Elective Surgical Delays Due to COVID-19: The Patient Lived Experience.

BACKGROUND: This qualitative research explored the lived experiences of patients who experienced postponement of elective cardiac and vascular surgery due to coronavirus disease 2019 (COVID-19). We know very little about patients during the novel coronavirus pandemic. Understanding the patient voice may play an important role in prioritization of postponed cases and triage moving forward. METHODS: Utilizing a hermeneutical phenomenological qualitative design, we interviewed 47 individuals who experienced a postponement of cardiac or vascular surgery due to the COVID-19 pandemic. Data were analyzed and informed by phenomenological research methods. RESULTS: Patients in our study described 3 key issues around their postponement of elective surgery. Patients described robust narratives about the meanings of their elective surgeries as the chance to "return to normal" and alleviate symptoms that impacted everyday life. Second, because of the meanings most of our patients ascribed to their surgeries, postponement often took a toll on how patients managed physical health and emotional well-being. Finally, paradoxically, many patients in our study were demonstrative that they would "rather die from a heart attack" than be exposed to the coronavirus. CONCLUSIONS: We identified several components of the patient experience, encompassing quality of life and other desired benefits of surgery, the risks of COVID, and difficulty reconciling the 2. Our study provides significant qualitative evidence to inform providers of important considerations when rescheduling the backlog of patients. The emotional and psychological distress that patients experienced due to postponement may also require additional considerations in postoperative recovery.

Prioritizing cardiovascular surgical care in COVID-19 pandemic: Shall we operate or defer?

BACKGROUND: The coronavirus disease (COVID-19) has affected a large population across the world. Patients with cardiovascular disease have increased morbidity and mortality due to coronavirus disease. The burden over the health care system has to be reduced in this global pandemic to provide optimal care of patients with COVID-19, as well not compromising those who are in need of emergent cardiovascular care. METHODS: There is a very limited data published defining which cardiovascular procedures are to be performed or to be deferred in the COVID-19 pandemic. In this article, we have reviewed a few published guidelines regarding cardiovascular surgery in COVID-19 pandemics. CONCLUSION: After reviewing a few available guidelines regarding cardiovascular surgery in COVID-19, we conclude to perform only those surgeries which cannot be deferred to a certain period of time, to reduce the burden of the health care system of the country, provide optimal care to patients with COVID-19, and to protect health care workers and cardiovascular patients from COVID-19.

[Countermeasures and treatment for aortic acute syndrome with 2019 coronavirus disease].

The 2019 coronavirus disease(COVID-19) has cost a great loss to the health and economic property of Chines people. Under such a special circumstance, how to deal with such patients with acute aortic syndrome has become a serious challenge. Rapid diagnosis of concomitant COVID-19, safe and effective transportation, implementation of the interventional procedure, protection of vascular surgical team and postoperative management and follow-up of such patients have become urgent problems for us. Combined with the latest novel government documents, the literature and the experiences from Wuhan, we answered the above questions briefly and plainly. We also hope to inspire the national vascular surgeons to manage critical emergencies in vascular surgery and even routine vascular diseases with COVID-19, as a final point to limit the severe epidemic situation, and minimize the damage of COVID-19.

Artificial Neural Network: A Method for Prediction of Surgery-Related Pressure Injury in Cardiovascular Surgical Patients.

PURPOSE: The aim of this study was to build an artificial neural network (ANN) model for predicting surgery-related pressure injury (SRPI) in cardiovascular surgical patients. DESIGN: Prospective cohort study. SUBJECTS AND SETTING: One hundred forty-nine patients who had cardiovascular surgery were included in the study. This study was conducted in a 1000-bed teaching hospital in Eastern China where 250 to 350 cardiac surgeries are performed each year. METHODS: We performed a prospective cohort study among consecutive patients undergoing cardiovascular surgery between January and December 2015. The ANN model was built based on possible SRPI risk factors. The model performance was tested by a receiver operating characteristic curve and the C-index. A C-index from 0.5 to 0.7 is classified as having low accuracy, 0.7 to 0.9 as having moderate accuracy, and 0.9 to 1.0 as having high accuracy. We also compared the actual SRPI incidences based on the ANN stratification. RESULTS: Thirty-seven of 147 patients developed SRPIs, yielding an incidence rate of 24.8% (95% CI, 18.1-32.6). The C-index was 0.815, which showed the ANN model had a moderate prediction value for SRPI. According to the ANN model, the SRPI predicting incidence ranged from 6.4% to 67.7%. Surgery-related pressure injury incidences were significantly different among 3 risk groups stratified by the ANN (P < .05). CONCLUSION: We established an ANN model that provides moderate prediction of SRPI in patients undergoing cardiovascular surgical procedures. Identification and additional associated factors should be incorporated into the ANN model to increase its predictive ability.

