Surgical left atrial appendage occlusion with concomitant cardiac surgical procedures: exacerbating heart failure or preventing stroke.

PURPOSE OF REVIEW: The left atrial appendage (LAA) is a common source of thromboembolic stroke in patients with atrial fibrillation. Current guidelines recommend consideration of surgical LAA occlusion concomitant with other cardiac surgical procedures based mostly on observational data and a few small trials. Recently published results of several large retrospective studies and one prospective trial are reviewed herein. RECENT FINDINGS: Large retrospective studies using quality and administrative databases show mixed results with regard to efficacy of surgical LAA occlusion in preventing stroke, although most showed stroke reduction in patients with a history of atrial fibrillation (AF). Safety concerns have been raised based on nonrandomized data suggesting increased complications. A recent large, multicenter international randomized study with 3-year follow-up demonstrated significant reduction in stroke following LAA occlusion with no differences in death or heart failure exacerbations. SUMMARY: Most patients with AF undergoing another cardiac surgical procedure should be considered for concomitant LAA occlusion as part of a heart team discussion. The choice of surgical closure technique is critical. There is insufficient data to recommend LAA occlusion as an alternative to anticoagulation.

Predictors of operating room extubation in adult cardiac surgery.

OBJECTIVE: The primary objective of the study was to identify perioperative factors associated with successful immediate extubation in the operating room after adult cardiac surgery. The secondary objective was to derive a simplified predictive scoring system to guide clinicians in operating room extubation. METHODS: All 1518 patients in this retrospective cohort study underwent standardized fast-track cardiac anesthetic protocol during adult cardiac surgery. Perioperative variables between patients who had successful extubation in the operating room versus in the intensive care unit were retrospectively analyzed using both univariate and multivariable logistic regression analyses. A predictive score of successful operating room extubation was constructed from the multivariable results of 800 patients (derivation set), and the scoring system was further tested using a validation set of 398 patients. RESULTS: Younger age, lower body mass index, higher preoperative serum albumin, absence of chronic lung disease and diabetes, less-invasive surgical approach, isolated coronary bypass surgery, elective surgery, and lower doses of intraoperative intravenous fentanyl were independently associated with higher probability of operating room extubation. The extubation prediction score created in a derivation set of patients performed well in the validation set. Patient scores less than 0 had a minimal probability of successful operating room extubation. Operating room extubation was highly predicted with scores of 5 or greater. CONCLUSIONS: Perioperative factors that are independently associated with successful operating room extubation after adult cardiac operations were identified, and an operating room extubation prediction scoring system was validated. This scoring system may be used to guide safe operating room extubation after cardiac operations.

Adolescents exhibit behavioral differences from adults during instrumental learning and extinction.

Adolescence is associated with the development of brain regions linked to cognition and emotion. Such changes are thought to contribute to the behavioral and neuropsychiatric vulnerabilities of this period. We compared adolescent (Postnatal Days 28-42) and adult (Postnatal Day 60+) rats as they performed a simple instrumental task and extinction. Rats were trained to poke into a hole for a food-pellet reinforcer. After six days of training, rats underwent extinction sessions in which the previously rewarded behavior was no longer reinforced. During extinction, we examined the effects of continued presentation of a cue light and food restriction. Adults and adolescents exhibited similar performance during training, although adolescents made more task-irrelevant pokes, consistent with increased exploration. Adults made more premature pokes, which could indicate a more exclusive focus on the task. During extinction, adolescents made more perseverative (previously reinforced) pokes than adults. This behavior was strongly modulated by the combination of motivational factors present (food restriction and cue light), indicating that adolescents were differentially sensitive to them. Furthermore, food restriction induced greater open-field activity in adolescents but not in adults. Thus, as the neural circuitry of motivated behavior develops substantially during adolescence, so too does the behavioral sensitivity to motivational factors. Understanding how such factors differently affect adolescents may shed light on mechanisms that lead to the development of disorders that are manifested during this period.