The elephant in the room: Exploring the influence and participation of patients in infection-related care across surgical pathways in South Africa and India.

OBJECTIVE: The irrational use of antibiotics is a leading contributor to antibiotic resistance. Antibiotic stewardship (AS) interventions predominantly focus on prescribers. This study investigated the influence and participation of inpatients in infection-related care, including antibiotic decision-making, within and across two tertiary hospitals in South Africa (Cape Town) and India (Kerala). METHODS: Through ethnographic enquiry of clinical practice in surgical pathways, including direct nonparticipant observation of clinical practices, healthcare worker (HCW), patient and carer interactions in surgical ward rounds and face-to-face interviews with participants (HCWs and patients), we sought to capture the implicit and explicit influence that patients and carers have in infection-related care. Field notes and interview transcripts were thematically coded, aided by NVivo 12® Pro software. RESULTS: Whilst observational data revealed the nuanced roles that patients/carers play in antibiotic decision-making, HCWs did not recognize these roles. Patients and carers, though invested in patient care, are not routinely involved, nor are they aware of the opportunities for engagement in infection-related decision-making. Patients associated clinical improvement with antibiotic use and did not consider hospitalization to be associated with infection acquisition or transmission, highlighting a lack of understanding of the threat of infection and antibiotic resistance. Patients' economic and cultural positionalities may influence their infection-related behaviours. In the study site in India, cultural norms mean that carers play widespread but unrecognized roles in inpatient care, participating in infection prevention activities. CONCLUSION: For patients to have a valuable role in AS and make informed decisions regarding their infection-related care, a mutual understanding of their role in this process among HCWs and patients is crucial. The observed differences between the two study sites indicate the critical need for understanding and addressing the contextual drivers that impact effective patient-centred healthcare delivery. PATIENT OR PUBLIC CONTRIBUTION: Ethnographic observations and interviews conducted in this study involved patients as participants. Patients were recruited for interviews after obtaining signed informed consent forms. Patients' identities were completely anonymized when presenting the study findings.

Outcomes after surgery for infective endocarditis.

The role of surgery in infective endocarditis is becoming established the world over. In spite of all recent advances, endocarditis remains a lethal disease following surgery. With the emergence of more difficult-to-treat microorganisms, sicker and older patients with multiple co-morbidities, and an increase in healthcare-associated infections, the need for surgery in the management of infective endocarditis is only bound to increase. Data on the use of surgery in endocarditis till date is largely from observational data due to the relative rarity of the disease and variable practice patterns around the world. Hopefully, with increasing awareness and more inter-institutional and international collaborations, more robust data will emerge to further establish the role of surgery. For the time being, individual patient management will require the active multi-disciplinary approach of an endocarditis team to provide the best possible outcomes. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01647-9.

Selecting the appropriate patients for coronary artery bypass grafting in ischemic cardiomyopathy-importance of myocardial viability.

Patients who undergo coronary artery bypass graft (CABG) surgery in ischemic cardiomyopathy have a survival advantage over medical therapy at 10 years. The survival advantage of CABG over medical therapy is due to its ability to reduce future myocardial infarction, and by conferring electrical stability. The presence of myocardial viability does not provide a differential survival advantage for CABG over medical therapy. Presence of angina and inducible ischemia are also less predictive of outcome. Moreover, CABG is associated with significant early mortality. Hence, careful patient selection is more important for reducing the early mortality and improving the long-term outcome than relying on results of myocardial viability. Younger patients with good exercise tolerance benefit the most, while patients who are frail and patients with renal dysfunction and dysfunctional right ventricle seem to have very high operative mortality. Elderly patients, because of poor life expectancy, do not benefit from CABG, but the age cutoff is not clear. Patients also need to have revascularizable targets, but this decision is often based on experience of the surgical team and heart team discussion. These recommendations are irrespective of the myocardial viability tests. Optimal medical treatment remains the cornerstone for management of ischemic cardiomyopathy.

Early and long-term outcomes of mitral valve replacement with mechanical valve in rheumatic heart disease.

