The Impact of Acute Kidney Injury on Chronic Kidney Disease After Cardiac Surgery: A Systematic Review and Meta-analysis.

OBJECTIVES: To evaluate the impact of acute kidney injury on transition to chronic kidney disease (CKD) after cardiac surgery and to determine frequency of incident CKD in these patients. DESIGN: A systematic review and meta-analysis of observational studies. SETTING: Electronic databases Medline and Embase were systematically searched from 1974 to February 6, 2023. PARTICIPANTS: Eligible studies were original observational studies on adult cardiac surgery patients, written in the English language, and with clear kidney disease definitions. Exclusion criteria were studies with previously transplanted populations, populations with preoperative kidney impairment, ventricular assist device procedures, endovascular procedures, a kidney follow-up period of <90 days, and studies not presenting necessary data for effect size calculations. INTERVENTIONS: Patients developing postoperative acute kidney injury after cardiac surgery were compared with patients who did not develop acute kidney injury. MEASUREMENTS AND MAIN RESULTS: The search identified 4,329 unique studies, 87 underwent full-text review, and 12 were included for analysis. Mean acute kidney injury occurrence across studies was 16% (minimum-maximum: 8-50), while mean occurrence of CKD was 24% (minimum-maximum: 3-35), with high variability depending on definitions and follow-up time. Acute kidney injury was associated with increased odds of CKD in all individual studies. The pooled odds ratio across studies was 5.67 (95% confidence interval, 3.34-9.64; p < 0.0001). CONCLUSIONS: Acute kidney injury after cardiac surgery was associated with a more than 5-fold increased odds of developing CKD. New-onset CKD occurred in almost 1 in 4 patients in the years after surgery.

Cirugía coronaria sin circulación extracorpórea / Coronary artery revascularization performed without extracorporeal circulation

La cirugía de revascularización coronaria (CABG) es el estándar de tratamiento para la revascularización de la enfermedad de la arteria coronaria izquierda y/o de tres vasos. La cirugía coronaria sin bomba (OPCAB) evita el uso de derivación cardiopulmonar y puede mejorar los resultados a largo plazo al reducir las tasas de lesión miocárdica perioperatoria, accidente cerebrovascular (ACV), deterioro neurocognitivo y mortalidad de causa cardiaca. En la actualidad, se han llevado a cabo diversos ensayos clínicos desde la popularización del OPCAB en la década de los 90. Sin embargo, hasta el momento no se ha demostrado ningún beneficio del OPCAB en comparación con la cirugía tradicional a pesar de las reducciones favorables a corto plazo en los requerimientos de transfusión y otras complicaciones postoperatorias. Además, OPCAB se asocia con una revascularización miocárdica menos eficaz y no previene por completo las complicaciones tradicionalmente asociadas con la circulación extracorpórea (CEC). Este artículo revisa la evidencia actual de OPCAB en comparación con CABG tradicional en cuanto a los resultados clínicos a corto y largo plazo. Se analizan los resultados de la cirugía coronaria sin circulación extracorpórea (CEC) , comparándola con la cirugía convencional (con CEC). La revascularización coronaria sin CEC presenta resultados similares a la convencional, siempre que se cumplan determinadas condiciones en la selección de los pacientes. Una de ellas, muy importante, es la mayor experiencia del cirujano con el procedimiento.

The results of coronary artery revascularization performed without extracorporeal circulation (off pump) are compared to those of the traditional ("on pump") procedure. Compliance with selective conditions are required to obtain similar results. The most important being the experience of the surgeon performing the off pump procedure.

Autonomic Neuromodulation for Atrial Fibrillation Following Cardiac Surgery: JACC Review Topic of the Week.

