Percutaneous dilatation tracheotomy in patients on extracorporeal membrane oxygenation after cardiac surgery.

BACKGROUND: Current practices regarding percutaneous dilatational tracheostomy in adult patients treated with extracorporeal membrane oxygenation (ECMO) after cardiac surgery is not completely defined. This study aimed to evaluate the safety of the percutaneous dilatational tracheostomy in patients with ECMO after cardiac surgery. METHODS: Between July 2017 and May 2021, 371 ECMO procedures were performed in more than 35,000 adult patients who underwent cardiac surgery in our hospital. Sixty-two patients underwent percutaneous dilatational tracheostomy (PDT) during or after ECMO. A retrospective analysis was performed comparing the incidence of complications and clinical outcomes of the two groups. RESULTS: Of the 371 patients treated with ECMO after adult cardiac surgery during the enrollment period, 22 (7.1%) and 40 (12.8%) underwent PDT during or after ECMO, respectively. The platelet count (PLT) of the day was significantly lower in the PDT during ECMO group (54 (34, 68) vs. 108 (69, 162) (thousands), p < 0.001)). The prothrombin time (PT) and activated partial thromboplastin time (APTT) of the day were longer in the PDT during ECMO group (15.8 (14.6, 19.9) vs. 13.8 (13.2, 15.2) seconds, p = 0.001, 43.8 (38.0, 49.4) vs. 35.2 (28.2, 40.9) seconds, p < 0.001, respectively). There was no significant difference in tracheotomy-related complications between the two groups. Significantly decreased ventilator time was observed in the PDT during ECMO group. CONCLUSIONS: Despite poor coagulation of the day, PDT during ECMO is safe and can appropriately reduce the duration of mechanical ventilation compared with PDT after ECMO weaning in adult patients who have undergone cardiac surgery.

Neurologic Complications in Adult Post-cardiotomy Cardiogenic Shock Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation: A Cohort Study.

Background: This study aims to describe the prevalence of neurologic complications and hospital outcome in adult post-cardiotomy cardiogenic shock (PCS) patients receiving veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support and factors associated with such adverse events. Methods: Four hundred and fifteen adult patients underwent cardiac surgery and received V-A ECMO for more than 24 h because of PCS. Patients were divided into two groups: those who developed a neurological complication and those who did not (control group). Multivariable logistic regression was performed to identify factors independently associated with neurologic complications. Results: Neurologic complications occurred in 87 patients (21.0%), including cerebral infarction in 33 patients (8.0%), brain death in 30 patients (7.2%), seizures in 14 patients (3.4%), and intracranial hemorrhage in 11 (2.7%) patients. In-hospital mortality in patients with neurologic complications was 90.8%, compared to 52.1% in control patients (p < 0.001). In a multivariable model, the lowest systolic blood pressure (SBP) level pre-ECMO (OR, 0.89; 95% CI: 0.86-0.93) and aortic surgery combined with coronary artery bypass grafting (OR, 9.22; 95% CI: 2.10-40.55) were associated with overall neurologic complications. Age (OR, 1.06; 95% CI: 1.01-1.12) and lowest SBP (OR, 0.81; 95% CI: 0.76-0.87) were correlative factors of brain death. Coagulation disorders (OR, 9.75; 95% CI: 1.83-51.89) and atrial fibrillation (OR, 12.19; 95% CI: 1.22-121.61) were shown to be associated independently with intracranial hemorrhage, whereas atrial fibrillation (OR, 8.15; 95% CI: 1.31-50.62) was also associated with cerebral infarction. Conclusions: Neurologic complications in adult PCS patients undergoing V-A ECMO support are frequent and associated with higher in-hospital mortality. Identified risk factors of neurologic complications might help to improve ECMO management and might reduce their occurrence.

Risk factors for agitation and hyperactive delirium in adult postcardiotomy patients with extracorporeal membrane oxygenation support: an observational study.