Background: Rheumatic fever and rheumatic heart disease is endemic in India. Mitral valve replacement with mechanical valve is the commonest surgical procedure performed in rheumatic heart disease (RHD). However, there are no studies reporting the long-term outcomes of mechanical mitral valve replacement in rheumatic heart disease from India. Objective: The primary objective of the study was to look at the long-term survival following mechanical mitral valve replacement in RHD. The secondary objectives included follow up complications and event-free survival. Methods: For this study, 238 patients who underwent mitral valve replacement with TTK Chitra™ valve from 1st January 2006 to 31st December 2018 for RHD were included for analysis and reporting. The median follow-up period was 3371.50 days (9.3 years). Total follow-up was 2044 patient-years. Results: The mean age of the study population was 39.72 ± 10.48 years (range: 18-68 years). Out of 238 patients operated, 155 patients (65.12%) were alive and 69 patients (28.99%) were dead, and 14 patients (5.88%) were lost to follow-up. The operative mortality was 6 (2.52%) and the follow-up mortality was 63 (26.47%). The reasons for follow-up mortality were cardiac complications in 22 (34.9%) patients, valve-related complications in 18 (28.5%) patients, sudden unexplained death in 13 (20.6%) patients, and non-valve/ non-cardiac death in 10patients (15.8%). The one-year survival was 94.0%, five-year survival was 83.6%, ten-year survival was 70.6% and 15-year survival was 62.9%. During follow-up, valve-related events occurred in 123(52%) patients. The 15-year event-free survival was 33.0%. Conclusions: The long term outcome of mechanical valve replacement of the mitral valve in RHD patients was less than favorable. Both cardiac complications and mechanical valve related complications reduced their survival.

Early and midterm outcomes after off pump coronary artery bypass surgery.

Purpose: There has been debate whether off pump coronary artery bypass surgery (OPCAB) has results comparable to conventional on pump bypass surgery. This has led to the low uptake of OPCAB in the West. In India, OPCAB is the default mode of coronary revascularization. However, there is scarce data on mid-term outcomes of OPCAB in our patients. This study aims to evaluate both short and mid-term mortality and analyze factors associated with mortality. Methods: This is a single center study of all consecutive patients undergoing isolated OPCAB from October 2014 to December 2019. Patient data was collected from hospital records and follow-up was from the hospital electronic medical records and telephone interviews. Mortality and factors contributing to survival were analyzed. Results: Operative mortality was 2.3%. Mid-term mortality was 5.5%. Preoperative renal dysfunction, post-operative renal failure, use of the intra-aortic balloon pump (IABP), re-exploration for bleeding, postoperative stroke, ventilation > 24 h, and postoperative atrial fibrillation were associated with operative mortality. Factors associated with mid-term mortality were age > 62 years, postoperative renal failure, IABP usage, ventilation time > 24 h, and postoperative atrial fibrillation. The mean survival time was 2343.55 + / - 15.27 days and 6-year survival was 88.7%. Conclusion: OPCAB can safely be performed with satisfactory short and mid-term outcomes. Further corroborative studies from different regions of the country or a multi-center study will help to establish the suitability of the technique in Indian patients.

A Case of Delayed Non-infective Cystic Swelling at the Pacemaker Pocket Site.

With the expanding indications for device implantation, the number of cardiac implantable electrophysiological devices (CIED) being implanted has increased drastically. In a patient presenting with swelling at the pacemaker pocket site several years after the implantation, an infective collection due to device seeding by blood-borne microorganisms is the first diagnosis that is commonly considered. Once the diagnosis of CIED infection is made, complete removal of all the hardware is usually performed. We are describing an unusual case of a 70-year-old male with a permanent pacemaker implanted 8 years ago, who came with insidiously growing swelling at the pacemaker pocket site. He was afebrile. On examination, the swelling was soft and mobile and had no signs of inflammation. Blood cultures after 3 days of incubation did not show any growth. Ultrasound examination revealed a cystic swelling with thick septations. CT showed features suggestive of a seroma measuring 6.7 x 9.4 x 11 cm. Antibiotics were given empirically. A total of 100ml of serosanguinous fluid was drained and the pocket wall was excised. Pulse Generator (PG) was placed back into the pocket and the leads were reconnected. Culture and sensitivity testing of the drained fluid and excised tissue did not show any growth and microscopy revealed no abnormal cells. The patient was followed up on a regular basis for six months. There was no recurrence of swelling at the pacemaker site. Even though an infective abscess is the commonest cause of pacemaker pocket swelling, a non-infective swelling, however rare, must be considered as a non-infective swelling does not require complete removal of the hardware.

