Perioperative Renin-Angiotensin System Inhibitors Improve Major Outcomes of Heart Failure Patients Undergoing Cardiac Surgery: A Propensity-Adjusted Cohort Study.

OBJECTIVE: The aim of this study was to study the association of perioperative administration of renin angiotensin system inhibitors (RASi) and clinical outcomes of patients with heart failure (HF) undergoing cardiac surgery. SUMMARY BACKGROUND DATA: It is controversial whether the perioperative RASi should be administered in HF patients undergoing cardiac surgery. METHODS: A total of 2338 patients with HF and undergoing CABG and/or valve surgeries at multiple hospitals from 2001 to 2015 were identified from STS database. After adjustment using propensity score and instrumental variable, logistic regression was conducted to analyze the influence of preoperative continuation of RASi (PreRASi) on short-term in-hospital outcomes. Independent risk factors of 30-day mortality, major adverse cardiovascular events (MACE), and renal failure were analyzed by use of stepwise logistic regression. The effects of pre- and postoperative use of RASi (PostRASi) on long-term mortality were analyzed using survival analyses. Stepwise Cox regression was conducted to analyze the independent risk factors of 6-year mortality. The relationships of HF status and surgery type with perioperative RASi, as well as PreRASi-PostRASi, were also evaluated by subgroup analyses. RESULTS: PreRASi was associated with lower incidences of 30-day mortality [ P < 0.0001, odds ratio (OR): 0.556, 95% confidence interval (CI) 0.405-0.763], stroke ( P =0.035, OR: 0.585, 95% CI: 0.355-0.962), renal failure ( P =0.007, OR: 0.663, 95% CI: 0.493-0.894). Both PreRASi ( P =0.0137) and PostRASi ( P =0.007) reduced 6-year mortality compared with the No-RASi groups. CONCLUSIONS: Pre- and postoperative use of RASi was associated with better outcomes for the patients who have HF and undergo CABG and/or valve surgeries. Preoperative continuation and postoperative restoration are warranted in these patients.

Feasibility of Postoperative Day One or Day Two Discharge After Robotic Cardiac Surgery.

INTRODUCTION: The robotic platform reduces the invasiveness of cardiac surgical procedures, thus facilitating earlier discharge in select patients. We sought to evaluate the characteristics, perioperative management, and early outcomes of patients who underwent postoperative day 1 or 2 (POD1-2) discharge after robotic cardiac surgery at our institution. METHODS: Retrospective review of 169 patients who underwent robotic cardiac surgery at our facility between 2019 and 2021 identified 57 patients discharged early on POD1 (n = 19) or POD2 (n = 38) and 112 patients who underwent standard discharge (POD3 or later). Relevant data were extracted and compared. RESULTS: In the early discharge group, median patient age was 62 [IQR: 55, 66] (IQR = interquartile range) years, and 70.2% (40/57) were male. Median Society of Thoracic Surgeons predictive risk of mortality score was 0.36 [IQR: 0.25, 0.56] %. The most common procedures performed were mitral valve repair [66.6%, (38/57)], atrial mass resection [10.5% (6/57)], and coronary artery bypass grafting [10.5% (6/57)]. The only significant differences between the POD1 and POD2 groups were shorter operative time, higher rate of in-operating room extubation, and shorter ICU length of stay in the POD1 group. Lower in-hospital morbidity and comparable 30-day mortality and readmission rates were observed between the early and standard discharge groups. CONCLUSIONS: POD1-2 discharge after various robotic cardiac operations afforded lower morbidity and similar 30-day readmission and mortality rates compared to discharge on POD3 or later. Our findings support the feasibility of POD1-2 discharge after robotic cardiac surgery for patients with low preoperative risk, an uncomplicated postoperative course, and appropriate postoperative management protocols.

Effect of lipid-lowering medications in patients with coronary artery bypass grafting surgery outcomes.

