Jugular venous congestion during off-pump lung transplantation is not associated with an increased risk of postoperative delirium.

INTRODUCTION: Delirium occurs frequently after lung transplantation and is associated with poor clinical outcomes. Significantly prolonged jugular venous congestion (JVC) occurs during off-pump lung transplantation and is thought to impair cerebral perfusion. Our study aimed to test the hypothesis that increased intraoperative JVC is associated with an increased risk of postoperative delirium among lung transplantation recipients. METHODS: This is a retrospective observational cohort study. Adult patients who received off-pump lung transplantation at the Vanderbilt University Medical Center between 2006 and 2016 are included. The magnitude of JVC was calculated by the area under the curve (AUC) of the central venous pressure (CVP) above the threshold of 12 mmHg. Postoperative delirium was assessed by Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) criteria during their ICU stay. Multivariate regression analysis was used to determine the association of intraoperative JVC with postoperative delirium, adjusting for baseline demographics, surgical, and intraoperative characteristics. RESULTS: Thirty-two (23.5%) out of 136 patients developed delirium in the ICU. There was no statistical difference in terms of intraoperative JVC between patients with delirium and those without (4058 ± 6650 vs. 3495 ± 10 151 mmHg min; p = .772). Furthermore, during multivariate regression analysis, JVC was not associated with an increased risk of delirium (odds ratio: 1.03 per 100 mmHg min increase in venous congestion; 95% confidence interval: .31, 3.39; p = .96). CONCLUSIONS: Delirium occurred frequently after off-pump lung transplantation. Although physiologically plausible, the present study did not find an association between increased JVC during off-pump lung transplantation and an increased risk of postoperative delirium.

Transcatheter and Surgical Aortic Valve Replacement Outcomes for Patients with Chronic Heart Failure.

OBJECTIVES: To determine in-hospital outcomes and assess high-risk groups among chronic heart failure (CHF) patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). DESIGN: A retrospective analysis of the Nationwide Inpatient Sample database from January 2012 to September 2015 was performed. SETTING: Hospitals across the United States that offer TAVRs or SAVRs. PARTICIPANTS: Adults with a diagnosis of CHF and AS. INTERVENTIONS: The patients underwent either TAVR or SAVR. MEASUREMENTS AND MAIN RESULTS: Totals of 5,871 and 4,008 CHF patients underwent TAVR and SAVR, respectively. TAVR patients were significantly older, more were female, and had a higher comorbidity burden. No significant differences in in-hospital mortality were noted between TAVR and SAVR. However, mean length of stay was significantly longer by 3.5 days in the SAVR group, as was the mean total cost. With the exception of complete heart block, permanent pacemaker implantation, and vascular complications, the majority of postoperative events were higher among the SAVR group. Multivariate regression analysis identified postoperative cardiac, respiratory and renal complications as significant predictors of in-hospital mortality for both groups. Additionally, age ≥75 years and vascular complications were significant predictors of mortality for patients undergoing TAVR. CONCLUSIONS: Among CHF patients with symptomatic AS, TAVR had similar in-hospital mortality rate compared with SAVR despite higher comorbidity burden. TAVR patients are at a lower risk of cardiovascular, respiratory, and renal complications and might lead to reduced length of hospital stay and cost. Hence, TAVR may be a safer option in this population.

Assessment of a multimodal analgesia protocol to allow the implementation of enhanced recovery after cardiac surgery: Retrospective analysis of patient outcomes.

STUDY OBJECTIVE: To investigate the impact of utilizing a multimodal analgesia protocol to allow the implementation of Enhanced Recovery after Cardiac Surgery (ERACS) in patients requiring cardio-pulmonary bypass. DESIGN: Retrospective analysis of patients treated with the proposed ERACS bundle in comparison to matched controls. SETTING: Single-center study. PATIENTS: A total of 50 patients undergoing elective cardiac surgery limited to on pump coronary artery bypass graft. MEASUREMENTS: Perioperative outcomes of 25 patients that underwent ERACS protocol and 25 controls were measured. In-operating room (OR) extubation, total intubation time, total intra-OP fentanyl given, total post-OP morphine equivalent given, intensive care unit (ICU) length of stay (LOS), hospital LOS and post-OP complications were examined. MAIN RESULTS: The ERACS group and control group were equivalent with regards to age, gender, comorbidities, ASA classification and type of surgery. Mean cardiac bypass time and mean aortic clamp time were similar. Extubation in the OR was achieved for 12 patients in the ERACS group compared to 1 in the control group. Post-operative opioid consumption was lower in ERACS group (27.3 vs. 51.7 morphine equivalents, p = 0.006). Although ICU LOS and hospital LOS were shorter in the ERACS group, this did not reach significance. CONCLUSIONS: The ERACS group showed a significant decrease in opioid use and increased incidence of successful in OR extubation.

Systolic anterior motion of the mitral valve after aortic valve replacement.

We present a case of severe systolic anterior motion developing intraoperatively after aortic valve replacement for aortic valve stenosis.

Intraoperative assessment of pulmonary artery pressure using transesophageal echocardiography in patients undergoing cardiac surgery.

We performed a retrospective chart review to investigate a potential relation between pulmonary artery (PA) diameter as measured by intraoperative transesophageal echocardiography and PA pressures measured by PA catheter with the aim of determining whether main PA diameter can aid clinicians in the diagnosis of PA hypertension. A total of 82 adult patients undergoing cardiac surgery were included in our study. Main PA diameter showed a moderate correlation with systolic and diastolic pressures, r = 0.576 (95% confidence interval [CI], 0.407-0.703), P < 0.001, and r = 0.504 (95% CI, 0.319-0.648), P < 0.001, respectively. The authors believe that although a moderate correlation exists between main PA diameter and PA pressure, confounding hemodynamic variables prevent main PA diameter from being an accurate and reliable means of diagnosing PA hypertension.