Cardiac tamponade as a presentation of COVID-19 after cardiac surgery.

We present two patients who turned positive for coronavirus disease 2019 (COVID-19) after elective cardiac surgery, developing postoperative pericardial effusion with tamponade. One of the patients who presented with tamponade had no other symptoms of COVID-19 infection. COVID-19 can rarely present with cardiac manifestations including pericardial effusion and tamponade. In the post cardiac surgery setting, this effect of the virus may be accentuated. Hence, a high index of suspicion and prompt management are the keys for a successful outcome.

Aortic root widening: "pro et contra".

In patients with a small aortic annulus, the clinical benefits of aortic valve replacement depend on avoidance of patient-prosthesis mismatch as it is associated with reduced overall survival. Aortic root widening or enlargement is a useful technique to implant larger valve prosthesis to prevent patient-prosthesis mismatch. Posterior annular enlargement is the commonest technique used for aortic root enlargement. Consistent enlargement of the aortic root requires more extensive procedures like Manouguian or Konno-Rastan techniques. The patients commonly selected are younger patients with good life expectancy. However, caution is advised in applying this procedure in elderly patients, patients with heavily calcified annulus and when performing concomitant procedures. There is no definitive conclusion on the best material to use for the reconstruction of aortic annulus and aorta in aortic root enlargement procedures.

Do alternative approaches work in surgical septal myectomy?

Trans-aortic septal myectomy is the gold standard for septal reduction therapy. This technique has low peri-procedural mortality and excellent long-term survival. Moreover, it relieves the heart failure symptoms and improves the quality of life. Secondary chordal cutting along with septal myectomy has shown to improve the outcome but can potentially cause deterioration of left ventricular function. In patients with relatively thin inter-ventricular septum, abnormalities of mitral valve apparatus may be the main reason for systolic anterior motion and left ventricular outflow tract obstruction. These patients may require additional procedures on the mitral valve to shift the coaptation plane away from outflow tract. Mitral valve replacement should be performed only in patients with intrinsic mitral valve abnormalities that are not suitable for repair and its routine use along with limited septal myectomy should be discouraged. Minimal access surgery although attractive in concept requires more robust data before universal application.

Posterior mitral leaflet plication with extended septal myectomy for hypertrophic obstructive cardiomyopathy.

Abnormalities of the mitral valve apparatus are a phenotypical expression of hypertrophic cardiomyopathy and can contribute to systolic anterior motion and left ventricular outflow tract obstruction. In patients with significant abnormalities of the mitral apparatus, adjunct procedures like plication of the anterior mitral leaflet and/or release of papillary muscles may be required to obtain sufficient relief of obstruction. Very rarely, an elongated posterior mitral leaflet is the main culprit for systolic anterior motion. In such cases, plication of the posterior mitral leaflet is a useful technique, in addition to septal myectomy, to abolish left ventricular outflow tract obstruction. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-021-01213-1.

Anomalous left atrial chorda and its association with mitral regurgitation.

Anomalous left atrial chorda is associated with mitral regurgitation. A young woman presenting for mitral valve repair with the diagnosis of mid-segment (A2) of anterior mitral leaflet prolapse causing severe mitral regurgitation. Transesophageal echocardiography examination in pre-bypass period showed an anomalous chorda attaching A2 to the left atrial roof, tethering the anterior mitral leaflet toward the atrial wall. Surgical findings confirmed the abnormally attached chordae and an absence of normal chorda of A2 segment. The anomalous chorda was resected and neo-chordae placed between the A2 segment and papillary muscles and annulus strengthened with an annuloplasty ring.

Effects of the COVID-19 Pandemic on Cardiac Surgery Practice and Outcomes.

