A pathway to earlier discharge following TAVI: Assessment of safety and resource utilization.

INTRODUCTION: There is considerable variability within the population of patients treated with transcatheter aortic valve implantation (TAVI), the procedural approach and time to discharge. In Belfast, from the commencement of our program, our approach has been to perform TAVI by the least invasive approach, where feasible, utilizing a percutaneous transfemoral route and local anesthetic. By analyzing our Belfast TAVI database we identified factors that predicted shorter admission times without impacting adversely on patient safety. Following this, we developed an early discharge pathway. The aim of this current study was to perform a prospective analysis of outcomes in our unit since implementation of this pathway assessing discharge time, mortality, serious adverse events, readmission, and resource implications for patients according to time to discharge. METHODS: Consecutive patients who underwent TAVI and were successfully discharged from 2013 to 2014 over a 14 month period were included, and analyzed according to time to discharge. Baseline and procedural characteristics, mortality, serious adverse events, readmission, and cost were assessed. RESULTS: In total 120 patients were included, 26 (21.7%) were discharged the same/next day, 39 (32.5%) early (>1-4 days), and 55 (45.8%) discharged in the late group. There was no significant difference in baseline or preprocedural characteristics. The incidence of complications was low, and there was no difference in 30-day mortality (P = 0.167) or readmission rates between groups (P = 0.952). Resource analysis revealed the late discharge group cost £3,091.6 more per patient per TAVI than same/next day discharge group. CONCLUSION: Same/next day discharge can be performed safely in appropriately selected patients. Although this will be achieved in a minority of patients (21.7% in this study using an early discharge pathway) it has potential for resource and cost savings. © 2015 Wiley Periodicals, Inc.

Device-related atypical pressure ulcer after cardiac surgery.

Medical devices must be closely monitored to prevent harm to patients. Pressure ulcers secondary to medical devices present a significant health burden in terms of length of stay in hospital and cost. Intensivists, anaesthetists and other professionals involved in managing critically ill patients following cardiac surgery need to be aware that pressure ulcers may develop in atypical sites and present at a later stage of the hospital stay. This case report highlights the important issue of device-related pressure ulcers in the cardiac surgical intensive care setting, particularly when the clinical status of the patient may preclude routine assessment and prophylaxis. An algorithm for preventing such pressure ulcers is suggested.

Benefits of the preemptive intra-aortic balloon pump: an audit of practice in a regional cardiothoracic center.

BACKGROUND: Recent evidence suggests that preemptive use of an intra-aortic balloon pump (IABP) is associated with better outcomes in high-risk patients undergoing cardiac surgery. This retrospective study compares preemptive (planned) use of the IABP to emergency (unplanned) use in a regional cardiothoracic center. METHODS: All patients who required an IABP from February 2003 to June 2006 were identified from theater records. The collected data included patient demographics, preoperative state, operative details, morbidity due to the IABP, and operative mortality. Patients were divided into 2 groups: planned use (preoperative plus elective intraoperative) and unplanned use (postoperative plus emergency intraoperative). Preoperative mortality risk was calculated with the logistic EuroSCORE. RESULTS: We identified 135 patients (75% male). There were no significant differences between the groups with respect to age, preoperative state, operation type, logistic EuroSCORE, or myocardial ischemia time. The 2 groups showed a significant difference in mortality: planned IABP insertion, 17%; unplanned insertion, 45% (P = .001). A multivariate analysis of the study population showed the logistic EuroSCORE (odds ratio, 0.974; 95% confidence interval, 0.950-0.998; P = .035) and timing of IABP use (odds ratio, 4.728; 95% confidence interval, 1.932-11.566; P = .001) to be independent predictors of mortality. CONCLUSION: Preemptive use of the IABP in this patient cohort was associated with a 50% advantage in mortality compared with emergency IABP use. The logistic EuroSCORE may be used preoperatively to guide IABP use. Complications are rare and can be treated successfully. The risk-to-benefit ratio of preemptive IABP use is low in this cohort of patients.

Radical excision of invasive thymoma with intracardiac extension.

A patient with a low grade malignant thymoma who also had pleural, pericardial and cardiac invasion with intracardiac extension, presented with signs of superior vena cava obstruction, moderate hepatosplenomegaly and a mediastinal mass on a plain chest radiograph. Radical excision requiring cardiopulmonary bypass for the removal of the intracardiac extension into the right atrium was performed. Despite the patient's failure to receive radiotherapy treatment, he was alive one year after surgery. This case is reported because this mode of presentation of intracardiac extension of a thymoma is uncommon and because only this method of radical excision could ensure near-total removal of the mass and prevent early death from cardiovascular complications.

Factors predicting loss and gain of red cell volume in cardiac surgery patients.

Haemoglobin may be a poor indicator of changes in red cell volume (RCV) because of factors such as haemodilution. This study has been designed to analyse what peri-operative variables may be associated with loss or gain in RCV due to bleeding or transfusion. Prospective observational study. Single centre study based in a regional cardiac surgery centre. Twenty-nine elective adult cardiac surgery patients. Loss and gain of RCV were measured in theatre and for the first 24 h post-operatively. Patient and operative factors analysed were age, sex, height, weight, body surface area (BSA), induction haematocrit (Hct), estimated pre-operative RCV and antiplatelet therapy taken less than 7 days before operation, cardiopulmonary bypass (CPB) time, aortic occlusion time, minimum and maximum CPB temperatures and fluid administered. Age, sex, height, weight, BSA and induction Hct were found to predict red cell transfusion but not RCV loss. The total number of red cells transfused was significantly associated with RCV lost when expressed as a percentage reduction in the estimated pre-operative RCV but not the absolute RCV lost. Pre-operative RCV, as predicted by the variables outlined above, is more important than RCV lost in triggering red cell transfusion.

Cor triatriatum sinister presenting in the adult as mitral stenosis.

Cor triatriatum sinister is a rare congenital defect in which the left atrium is divided by a fibromuscular membrane into two distinct chambers. Classically, patients present in infancy although in some cases they remain asymptomatic until adulthood. The clinical features on presentation can mimic those of mitral stenosis due to the obstructive properties of the membrane. Cor triatriatum sinister presented in this case in an adult as mitral stenosis. Factors that may be relevant in determining late presentation are also discussed.

Non-invasive assessment of bleeding pulmonary artery aneurysms due to Behçet disease.

Because of its ability to depict intravascular, intramural, and extramural pathology, non-invasive imaging is well suited to assessing life-threatening hemoptysis that may complicate Behçet disease. We made exclusive use of CT angiography supplemented by MR to identify pulmonary thromboembolism, mediastinal lymphadenopathy, and bilateral pulmonary artery aneurysms with signs of previous unilateral rupture. Two-dimensional reformatted CT images provided surgeons with a road map of upstream and downstream vascular relationships prior to aneurysm resection. Imaging findings were confirmed by surgery and pathology. Non-invasive imaging proved to be a useful alternative to standard catheter arteriography in the preoperative assessment of hemoptysis in this patient with Behçet disease.