Perioperative cardiovascular monitoring of high-risk patients: a consensus of 12.

A significant number of surgical patients are at risk of intra- or post-operative complications or both, which are associated with increased lengths of stay, costs, and mortality. Reducing these risks is important for the individual patient but also for health-care planners and managers. Insufficient tissue perfusion and cellular oxygenation due to hypovolemia, heart dysfunction or both is one of the leading causes of perioperative complications. Adequate perioperative management guided by effective and timely hemodynamic monitoring can help reduce the risk of complications and thus potentially improve outcomes. In this review, we describe the various available hemodynamic monitoring systems and how they can best be used to guide cardiovascular and fluid management in the perioperative period in high-risk surgical patients.

CSANZ Position Statement on Sedation for Cardiovascular Procedures (2014).

The Cardiac Society of Australia and New Zealand (CSANZ) Position Statement describes evidence-based standards of training, pre-procedural assessment, procedural conduct and post-procedure care with respect to sedation for cardiovascular procedures. It also describes the environment in which sedation for electrophysiological and other cardiac procedures may be performed. This Statement was developed by a Working Group of the Cardiac Society of Australia and New Zealand. It was reviewed by the Continuing Education and Recertification Committee and ratified at the CSANZ Board meeting held on Friday 7 March 2014.

[Diagnosis and treatment of aortic diseases : new guidelines of the European Society of Cardiology 2014]. / Diagnostik und Therapie von Aortenerkrankungen : Neue Leitlinien der Europäischen Gesellschaft für Kardiologie 2014.

In September 2014 the European Society of Cardiology issued guidelines for the diagnosis and treatment of aortic diseases in adults. Contrast-enhanced computed tomography (CT) represents the imaging modality of first choice as it is rapidly and almost ubiquitously available and can evaluate the entire aorta in a single-step examination. In patients with a high clinical suspicion of an acute aortic syndrome based on (family) history and symptoms, CT should be performed without further delay to confirm or refute the diagnosis. Diseases involving the ascending aorta remain a domain of open surgery, be it on an emergency basis in an acute type A dissection or electively in asymptomatic aneurysms with an aortic diameter >5.5 cm. The presence of risk factors (e. g. bicuspid aortic valve, Marfan syndrome and aortic dissection/rupture in the family history) may prompt earlier surgical repair at a lower threshold diameter. The treatment of descending aortic disease is primarily conservative including modification of cardiovascular risk factors. If indicated, endovascular aortic stent graft repair appears to be superior to open surgery for descending thoracic aortic disease or equivalent in the treatment of infrarenal abdominal aortic aneurysms. The management of aortic diseases related to genetic connective tissue diseases (e. g. Marfan syndrome, Loeys-Dietz syndrome and Ehlers-Danlos syndrome) is complex and requires special multidisciplinary expertise.

[The 2014 ESC guidelines on the diagnosis and management of hypertrophic cardiomyopathy : what is new?]. / ESC-Leitlinie 2014 zur Diagnose und zum Management der hypertrophischen Kardiomyopathie : Was ist neu?