Autonomic neuromodulation therapies (ANMTs) (ie, ganglionated plexus ablation, epicardial injections for temporary neurotoxicity, low-level vagus nerve stimulation [LL-VNS], stellate ganglion block, baroreceptor stimulation, spinal cord stimulation, and renal nerve denervation) constitute an emerging therapeutic approach for arrhythmias. Very little is known about ANMTs' preventive potential for postoperative atrial fibrillation (POAF) after cardiac surgery. The purpose of this review is to summarize and critically appraise the currently available evidence. Herein, the authors conducted a systematic review of 922 articles that yielded 7 randomized controlled trials. In the meta-analysis, ANMTs reduced POAF incidence (OR: 0.37; 95% CI: 0.25 to 0.55) and burden (mean difference [MD]: -3.51 hours; 95% CI: -6.64 to -0.38 hours), length of stay (MD: -0.82 days; 95% CI: -1.59 to -0.04 days), and interleukin-6 (MD: -79.92 pg/mL; 95% CI: -151.12 to -8.33 pg/mL), mainly attributed to LL-VNS and epicardial injections. Moving forward, these findings establish a base for future larger and comparative trials with ANMTs, to optimize and expand their use.

Understanding the Aortic Root Using Computed Tomographic Assessment: A Potential Pathway to Improved Customized Surgical Repair.

There is continued interest in surgical repair of both the congenitally malformed aortic valve, and the valve with acquired dysfunction. Aortic valvar repair based on a geometric approach has demonstrated improved durability and outcomes. Such an approach requires a thorough comprehension of the complex 3-dimensional anatomy of both the normal and congenitally malformed aortic root. In this review, we provide an understanding of this anatomy based on the features that can accurately be revealed by contrast-enhanced computed tomographic imaging. We highlight the complimentary role that such imaging, with multiplanar reformatting and 3-dimensional reconstructions, can play in selection of patients, and subsequent presurgical planning for valvar repair. The technique compliments other established techniques for perioperative imaging, with echocardiography maintaining its central role in assessment, and enhances direct surgical evaluation. This additive morphological and functional information holds the potential for improving selection of patients, surgical planning, subsequent surgical repair, and hopefully the subsequent outcomes.

Left atrial appendage closure - Current status and future directions.

Percutaneous left atrial appendage closure (LAAC) has become an important non-pharmacological intervention for stroke prevention in patients with non-valvular atrial fibrillation (AF). LAAC aims to reduce the risk of thromboembolism without increasing the risk of bleeding, a crucial strategy for patients at high risk for bleeding. Over the last few decades, the safety and long-term efficacy of the procedure in specific populations have grown, and more patients are being treated with these devices. Current and future studies focus on expanding the target population as well as the iteration of current technology. This article reviews recent, present, and future LAAC studies on the two most common devices, the Watchman device (Boston Scientific Corporation) and the Amplatzer cardiac plug (ACP) (St. Jude Medical, Minneapolis, MN), and their subsequent next generations, the Watchman FLX, and the Amulet, respectively.

Providing safe perioperative care in cardiac surgery during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has potentiated the need for implementation of strict safety measures in the medical care of surgical patients - and especially in cardiac surgery patients, who are at a higher risk of COVID-19-associated morbidity and mortality. Such measures not only require minimization of patients' exposure to COVID-19 but also careful balancing of the risks of postponing nonemergent surgical procedures and providing appropriate and timely surgical care. We provide an overview of current evidence for preoperative strategies used in cardiac surgery patients, including risk stratification, telemedicine, logistical challenges during inpatient care, appropriate screening capacity, and decision-making on when to safely operate on COVID-19 patients. Further, we focus on perioperative measures such as safe operating room management and address the dilemma over when to perform cardiovascular surgical procedures in patients at risk.

A Simple Percutaneous Retrieval Technique for an Embolized Watchman Left Atrial Appendage Closure Device in the Thoracic Aorta Using a Homemade Snare.

A 60-year old male with paroxysmal atrial fibrillation underwent a combined procedure of left atrial appendage occlusion and pulmonary vein isolation. However, an acute intraprocedural 24-mm Watchman device dislodgement occurred, and thus a decision for urgent surgery was made. However, it was noted during the surgery that the device had migrated further to the descending aorta, just distal to the left subclavian artery. Since a right sternotomy access for retrieval was not feasible, a percutaneous approach was justified. A homemade snare was created using a combination of a long sheath, J-wire, and a regular snare, and the device was successfully retrieved without significant difficulty.

The impact of COVID-19 pandemic on aortic valve surgical service: a single centre experience.

