Temporal trends and predictors of surgical ablation for atrial fibrillation across a multistate healthcare system.

BACKGROUND: Multiple class I and class IIa recommendations exist related to surgical ablation (SA) of atrial fibrillation (AF) in patients undergoing cardiac surgery. OBJECTIVE: Examine temporal trends and predictors of SA for AF in a large US healthcare system. METHODS: We retrospectively analyzed data from the Society for Thoracic Surgery (STS) Adult Cardiac Surgery Database for 21 hospitals in the Providence St. Joseph Health system. All patients with preoperative AF who underwent isolated coronary artery bypass graft (CABG) surgery, isolated aortic valve replacement (AVR), AVR with CABG surgery (AVR+CABG), isolated mitral valve repair or replacement (MVRr), and MVRr with CABG surgery (MVRr+CABG) from July 1, 2014, to March 31, 2020 were included. Temporal trends in SA were evaluated using the Cochran-Armitage trends test. A multilevel logistic regression model was used to examine patient-, hospital-, and surgeon-level predictors of SA. RESULTS: Among 3124 patients with preoperative AF, 910 (29.1%) underwent SA. This was performed most often in those undergoing isolated MVRr (n = 324, 44.8%) or MVRr+CABG (n = 75, 35.2%). Rates of SA increased over time and were highly variable between hospitals. Years since graduation from medical school for the primary operator was one of the few predictors of SA: odds ratio (95% confidence interval) = 0.71 (0.56-0.90) for every 10-year increase. Annual surgical (both hospital and operator) and AF catheter ablation volumes were not predictive of SA. CONCLUSION: Wide variability in rates of SA for AF exist, underscoring the need for greater preoperative collaboration between cardiologists, electrophysiologists, and cardiac surgeons.

Postoperative Rheumatic Heart Disease Follow-Up: Creating a National Registry and First Results from Rwanda.

Background: In many developing countries, rheumatic heart disease (RHD) is diagnosed at an advanced stage and requires surgery for patient survival. However, access to cardiac surgery in this context is limited and often provided through partnerships, requiring centralized patient data systems for monitoring and follow-up. Objectives: This study used data from a national postoperative RHD registry to analyze clinical outcomes of Rwandan patients who received surgery between 2006 and 2017. Methods: The RHD registry was created in 2017 using data compiled from Rwanda Ministry of Health and RHD surgery partners. We extracted pre- and post-operative data on patients who were alive and in care. We excluded patients who died or were lost to follow-up, as their data was not collected in the registry. We evaluated the association between demographic, surgical, and follow-up characteristics and most recent patient symptoms, categorized by New York Heart Association (NYHA) class. Findings: Among the 191 patients eligible for inclusion in this study, 107(56.0%) were female, 110(57.6%) were adults at the time of surgery (>15 years), and 128(67.4%) had surgery in Rwanda. Most patients (n = 166, 86.9%) were on penicillin prophylaxis. Of the patients with mechanical valves, 47(29.9%) had therapeutic International Normalized Ratio values. 90% of patients were asymptomatic (NYHA I) at the time of most recent visit. NYHA class was not significantly associated with any of the considered variables. The median length of follow-up for patients was four years (IQR: 2, 5 years). Conclusion: This study shows both the feasibility and challenges of creating a RHD registry 11 years after the national initiation of RHD surgeries. Most patients captured in the registry are asymptomatic; however, collecting details on patients who had died or were lost to follow-up has proven difficult. Implementing strategies to maintain a complete and up-to-date registry will facilitate follow-up for pre- and postoperative patients.

Congenital Ventricular Diverticulum or Aneurysm: A Difficult Diagnosis to Make.

A pouch protruding from the free wall of the left ventricle may be either a congenital ventricular diverticulum (CVD) or aneurysm (CVA). Being aware of these rare congenital anomalies is critical in making the diagnosis. Differentiating the two is important for treatment decisions. We describe a patient with dextrocardia, Tetralogy of Fallot, and a congenital left ventricular apical diverticulum diagnosed following the induction of anesthesia. CVD and CVA may present in the antenatal period through late adulthood with differing morphology, location, and symptoms. Echocardiography is paramount in the diagnosis and characterization of these lesions. If this anomaly is encountered after the induction of anesthesia or during intraoperative echocardiography, the cardiothoracic anesthesiologist should make the surgical team aware so it can be further characterized and a treatment plan made prior to incision.