The 2014 European Society of Cardiology (ESC) guidelines on the diagnosis and management of hypertrophic cardiomyopathy (HCM) comprise 133 recommendations with 506 references. In comparison to the last 10-year-old American College of Cardiology Foundation (ACCF)/ESC guidelines new data have been added, such as recent studies on genetics, updated recommendations for family and genetic screening, a special emphasis on red flags in clinical symptomatology and diagnostic features for the identification of non-obstructive variants of HCM, on multimodality non-invasive imaging by echocardiography and cardiac magnetic resonance imaging (MRI) and a HCM risk formula for the assessment of sudden cardiac death within 5 years. Nevertheless, it should not be forgotten that the majority of patients with HCM lead a normal life. This detailed update and the structured recommendations are an excellent summary of the current knowledge on HCM for the cardiomyopathy specialist and also for internists and general physicians.

[European Society of Cardiology guidelines for the management of complex grown-up congenital heart disease]. / Recommandations européennes pour la prise en charge des cardiopathies congénitales complexes de l'adulte.

The number of patients with Grown-Up Congenital Heart disease (GUCH) consulting adult cardiologists is steadily increasing. These patients have either a non-diagnosed congenital heart disease revealed at adulthood, or a diagnosed congenital heart disease for which one or multiple interventions have possibly been performed during childhood. In this article, we summarize the recommendations of the European Society of Cardiology of 2010 for complex congenital heart disease.

Implementing a Preoperative Anemia Optimization Protocol for Cardiovascular Surgery Patients: A Quality Improvement Project.

BACKGROUND: Patients with anemia have poorer outcomes following cardiac surgery than do those without anemia. To improve outcomes, the Enhanced Recovery After Surgery cardiac recommendations include optimizing patients' condition, including treating anemia, before surgery. LOCAL PROBLEM: Despite implementing Enhanced Recovery After Surgery initiatives, a midwestern cardiothoracic surgery group recognized a care gap in preoperative patients with anemia. No standardized protocol was in use. METHODS: An anemia optimization protocol was developed for perioperative care of patients with anemia. Data from retrospective medical record review were analyzed to determine relationships between protocol use and secondary outcomes. The protocol was created using best evidence and expert consensus. Cardiac surgery and hematology specialists revised the protocol and agreed on a final version. The protocol was integrated into the consultation process for cardiac surgery patients. RESULTS: During the implementation period, 23 of 55 patients with anemia (42%) received interventions via the anemia optimization protocol. The mean quantity of packed red blood cells transfused perioperatively per patient was 1.9 U in the protocol group and 3.5 U in the nonprotocol group. In the subgroup of patients experiencing postoperative acute kidney injury, the mean increase in creatinine level was 0.65 mg/dL in the protocol group and 1.52 mg/dL in the nonprotocol group. Four patients in the protocol group (17%) and 6 patients in the nonprotocol group (19%) experienced postoperative acute kidney injury. CONCLUSION: Preoperative anemia is associated with poorer cardiac surgical outcomes. Incorporating the anemia optimization protocol into practice may mitigate the risk of postoperative complications for patients with anemia. Continued use of the protocol is recommended.

Pharmacological and non-pharmacological therapy for arrhythmias in the pediatric population: EHRA and AEPC-Arrhythmia Working Group joint consensus statement.

In children with structurally normal hearts, the mechanisms of arrhythmias are usually the same as in the adult patient. Some arrhythmias are particularly associated with young age and very rarely seen in adult patients. Arrhythmias in structural heart disease may be associated either with the underlying abnormality or result from surgical intervention. Chronic haemodynamic stress of congenital heart disease (CHD) might create an electrophysiological and anatomic substrate highly favourable for re-entrant arrhythmias. As a general rule, prescription of antiarrhythmic drugs requires a clear diagnosis with electrocardiographic documentation of a given arrhythmia. Risk-benefit analysis of drug therapy should be considered when facing an arrhythmia in a child. Prophylactic antiarrhythmic drug therapy is given only to protect the child from recurrent supraventricular tachycardia during this time span until the disease will eventually cease spontaneously. In the last decades, radiofrequency catheter ablation is progressively used as curative therapy for tachyarrhythmias in children and patients with or without CHD. Even in young children, procedures can be performed with high success rates and low complication rates as shown by several retrospective and prospective paediatric multi-centre studies. Three-dimensional mapping and non-fluoroscopic navigation techniques and enhanced catheter technology have further improved safety and efficacy even in CHD patients with complex arrhythmias. During last decades, cardiac devices (pacemakers and implantable cardiac defibrillator) have developed rapidly. The pacing generator size has diminished and the pacing leads have become progressively thinner. These developments have made application of cardiac pacing in children easier although no dedicated paediatric pacing systems exist.