BACKGROUND: While the coronavirus disease 2019 (COVID-19) pandemic has affected all aspects of health care, its impact on cardiac surgical practice and outcomes is yet to be determined. We compared the outcomes of our cardiac surgical practice from the past year during the pandemic to those in a similar pre-pandemic period. METHODS: Retrospective data were collected from 307 patients who were involved in all adult cardiac surgical procedures performed between March 2020 and February 2021, which was considered the pandemic period, at Amrita Institute of Medical Sciences, India. These were compared with data from the 1-year period between March 2019 and February 2020. During that earlier period, 491 patients underwent surgery, and the surgical outcomes were assessed. Outpatient visit data were also collected to evaluate the effect of COVID-19 on outpatient follow-up visits. RESULTS: A 37% decrease in surgical case volume was observed during the study period. No difference was found in operative mortality between the 2 time periods (3.3% vs. 2.6%, p=0.383). Overall postoperative complications were less frequent during this period, at 23% compared to 38% the previous year (p<0.001). CONCLUSION: The COVID-19 pandemic caused a dramatic decrease in surgical volume and outpatient medical follow-up. However, the pandemic and its attendant social restrictions did not yield a significant change in the surgical outcomes of our patients. Hence, it is reasonable to continue cardiac surgical care during global health crises, and this can be done with good results.

Surgery for infective endocarditis-analysis of factors affecting outcome.

PURPOSE: Despite advances in medical care, infective endocarditis (IE) has high mortality. Surgery for IE though recommended for complications of the disease is still not commonly offered due to conflicting reports in the literature. We reviewed our results of surgery for IE from the last 5 years to assess their outcome. METHODS: A retrospective review from a single center of consecutive patients who underwent surgery for infective endocarditis from September 2014 to December 2019 was done. Data was collected from hospital records and follow-up done up to May 2020. Outcomes evaluated were mortality, follow-up survival, and postoperative complications. Factors affecting mortality and survival were analyzed. RESULTS: Ninety-seven patients underwent surgery for IE during this period. Seventy-nine had native valve endocarditis (NVE) and 18 had prosthetic valve endocarditis (PVE). The overall postoperative mortality was 13%, with mortality for native valve endocarditis being 11% and that for prosthetic valve endocarditis being 22%, which was not statistically significant. Three-year survival for the overall group was 88.7% with 88.1% for NVE and 91.7% for PVE. Multivariate predictors of operative mortality were a high EuroSCORE II, diabetes mellitus, and the presence of Staphylococcus organism. CONCLUSION: Surgery for infective endocarditis has a very acceptable early outcome and intermediate-term survival.

Disappearing left atrial appendage clot-the need for a more meticulous search.

Left atrial clots are occasionally seen in patients with long-standing atrial fibrillation who come for valve surgery. Once identified on echocardiogram, intraoperative identification and retrieval of the clot are essential in order to prevent the possibly devastating complication of embolism and stroke. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-021-01154-9.

Surgical Challenges in Retrieval of an Embolized Transcatheter Valve From the Aorta.

Embolization of a transcatheter aortic valve is a rare complication. Surgery is required if percutaneous retrieval is not possible. We present a case of embolization of an Evolut R device (Medtronic, Minneapolis, MN) into the ascending aorta. This device, owing to its taller profile, presents unique surgical challenges in retrieval with respect to arterial access and cross clamping of the aorta. Prior knowledge of the profile of the various devices is critical to ensure a safe retrieval and smooth conduct of the operation.

Bleeding complications after dual antiplatelet therapy with ticagrelor versus dual antiplatelet therapy with clopidogrel-a propensity-matched comparative study of two antiplatelet regimes in off-pump coronary artery bypass grafting.