Predictors of ARF after cardiac surgical procedures.

BACKGROUND: In a pilot study, a low preoperative serum ferritin level predicted increased risk for acute renal failure (ARF) after cardiopulmonary bypass. It was hypothesized that this may reflect a decreased ability to bind free iron and defend against oxidative stress. However, the pilot study was performed in a small number of patients (n = 30) operated on by a single surgeon. The purpose of this study was to validate whether the serum ferritin level predicts ARF in a larger sample. METHODS: The present study evaluated 120 patients who underwent procedures performed by eight surgeons at another tertiary referral center. Data were collected prospectively and included patient characteristics, laboratory studies, procedure types, and postoperative course. ARF was defined as a 25% or greater increase in creatinine level 48 hours after surgery. RESULTS: The frequency of ARF was 42%, but no patient required dialysis therapy. Preoperative serum ferritin levels did not differ in the groups with and without ARF (158 +/- 119 and 163 +/- 125 ng/mL, respectively), and rates of ARF did not differ when examined by ferritin quartiles. ARF was more frequent in those who underwent valve surgery (54% versus 35% in patients who did not undergo valve procedures; P = 0.044). The odds ratio for ARF after valve surgery was 2.58 (95% confidence interval, 1.06 to 6.29; P = 0.037), adjusted for longer times of surgery and aortic cross-clamp. Most excess ARF occurred in those who underwent aortic valve replacement (AVR; 62%; P = 0.014 versus nonvalve procedures). CONCLUSION: Low preoperative serum ferritin level was not confirmed to predict ARF after cardiac surgery. Valve procedures, particularly AVR, increased the risk for ARF.

Successful use of Argatroban as a heparin substitute during cardiopulmonary bypass: heparin-induced thrombocytopenia in a high-risk cardiac surgical patient.

Whereas heparin is the most widely used intravenous anticoagulant in the US for the treatment of thromboembolic disease and is a seminal adjunct to many clinical procedures, its use can cause serious adverse events. Heparin-induced thrombocytopenia (HIT) has emerged as one of the most frequently seen complications of heparin therapy and can be a life-threatening immunohematological challenge for patients requiring cardiopulmonary bypass (CPB) with obligatory heparin exposure. Unfortunately, lack of convenient monitoring techniques and the presence of HIT and other comorbidities in the complex patient frequently limits or precludes the use of most alternatives to heparin anticoagulation during CPB. This case report describes the successful use of the celite activated clotting time and high-dose thrombin time, while using the direct thrombin inhibitor Argatroban as an alternative to heparin anticoagulation during CPB in a high-risk patient presenting with type II HIT, end-stage renal failure, and ischemic cardiomyopathy with ventricular fibrillatory arrest.

A versatile extracorporeal circuit for use during repair of descending and thoracoabdominal aortic aneurysms in high-risk patients with cardiac and/or pulmonary dysfunction: a novel approach to a significant perfusion management dilemma.

The incidence of ischemic complications associated with repair of descending and thoracoabdominal aortic aneurysms has been significantly reduced by the use of distal aortic perfusion with moderate hypothermia, cerebral spinal fluid drainage, and segmental sequential clamping techniques. However, because the maintenance of proximal perfusion, the adequacy of left heart bypass (LHB), and the ability to ventilate patients on only one lung are all dependent on ventricular and pulmonary function, high-risk patients with descending and/or thoracoabdominal aortic aneurysms in the presence of cardiopulmonary insufficiency or instability present a difficult challenge for the surgical team. Traditional closed LHB circuits become nonfunctional in the event of cardiac arrest or refractory arrhythmias that create hemodynamic instability and are unable to provide necessary pulmonary support if the patient fails to ventilate adequately on one lung during thoracotomy. Furthermore, converting a patient from closed LHB to traditional venoarterial cardiopulmonary bypass (CPB) is frequently difficult, especially when the perfusionist works without the benefit of extra personnel to assist during such crises. Consequently, a modified extracorporeal circuit was designed to provide closed LHB with desired therapeutic adjuncts while also satisfying the additional need for a rapid infusion device, a source of supplemental ventilation/oxygenation, and, if necessary, the ability to convert the patient to venoarterial CPB conveniently in the event of cardiac and/or pulmonary failure during surgery to repair descending and/or thoracoabdominal aortic aneurysms.