortalidade , Humanos , Incidência , Lactente , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo , Trombose Venosa/etiologiaRESUMO
PURPOSE: Children with complex congenital heart disease (CHD) experience high incidence of perioperative seizures. Population-based studies also report high epilepsy co-morbidity in CHD. Given the increasing survival of patients with CHD and the interference of seizures and epilepsy with the long-term outcomes, characterizing them in this population is of high relevance. This study investigated the incidence and risk factors of perioperative clinical seizures (CS) and epilepsy in a prospective cohort of children with complex CHD who underwent cardiac surgery. METHODS: We included 128 consecutive children with CHD, followed for at least two years at the neurocardiac clinic of Montreal's Sainte-Justine University Hospital Center. We collected perinatal, surgical, critical care and clinical follow-up information and performed logistic regression to reveal risk factors of CS and epilepsy. RESULTS: Ten patients (7.8%) experienced perioperative CS. Four of them (40%) developed epilepsy. The incidence of epilepsy was therefore 3.1%. Higher surgical complexity scores, delayed sternal closure, extracorporeal membrane oxygenation (ECMO) use, longer intensive care and hospital stay were associated with CS. ECMO use and hospital stay were also associated with epilepsy. Nine (90%) patients with CS had brain injuries: five strokes, one white matter and three hypoxic-ischemic injury (HII). All patients with HII developed epilepsy, which became intractable in one of them. CONCLUSION: Our study reports high incidence, surgical risk factors and brain injury patterns underlying CS and epilepsy in CHD. Further studies are needed to investigate how epilepsy interferes with neurodevelopment and quality of life in CHD.