BACKGROUND: Agitation and delirium in critically ill patients after cardiac surgery carry poor in-hospital prognosis. Identifying risk factors may promote its prevention and management. Accordingly, this study aimed to evaluate the incidence of agitation and hyperactive delirium in postcardiotomy patients during the extracorporeal membrane oxygenation support and to identify the risk factors for its development. METHODS: This single center, retrospective study was conducted at Beijing Anzhen Hospital, Capital Medical University. Data were extracted from the prospective institutional registry database of extracorporeal membrane oxygenation patients. Univariate and multivariate logistic regression analyses were performed to predict risk factors. RESULTS: A total of 170 consecutive adult patients underwent extracorporeal membrane oxygenation in our hospital from January 2016 to December 2017. Ninety-four patients were included in the final analysis. The incidence of agitation and hyperactive delirium was 35% in our population of extracorporeal membrane oxygenation-supported postcardiotomy patients. Agitation and delirium usually occurred within the first 3 days of extracorporeal membrane oxygenation. Multivariable analysis showed that history of previous stroke (without preoperative cognitive dysfunction; odds ratio, 4.425, 95% confidence interval: 1.171-16.716; p = 0.028) and mean arterial pressure reduction (before extracorporeal membrane oxygenation initiation) ⩾ 49 mmHg (odds ratio, 7.570, 95% confidence interval: 2.366-24.219, p = 0.001) were independent risk factors for agitation and hyperactive delirium during extracorporeal membrane oxygenation support. The areas under the receiver operating characteristic curve for the prediction of agitation and hyperactive delirium was 0.704 (95% confidence interval 0.589-0.820, p = 0.001). There was more severe arrhythmia in the agitation patients. CONCLUSION: Our results suggest that the prevalence of agitation and hyperactive delirium in postcardiotomy patients with extracorporeal membrane oxygenation support is high. In addition, previous stroke and severe mean arterial pressure reduction before extracorporeal membrane oxygenation initiation is predictive of agitation and hyperactive delirium.

Preoperative intra-aortic balloon pump inserted in acute myocardial infarction patients without cardiogenic shock undergoing surgical coronary revascularization.

OBJECTIVES: The benefit of preoperative intra-aortic balloon pump implantation in high-risk cardiac surgery patients is still debated. The role of preoperative intra-aortic balloon pump insertion in acute myocardial infarction patients without cardiogenic shock undergoing off-pump coronary artery bypass grafting remains unknown. This study aimed to determine the efficacy and safety of the preoperative intra-aortic balloon pump insertion in those patients undergoing off-pump coronary artery bypass grafting. METHODS: A total of 421 consecutive acute myocardial infarction patients without cardiogenic shock who underwent isolated off-pump coronary artery bypass grafting were enrolled in this retrospective observational propensity score-matched analysis study. Patients who received intra-aortic balloon pump before off-pump coronary artery bypass grafting (the intra-aortic balloon pump group, n = 157) were compared with those who had not (control group, n = 264). The 30-day postoperative survival, postoperative complications, and postoperative hospital length of stay were compared between the two groups. RESULTS: A total of 99 pairs of patients were matched. The preoperative intra-aortic balloon pump did not show a 30-day postoperative survival benefit compared with the control group (hazard ratio, 0.9; 95% confidence interval, 0.2-4.2; p = 0.92). Patients with preoperative intra-aortic balloon pump were more likely to have shorter postoperative lengths of stay (8 (6-11) days vs. 10 (6-15) days, p = 0.02) and decreased total days in the hospital (median days: 18.2 vs. 21.8, p = 0.02) compared to patients without balloon pumps. CONCLUSION: Preoperative intra-aortic balloon pump insertion in acute myocardial infarction patients without cardiogenic shock undergoing off-pump coronary artery bypass grafting improved convalescence as shown by significantly shorter postoperative lengths of hospital stay.

Safety of Hypothermic Circulatory Arrest During Unilateral Antegrade Cerebral Perfusion for Aortic Arch Surgery.