BACKGROUND: Increased life expectancy and improved medical technology allow increasing numbers of elderly patients to undergo cardiac surgery. Elderly patients may be at greater risk of postoperative morbidity and mortality. Complications can lead to worsened quality of life, shortened life expectancy and higher healthcare costs. Reducing perioperative complications, especially severe adverse events, is key to improving outcomes in patients undergoing cardiac surgery. The objective of this study is to determine whether perioperative lipid-lowering medication use is associated with a reduced risk of complications and mortality after coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). METHODS: After IRB approval, we reviewed charts of 9,518 patients who underwent cardiac surgery with CPB at three medical centers between July 2001 and June 2015. The relationship between perioperative lipid-lowering treatment and postoperative outcome was investigated. 3,988 patients who underwent CABG met inclusion criteria and were analyzed. Patients were divided into lipid-lowering or non-lipid-lowering treatment groups. RESULTS: A total of 3,988 patients were included in the final analysis. Compared to the patients without lipid-lowering medications, the patients with lipid-lowering medications had lower postoperative neurologic complications and overall mortality (P < 0.05). Propensity weighted risk-adjustment showed that lipid-lowering medication reduced in-hospital total complications (odds ratio (OR) = 0.856; 95% CI 0.781-0.938; P < 0.001); all neurologic complications (OR = 0.572; 95% CI 0.441-0.739; P < 0.001) including stroke (OR = 0.481; 95% CI 0.349-0.654; P < 0.001); in-hospital mortality (OR = 0.616; 95% CI 0.432-0.869; P = 0.006; P < 0.001); and overall mortality (OR = 0.723; 95% CI 0.634-0.824; P < 0.001). In addition, the results indicated postoperative lipid-lowering medication use was associated with improved long-term survival in this patient population. CONCLUSIONS: Perioperative lipid-lowering medication use was associated with significantly reduced postoperative adverse events and improved overall outcome in elderly patients undergoing CABG surgery with CPB.

Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery.

Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.

Acute Amiodarone Pulmonary Toxicity.

Amiodarone is an effective antiarrhythmic that frequently is used during the perioperative period. Amiodarone possesses a significant adverse reaction profile. Amiodarone-induced pulmonary toxicity (AIPT) is among the most serious adverse effects and is a leading cause of death associated with its use. Despite significant advances in the understanding of AIPT, its etiology and pathogenesis remain incompletely understood. The diagnosis of AIPT is one of exclusion. The clinical manifestations of AIPT are categorized broadly as acute, subacute, and chronic. Acute AIPT is a rarer and more aggressive form of the disease, most often encountered in cardiothoracic surgery. Acute respiratory distress syndrome (ARDS) is the predominating pattern of amiodarone's acute pulmonary toxicity. The incidence, risk factors, pathogenesis, and diagnosis of acute AIPT are speculative. Early cardiothoracic literature investigating AIPT often attributed amiodarone to the development of postoperative ARDS. Subsequent studies have found no association between amiodarone and acute AIPT and ARDS development. As a drug that is frequently prescribed to a patient population deemed most at risk for this fatal disease, the conflicting evidence on acute AIPT needs further investigation and clarification.

Intranasal Medication Administration Using a Squeeze Bottle Atomizer Results in Overdosing if Deployed in Supine Patients.

BACKGROUND: Vasoconstrictors and local anesthetics are commonly administered using a squeeze bottle atomizer to the nasal mucosa to reduce edema, limit bleeding, and provide analgesia. Despite widespread use, there are few clinical guidelines that address technical details related to safe administration. The purpose of this study was to quantify, via simulation, the amount of liquid delivered to the nasal mucosa when patients are in the supine and upright positions and administration parameters that would reliably provide the desired amount of medication per spray. METHODS: A convenience sample of 10 anesthesia residents was studied. Providers were instructed to use a 25-mL dip and tube nasal squeeze bottle to administer the test solution (sterile water) to a mannequin in the upright (90° elevation) and supine (0° elevation) position. After mannequin testing, additional testing was completed with the spray bottles at 0°, 15°, 30°, 45°, and 90° to determine the relationship between the angles of administration and the amount of liquid dispensed. RESULTS: The mean volume delivered per spray was substantially greater when administered in the supine position (0.56 ± 0.22 mL) compared with the upright position (0.041 ± 0.02 mL, difference = 0.52 mL, 95% confidence interval [CI], 0.37-0.67 mL, P < .001). Converting the administered volume to the dose of phenylephrine that would be administered using our standard 0.25% solution, an estimated additional 1300 mcg is delivered per spray in the supine position compared with the upright position (95% CI, 925-1675 mcg, P < .001). Administration with a delivery angle of ≤30° resulted in significantly more volume than when the bottle was oriented at a 90° angle. The volume dispensed at 45° was not different from the volume delivered at 90° (0.032 ± 0.006 mL vs 0.030 ± 0.005 mL, P = .34). CONCLUSIONS: We found a 14-fold increase in the volume (ie, dose) delivered per spray when a nasal squeeze bottle was used with a mannequin in the supine position compared with the upright position. Given the reported toxicity from the use of intranasal medication and the inadvertent overdosing that occurs when squeeze bottle atomizers are used in clinical practice, our data suggest that all intranasal drugs should be administered with a precise, metered-dose device. If a metered-dose device is unavailable, the medication should be delivered at an angle of ≥45°; however, we recommend administering the drug with the patient in the sitting position and the bottle at 90° because only a small change in angle below 45° will result in a substantial increase in medication delivered.

