The effect of the anticholinergic burden on mortality following elective cardiac surgery.

OBJECTIVE: The cumulative effect of drugs with anticholinergic properties may pose a significant risk in the post-discharge period of patients who have undergone elective cardiac surgery. The aim of this study was to investigate the association between anticholinergic burden and 6-month postdischarge mortality in older cardiac surgery patients. METHODS: This study performed a retrospective longitudinal analysis of patients undergoing elective cardiac surgery at a tertiary care centre from January 2021 to January 2022. The Deyo-Charlson comorbidity index (D-CCI) was used to estimate the burden of comorbidities. The anticholinergic burden was assessed using the Anticholinergic Cognitive Burden scale (ACB) and Drug Burden Index (DBI) scale. All-cause postdischarge mortality was determined from electronic medical records. RESULTS: A total of 255 older adults who had undergone elective cardiac surgery and had been followed up for at least 6 months were included in this study. Approximately 12.5% (n = 32) of older patients died within 6 months of discharge. In multivariate Cox regression analysis, ACB (HR:1.31, 95%CI:1.10-1.56 p = 0.01) and DBI (HR:2.08, 95%CI:1.27-3.39 p = 0.01) showed significantly increased risk of 6-month postdischarge mortality after adjusting for several possible confounders (age, gender, D-CCl, and American Society of Anaesthesiologists (ASA) score). Overall event-free survival differed significantly between patients undergoing cardiac surgery based on anticholinergic burden according to the group-stratified ACB and DBI scales (χ2: 5.907, log-rank test, p = 0.015 and χ2: 15.389, log-rank test, p < 0.001 respectively). CONCLUSION: The anticholinergic burden is associated with 6-month all-cause post-discharge mortality in older cardiac surgery patients. A deprescribing approach should be considered, especially for older adults in the perioperative period. TRIAL REGISTRATION: The trial was retrospectively registered at ClinicalTrials.gov. Identifier: NCT05312684 Registered on 5 April 2022.

Predictive Parameters of Type 1A Endoleak for Elective Endovascular Aortic Repair: A Single-Center Experience.

BACKGROUND: One of the most important factors that affects the success of Endovascular Aortic Repair (EVAR) treatment is the morphology of the neck of the aneurysm. Today, EVAR can be performed even in patients who do not meet the Instruction For Use criteria with hostile neck risk factors; thanks to the developing experience and technology. Our aim in this study was to determine risk factors for Type 1a endoleaks in patients who underwent EVAR and predictive factors for Type 1a endoleaks in patients with combinations of these risk factors. METHODS: Patients who underwent elective EVAR for infrarenal abdominal aortic aneurysm in our medical center between July 2016 and January 2021 were enrolled. Of these 244 patients, 180 patients with documented preoperative and postoperative computed tomographic angiography results and a follow-up of at least 1 year were included in the study. The Mann-Whitney U test and Student's t-test were used to assess the relationship between nominal data and numerical values, and the t-test and Wilcoxon test were used to compare dependent groups. Logistic regression analysis was performed to model risk factors associated with endoleaks. RESULTS: The results showed that a neck length less than 15 mm increased the development of type 1a endoleak by 10.4 times (P < 0.001). Furthermore, a neck diameter more than 28 mm increased the development of type 1a endoleak by 21.9 times (P = 0.04). A conical neck structure (gradual neck dilation > 2 mm) increased the development of type 1a endoleaks 4.8 times (P = 0.04). The presence of calcification (> 150 Hounsfield Unit and > 2 mm) in the neck increased the risk of type 1a endoleaks fourfold (P = 0.04). Hostile neck parameters were analyzed and patients with only 1 parameter (n = 69) had a 7.2% type 1a endoleak rate, while patients with 2 parameters (n = 15) had 26.6% and patients with more than 2 parameters (n = 11) had 45.5% type 1a endoleak rate. CONCLUSIONS: Morphologic features of the neck structure of the aneurysm are among the most important parameters that affect the success of EVAR treatment. Alternative treatments should be considered in patients with more than 1 unfavorable neck parameter.

A new hematologic predictor of major adverse events after cardiac surgery: red cell distribution width to lymphocyte ratio.

BACKGROUND: The perioperative risk factors that cause severe morbidity and prolongation of postoperative hospital stay after cardiac surgery should be determined. Various scores have been used to predict morbidity and mortality. Preoperative blood counts are considered potential biomarkers of inflammation and oxidative stress. Inflammatory and immune imbalances may have a significant impact on postoperative adverse events. The present study aimed to investigate the association and potential predictive properties of red cell distribution width/ lymphocyte ratio (RLR) for major adverse events in adult patients who underwent coronary surgery with cardiopulmonary bypass. METHODS: After approval from the ethics committee, pre- and post-operative data of 700 patients were obtained from the electronic database of the hospital, intra- and post-operative anesthesia, and intensive care unit follow-up charts. We performed a stepwise multiple logistic regression analysis to investigate the association of RLR with major adverse events in adult patients who underwent coronary surgery with cardiopulmonary bypass. RESULTS: Among 700 patients, 47 (6.7%) had major adverse events after surgery. Multivariate logistic regression analysis showed that age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.03-1.12; P < 0.001), mean platelet volume (OR, 1.49; 95% CI, 1.07-2.06; P = 0.017), and RLR (OR, 1.21; 95% CI, 1.02-1.43; P = 0.026) were significantly associated with major adverse events. CONCLUSIONS: RLR indicates the balance between inflammatory and immune responses. Therefore, it can be used to predict adverse events following coronary surgery.