BACKGROUND: Hypothermic circulatory arrest (HCA) with adjunctive unilateral antegrade cerebral perfusion (UACP) is widely used as a cerebral protection strategy during aortic arch surgery. However, the ideal temperature for HCA during UACP remains unknown. The study compared clinical outcomes of patients in different temperature groups for HCA during UACP. METHODS: From January 2009 to January 2016, 1691 patients who underwent aortic arch surgery for HCA during UACP in Beijing Anzhen Hospital were categorized into 2 groups according to nasopharyngeal temperature before initiating systemic circulatory arrest: the low temperature group (≤ 24°C, 22.9°C; 22.0°C-23.5°C; n = 1207) and the high temperature group (24.1°C-28.0°C, 24.6°C; 24.3°C-24.9°C; n = 484). After balancing the differences of baseline conditions by propensity score matching, 473 pairs of patients were matched, and the prognosis was compared with matched patients. RESULTS: The multivariable Cox regression analysis shows the high temperature group was an independent predictor for 30-day mortality (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.33-0.93; P = 0.03). After matching, the high temperature group was still an independent predictor of 30-day mortality (HR, 0.55; 95% CI, 0.32-0.98; P = 0.04). In subgroup analyses, there was an interaction between the high temperature group and UACP > 40 minutes for 30-day mortality (Pfor interaction< 0.05). The high temperature group had a significant protective effect in the UACP ≤ 40 minutes subgroup (HR, 0.30; 95% CI, 0.12-0.74; P = 0.01) but not in the UACP > 40 minutes subgroup (HR, 1.00; 95% CI, 0.46-2.20; P = 0.99). CONCLUSIONS: This study shows that the high temperature (24.1°C-28.0°C) management strategy for HCA during UACP is safer for UACP ≤ 40 minutes. High temperature benefits were not found in patients for UACP > 40 minutes.

Clinical application of intra-aortic balloon counterpulsation in high-risk patients undergoing cardiac surgery.

The intra-aortic balloon pump (IABP) has been the most commonly used mechanical circulatory support device for nearly five decades. In theory, the IABP can increase the blood and oxygen supply of the coronary artery by increasing the diastolic pressure in the aortic root when the balloon is inflated and reduce left ventricular afterload by rapidly deflating the balloon during the systolic phase. Therefore, some researchers put forward the idea of preoperative prophylactic use of an IABP, which has been frequently performed in high-risk patients undergoing elective percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). Previous studies have suggested preoperative IABP has a controversial effect on patients undergoing revascularization; the role of preoperative IABP insertion in those patients undergoing CABG alone remains uncertain. This review will give further insight into routine IABP use by presenting the basic principles and discussing current evidence.

Preoperative intra-aortic balloon pump improves the clinical outcomes of off-pump coronary artery bypass grafting in left ventricular dysfunction patients.

Severe left ventricular (LV) dysfunction patients undergoing off-pump coronary artery bypass grafting (OPCAB) are often associated with a higher mortality. The efficacy and safety of the preoperative prophylactic intra-aortic balloon pump (IABP) insertion is not well established. 416 consecutive patients with severe LV dysfunction (ejection fraction ≤35%) undergoing isolated OPCAB were enrolled in a retrospective observational study. 191 patients was enrolled in the IABP group; the remaining 225 patients was in control group. A total of 129 pairs of patients were propensity-score matched. No significant differences in demographic and preoperative risk factors were found between the two groups. The postoperative 30-day mortality occurred more frequently in the control group compared with the IABP group (8.5% vs. 1.6%, p = 0.02). There was a significant reduction of low cardiac output syndrome in the IABP group compared with the control group (14% vs. 6.2%, p = 0.04). Prolonged mechanical ventilation (≥48 h) occurred more frequently in the control group (34.9% vs. 20.9%, p = 0.02). IABP also decreased the postoperative length of stay. Preoperative IABP was associated with a lower 30-day mortality, suggesting that it is effective in patients with severe LV dysfunction undergoing OPCAB.