PURPOSE: Ticagrelor combined with aspirin had shown better saphenous vein graft patency than aspirin with clopidogrel after off-pump coronary artery bypass grafting. However, the safety of this drug in regard to bleeding complications remains unknown. The aim of our study was to assess the bleeding complications of dual antiplatelet therapy with aspirin and ticagrelor compared with aspirin and clopidogrel within the first 3 months after off-pump surgery. METHODS: Three hundred eighty-two consecutive patients who were prescribed aspirin with ticagrelor (ticagrelor group) were compared with 660 patients who received aspirin and clopidogrel (clopidogrel group). After propensity matching, 144 patients in each group were compared for bleeding events and major adverse cardiac and cerebral events. Major bleeding was defined as composite outcome of re-exploration for bleeding, any fatal bleeding, intracranial bleeding, and any bleeding requiring hospitalization. RESULTS: Patients in the ticagrelor group had more incidence of re-exploration for bleeding (p = 0.042), pericardial effusion requiring drainage (p = 0.007), readmissions (p < 0.01), gastrointestinal bleeding (p = 0.01), and major bleeding (5.8% vs. 2.1%, p < 0.01, OR 2.8 (1.43-5.58)). After propensity analysis, gastrointestinal bleed (p = 0.024), major bleeding (7.6% vs.1.4%, p < 0.001, OR 5.8 (1.28-26.97)), length of ICU stay (p = 0.039), and readmissions (p = 0.003, OR 11.83 (1.51-92.86)) were more in the ticagrelor group. Major adverse cardiac and cerebral events were similar between the groups. CONCLUSION: Dual antiplatelet therapy with aspirin and ticagrelor increased gastrointestinal bleeding events, major bleeding events, and readmission rates compared with aspirin and clopidogrel after off-pump coronary artery bypass grafting.

Accurate localization and echocardiographic-pathologic correlation of tricuspid valve angiolipoma by intraoperative transesophageal echocardiography.

Angiolipoma (angiolipohamartoma) of the tricuspid valve (TV) is a rare tumor which may be occasionally misdiagnosed as right atrial (RA) myxoma. Transesophageal echocardiography (TEE) provides accurate information regarding the size, shape, mobility as well as site of attachment of RA tumors and is a superior modality as compared to transthoracic echocardiography (TTE). Correct diagnosis of RA tumors has therapeutic significance and guides management of patients, as myxomas are generally more aggressively managed than lipomas. We describe a rare case of a pedunculated angiolipoma of the TV which was misdiagnosed as RA myxoma on TTE and discuss the echocardiographic-pathologic correlates of the tumor as well as its accurate localization by TEE.

Predictors of acute kidney injury in patients undergoing adult cardiac surgery.

BACKGROUND: Acute kidney injury (AKI) after cardiac surgery (CS) is not uncommon and has serious effects on mortality and morbidity. A majority of patients suffer mild forms of AKI. There is a paucity of Indian data regarding this important complication after CS. AIMS AND OBJECTIVES: The primary objective was to study the incidence of AKI associated with CS in an Indian study population. Secondary objectives were to describe the risk factors associated with AKI-CS in our population and to generate outcome data in patients who suffer this complication. METHODS: Serial patients (n = 400) presenting for adult CS (emergency/elective) at a tertiary referral care hospital in South India from August 2016 to November 2017 were included as the study individuals. The incidence of AKI-CS AKI network (AKIN criteria), risk factors associated with this condition and the outcomes following AKI-CS are described. RESULTS: Out of 400, 37 (9.25%) patients developed AKI after CS. AKI associated with CS was associated with a mortality of 13.5% (no AKI group mortality 2.8%, P = 0.001 [P < 0.05]). When AKI was severe enough to need renal replacement therapy, the mortality increased to 75%. Patients with AKI had a mean hospital stay 16.92 ± 12.75 days which was comparatively longer than patients without AKI (14 ± 7.98 days). Recent acute coronary syndrome, postoperative atrial fibrillation, and systemic hypertension significantly predicted the onset of AKI-CS in our population. CONCLUSIONS: The overall incidence of AKI-CS was 9.25%. The incidence of AKI-CS requiring dialysis (Stage 3 AKIN) AKI-CS was lower (2%). However, mortality risks were disproportionately high in patients with AKIN Stage 3 AKI-CS (75%). There is a need for quality improvement in the care of patients with AKI-CS in its most severe forms since mortality risks posed by the development of Stage 3 AKIN AKI is higher than reported in other index populations from high resource settings.