Tips and tricks about surgeon-modified fenestrated stent grafting for celiac truncus.

Currently, thoracic endovascular aortic repair is usually the first-line treatment option for descending aortic pathologies. Supra-aortic or visceral branches sometimes involve assistive thoracic endovascular aortic repair techniques; hybrid procedures or intentional coverage may be performed during the procedure to achieve a sufficient proximal or distal landing zone. Most surgeons may agree on selective coverage of celiac truncus, but revascularization is preferred to reduce the risk of ischemic complications. Herein, we present the first successful surgeonmodified fenestrated stent graft procedure for celiac truncus in a patient with Crawford type V descending aortic aneurysm in Türkiye.

Funnel technique for wide infrarenal aneurysm neck with Lifetech Ankura™ Stent Graft System.

BACKGROUND: In this study, we present our mid-term results in patients undergoing treatment with the funnel technique and describe technical issues for this bailout technique in extra-wide infrarenal necks. METHODS: Between January 2018 and June 2020, a total of seven male, symptomatic patients (median: 74.5 years; range, 64 to 84 years) who had comorbidities and were in the American Society for Anesthesiologists Class IV and treated by the funnel technique in an endovascular fashion were included. Pre- and post-procedural data of the patients, early mortality and technical success rates were evaluated. RESULTS: There was no early mortality. Technical success rate was 100%. There was no type I or III endoleaks at the completion angiography. All patients were discharged without any problem on the second or third day of the procedure. The median follow-up was 13 (range, 6 to 28) months. The aneurysm sac shrinkage was achieved in all patients over six months of follow up. During the follow-up period, no proximal endoleak or infrarenal aortic neck diameter enlargement was found. CONCLUSION: Based on our limited experience, the funnel technique may be considered more than a bailout procedure under special circumstances.

What factors counteract mid-term survival following endovascular repair of abdominal aortic aneurysms?

INTRODUCTION: Endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is increasingly used, and has become the standard treatment option for AAA. AIM: To evaluate the outcomes and predictors of survival of endovascular treatment of AAA in the short- and medium-term. MATERIAL AND METHODS: A total of 222 patients having endovascular AAA repair between January 2013 and December 2019 by the same surgical team were included in the study. Patient demographics, perioperative and follow-up data including mortality, complications, and need for secondary intervention were collected. The primary endpoint was all-cause mortality. Kaplan-Meier analysis was conducted for survival and Cox regression models were assessed for predictors of survival. RESULTS: The median age was 70 years, with male predominance (202 patients, 91%). Thirty-day mortality was 1.8%. Median follow-up to the primary endpoint was 20 months (range: 1-80 months). Survival rates at 1, 3, and 5 years were 93.5%, 81.4%, and 62.2%, respectively. Freedom from secondary intervention rates were 95.5% at 1 year, 88.7% at 3 years, and 82.1% at 5 years. Cox proportional hazard models showed that preoperative creatinine levels ≥ 1.8 mg/dl (hazard ratio (HR) = 2.68, 95% CI: 1.21-6.42, p = 0.027), haemoglobin levels < 10 gr/dl (HR = 3.38, 95% CI: 1.16-9.90, p = 0.026), ejection fraction < 30% (HR = 5.67, 95% CI: 1.29-24.86, p = 0.021), and AAA diameter ≥ 6.0 cm (HR = 2.20, 95% CI: 1.01-4.81, p = 0.049) were independently associated with mid-term survival. CONCLUSIONS: EVAR is a safe procedure with low postoperative morbidity and mortality. This study confirms that the mid-term survival and results are favourable. However, the analysed factors in this study that predict reduced survival (high preoperative creatinine, low haemoglobin, low ejection fraction and larger aneurysms) should be judged when planning endovascular repair of AAA.

Perioperative planning for cardiovascular operations in the COVID-19 pandemic.

Coronavirus disease-2019 (COVID-19) is a serious health concern which alert all healthcare professionals worldwide. There are two main issues caused by this pandemic regarding for the healthcare system. First, it is a necessity to postpone many elective procedures/surgeries to reduce the burden of the healthcare system which may be confronted with strain by the increased speed of transmission. Therefore, we aimed to develop an algorithm called as Level of Priority to identify the priority and deferrability of cardiovascular diseases requiring surgery. Second, it is essential to perform surgery and intensive care unit follow-up in a setting where the infection prevention measures are followed for primary patients requiring emergency cardiovascular surgery. In this article, we present necessary precautions to be exercised to provide the patient safety and the highest level of protection for the surgical team.