Preoperative Aspirin Does Not Increase Transfusion or Reoperation in Isolated Valve Surgery.

OBJECTIVE: Preoperative aspirin has been studied in patients undergoing isolated coronary artery bypass graft surgery. However, there is a paucity of clinical data available evaluating perioperative aspirin in other cardiac surgical procedures. This study was designed to investigate the effects of aspirin on bleeding and transfusion in patients undergoing non-emergent, isolated, heart valve repair or replacement. DESIGN: Retrospective, cohort study. SETTING: Academic medical center. PARTICIPANTS: A total of 694 consecutive patients having non-emergent, isolated, valve repair or replacement surgery at an academic medical center were identified. INTERVENTIONS: Of the 488 patients who met inclusion criteria, 2 groups were defined based on their preoperative use of aspirin: those taking (n = 282), and those not taking (n = 206) aspirin within 5 days of surgery. MEASUREMENTS AND MAIN RESULTS: Binary logistic regression was used to examine relationships among demographic and clinical variables. No significant difference was found between the aspirin and non-aspirin groups with respect to the percentage receiving red blood cell (RBC) transfusion, mean RBC units transfused in those who required transfusion, massive transfusion of RBC, or amounts of fresh frozen plasma, cryoprecipitate, or platelets. Aspirin was not associated with an increase in the rate of re-exploration for bleeding (5.3% v 6.3%, p = 0.478). Major adverse cardiocerebral events (MACE), 30-day mortality, and 30-day readmission rates were not statistically different between the aspirin-and non-aspirin-treated groups. CONCLUSIONS: Preoperative aspirin therapy in elective, isolated, valve surgery did not result in an increase in transfusion or reoperation for bleeding and was not associated with reduced readmission rate, MACE, or 30-day mortality.

Evidence for preoperative aspirin improving major outcomes in patients with chronic kidney disease undergoing cardiac surgery: a cohort study.

BACKGROUND: Effects of aspirin on patients with chronic kidney disease (CKD) remains unclear. This study aimed to examine the effect of preoperative aspirin use on postoperative renal function and 30-day mortality in patients with CKD undergoing cardiac surgery. METHODS: A retrospective cohort study was performed on consecutive patients (n = 5175) receiving cardiac surgery in 2 tertiary hospitals. Of all patients, 3585 met the inclusion criteria and underwent the analysis to determine the association of preoperative aspirin with incidence of acute kidney injury (AKI) and death based on estimated glomerular filtration rate (eGFR). RESULTS: Of 3585 patients, 31.5% had CKD (eGFR < 60 mL/min/1.73 m2) at baseline and 27.6% had AKI postoperatively. The baseline eGFR had a nonlinear relationship with the incidence and stages of AKI. As eGFR decreased to 15 to 30 from more than or equal to 90 mL/min/1.73 m2, AKI and 30-day mortality increased to 50.5% from 23.5% and to 11.9% from 2.6%, respectively (P < 0.001). However, preoperative aspirin use was associated with a significant decrease in postoperative AKI and 30-day mortality in patients with CKD undergoing cardiac surgery, in particular, the survival benefit associated with aspirin was greater in patients with CKD (vs normal kidney function): 30-day mortality was reduced by 23.3%, 58.2%, or 70.0% for patients with baseline eGFR more than or equal to 90, 30 to 59, or 15 to 30 mL/min/1.73 m2, respectively (P trend < 0.001). CONCLUSIONS: For patients with CKD undergoing cardiac surgery, preoperative aspirin therapy was associated with renal protection and mortality decline. The magnitude of the survival benefit was greater in patients with CKD than normal kidney function.