[Adults with congenital heart disease: treatment and medical problems]. / Erwachsene mit angeborenen Herzfehlern : Versorgungssituation und medizinische Probleme.

By improvement of the medical care, children with congenital heart disease survive in much greater numbers: the figure of ACHD-patients in Germany is estimated up to 203,000 to 301,000. The need for a specialized care of these patients is accepted by the scientific societies, who introduced a certification for doctors and centers and created guidelines. The medical problems include imaging, treatment of arrhythmia, congestive heart failure and cyanosis, prophylaxis of infectious endocarditis, exercise and pregnancy. For the most frequent defects, indication for treatment and postoperative care is summarized.

A comparative evaluation of transesophageal and transthoracic echocardiography for measurement of left ventricular systolic strain using speckle tracking.

OBJECTIVE: The authors hypothesized that the measurement of strain by speckle tracking with transesophageal echocardiography (TEE) is feasible and comparable to transthoracic echocardiography (TTE). DESIGN: A prospective observational comparative study. SETTING: A university hospital. PARTICIPANTS: Adult patients undergoing elective cardiac surgery. INTERVENTIONS: Structured intraoperative TTE and TEE examination. MEASUREMENTS AND MAIN RESULTS: Images were obtained after the induction of anesthesia from 25 patients to enable speckle tracking of the left ventricle in comparable short- and long-axis (SAX and LAX) views using TTE and TEE. Left ventricular strain was measured offline using both modalities and correlation assessed using the Pearson test with assessment of bias using the Bland-Altman method. Significantly more segments were tracked by TEE than TTE in LAX views but not SAX views. Correlation was moderate between TTE and TEE (r = 0.5-0.6) for longitudinal strain in the LAX views, whereas it was poor for regional radial strain (r = 0.07). Correlation for global circumferential strain was higher for the apical SAX views (r = 0.7) than the basal or mid- SAX views. Speckle tracking by TEE showed excellent reproducibility with small bias. CONCLUSIONS: Strain measured by speckle tracking in TEE correlated moderately with TTE for global strain and poorly for regional strain. This may be explained by differences in scanning frequency and other imaging factors. Nevertheless, because of the high degree of reproducibility, it may be a useful tool to quantify intraoperative changes in ventricular function with TEE. However, equivalence between TTE and TEE cannot be assumed, and limits of comparability should be recognized.

Developing a benchmarking process in perfusion: a report of the Perfusion Downunder Collaboration.

Improving and understanding clinical practice is an appropriate goal for the perfusion community. The Perfusion Downunder Collaboration has established a multi-center perfusion focused database aimed at achieving these goals through the development of quantitative quality indicators for clinical improvement through benchmarking. Data were collected using the Perfusion Downunder Collaboration database from procedures performed in eight Australian and New Zealand cardiac centers between March 2007 and February 2011. At the Perfusion Downunder Meeting in 2010, it was agreed by consensus, to report quality indicators (QI) for glucose level, arterial outlet temperature, and pCOz management during cardiopulmonary bypass. The values chosen for each QI were: blood glucose > or =4 mmol/L and < or =10 mmol/L; arterial outlet temperature < or = 37 degrees C; and arterial blood gas pCO2 > or =35 and < or =45 mmHg. The QI data were used to derive benchmarks using the Achievable Benchmark of Care (ABC) methodology to identify the incidence of QIs at the best performing centers. Five thousand four hundred and sixty-five procedures were evaluated to derive QI and benchmark data. The incidence of the blood glucose QI ranged from 37-96% of procedures, with a benchmark value of 90%. The arterial outlet temperature QI occurred in 16-98% of procedures with the benchmark of 94%; while the arterial pCO2 QI occurred in 21-91%, with the benchmark value of 80%. We have derived QIs and benchmark calculations for the management of several key aspects of cardiopulmonary bypass to provide a platform for improving the quality of perfusion practice.

[Cryoballoon ablation for pulmonary vein isolation to treat atrial fibrillation: first experience in Russian Federation].

Cryoballon ablation (CBA) for pulmonary vein (PV) isolation is a new method for catheter-based treatment of patients with atrial fibrillation (AF). The purpose of our work is to describe the CBA technique and to report its short-term results. Methods. CBA was performed in 12 patients (8 men; age 53.1+/-5.7 years) with highly symptomatic drug-refractory AF. Paroxysmal AF was present in 11 and persistent AF - in 1 patient. CBA procedure was carried out under general anesthesia with intubation in 6 and under light sedation in 6 patients. After transseptal access and direct PV angiography, 28 mm-cryoballoon was introduced into the left atrium, and more or equal 2 cryoapplications were delivered to each PV, once good PV occlusion was obtained. PV isolation was verified utilizing a circular mapping catheter. Arrhythmia recurrences were monitored every 3 months after ablation using 24-hour Holter, and additional ECG registrations. Holter monitoring was also performed in a case of symptoms. Results. Complete electrical PV isolation was achieved by only cryoballoon ablation in 11 patients, and additional cryocatheter touch-up ablation was required in left PVs in 1 patient. Total procedure time was 203.1+/-34.2 min, fluoroscopy time - 50.5+/-14.0 min. There were no complications. During a mean follow-up period of 136.8+/-59.8 days 9 (75%) patients were free from arrhythmia recurrence after a single procedure. Redo ablation was required in 1 patient, in whom electrical reconnection to all PVs was documented. Conclusion. CBA is a novel promising technique for treatment of patients with AF, and now is available in Russian Federation. The method standardizes and facilitates interventional AF treatment with acute isolation of 96% PVs. The short-term follow-up shows freedom from atrial tachyarrhythmias in 75% of patients.

Impact of intraoperative transesophageal echocardiography on surgical decisions in the cardiovascular operating room.

OBJECTIVES: To assess the usefulness of intraoperative transesophageal echocardiography (IOTEE) in a cardiac surgery department. STUDY DESIGN: Patients were examined with IOTEE before and after cardiopulmonary bypass. All studies were performed with a Toshiba 270 SSA model imaging device. All IOTEE examinations were performed by two cardiovascular surgery residents who are experienced in IOTEE. RESULTS: A total of 466 patients (239 men, 227 women) were examined by IOTEE from 2001 through 2007. Of these 182 (39%) were performed during correction of valvular pathologies, 193 (41%) during coronary operations, 34 (7%) during combined operations (either valvular or coronary bypass), 8 (1.7%) in adult congenital heart operations, 7 (1.5%) in cardiac mass operations, and the rest in other miscellaneous operations. TEE examinations performed before and after the cardiopulmonary bypass influenced surgical decisions by 14.8% and 9.0%, respectively. Decisions regarding the mitral valve were the most frequent followed by decisions regarding the tricuspid valve. CONCLUSION: IOTEE significantly affected decision making in cardiac surgery operating room. IOTEE examination must be a standard procedure for all patients undergoing cardiac surgery.

Progress towards a National Cardiac Procedure Database--development of the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) and Melbourne Interventional Group (MIG) registries.

Since the call for a National Cardiac Procedures Database in 2001, much work has been accomplished in both cardiac surgery and interventional cardiology in an attempt to establish a unified, systematic approach to data collection, defining a common minimum dataset pertinent to the Australian context, and instituting quality control measures to ensure integrity and privacy of data. In this paper we outline the aims of the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) and the Melbourne Interventional Group (MIG) registries, and propose a comprehensive set of standardised data elements and their definitions to facilitate transparency in data collection, consistency between these and other data sets, and encourage ongoing peer-review. The aims are to improve outcomes for patients by determining key performance indicators and standards of performance for hospital units, to allow estimation of procedural risks and likelihood of outcomes for patients, and to report outcomes to relevant stake-holders and the public.