BACKGROUND: The coronavirus-disease 2019 (COVID-19) pandemic imposed an unprecedented burden on the provision of cardiac surgical services. The reallocation of workforce and resources necessitated the postponement of elective operations in this cohort of high-risk patients. We investigated the impact of this outbreak on the aortic valve surgery activity at a single two-site centre in the United Kingdom. METHODS: Data were extracted from the local surgical database, including the demographics, clinical characteristics, and outcomes of patients operated on from March 2020 to May 2020 with only one of the two sites resuming operative activity and compared with the respective 2019 period. A similar comparison was conducted with the period between June 2020 and August 2020, when operative activity was restored at both institutional sites. The experience of centres world-wide was invoked to assess the efficiency of our services. RESULTS: There was an initial 38.2% reduction in the total number of operations with a 70% reduction in elective cases, compared with a 159% increase in urgent and emergency operations. The attendant surgical risk was significantly higher [median Euroscore II was 2.7 [1.9-5.2] in 2020 versus 2.1 [0.9-3.7] in 2019 (p = 0.005)] but neither 30-day survival nor freedom from major post-operative complications (re-sternotomy for bleeding/tamponade, transient ischemic attack/stroke, renal replacement therapy) was compromised (p > 0.05 for all comparisons). Recommencement of activity at both institutional sites conferred a surgical volume within 17% of the pre-COVID-19 era. CONCLUSIONS: Our institution managed to offer a considerable volume of aortic valve surgical activity over the first COVID-19 outbreak to a cohort of higher-risk patients, without compromising post-operative outcomes. A backlog of elective cases is expected to develop, the accommodation of which after surgical activity normalisation will be crucial to monitor.

Trisomy 18 Trends over the Last 20 Years.

OBJECTIVE: To evaluate the trends in hospitalizations for children with trisomy 18 over time and to determine the rate of invasive procedures on these children, using a large inpatient database. STUDY DESIGN: A retrospective analysis using the Kids' Inpatient Database from 1997 to 2016 was performed for trisomy 18. We evaluated survival to discharge as well as the presence of pulmonary, skeletal, neurologic, gastrointestinal, renal, and hematologic/bleeding problems. We also searched for the following interventions, if performed: gastrostomy tube placement, tracheostomy, or cardiac procedure. RESULTS: Over this period 10 151 admissions occurred in children with a diagnosis of trisomy 18. Between 1997 and 2016, the number of children admitted annually with trisomy 18 increased 74% from 1036 to 1798. The proportion of patients born prematurely remained stable at 14%-16% throughout the study. Gastrostomy tube placement increased 12-fold during the study period, tracheostomy increased 11-fold, and cardiac intervention increased 5-fold. The overall mortality rate decreased in those with trisomy 18 from 32% in 1997 to 21% in 2016. CONCLUSIONS: We highlight a decreased inpatient mortality rate during the study period. The number of children undergoing interventions such as gastrostomy tube and tracheostomy increased, as did the number of children undergoing cardiac intervention. Although the number of procedures has increased with the mortality rate decreasing, it is unclear at present whether the 2 are related.

Current practice and future prospects in left atrial appendage occlusion.

The thromboembolic complications of Atrial fibrillation (AF) remain a major problem in contemporary clinical practice. Despite advances and developments in anticoagulation strategies, therapy is complicated by the high risk of bleeding complications and need for meticulous medication compliance. Over the past few decades, the left atrial appendage has emerged as a promising therapeutic target to prevent thromboembolic events while mitigating bleeding complications and compliance issues. Emerging data indicates that it is a safe, effective and feasible alternative to systemic anticoagulation in patients with non-valvular AF. A number of devices have been developed for endocardial or epicardial based isolation of the left atrial appendage. Increasing experience has improved overall procedural safety and ease while simultaneously reducing device related complication rates. Furthermore, increasing recognition of the non-mechanical advantages of this procedure has led to further interest in its utility for further indications beyond the prevention of thromboembolic complications. In this review, we present a comprehensive overview of the evolution of left atrial appendage occlusion, commercially available devices and the role of this modality in the current management of AF. We also provide a brief outline of the landmark trials supporting this approach as well as the ongoing research and future prospects of left atrial appendage occlusion.

Pro-Con Debate: Fibrinogen Concentrate or Cryoprecipitate for Treatment of Acquired Hypofibrinogenemia in Cardiac Surgical Patients.

Cryoprecipitate has been the gold standard for treating acquired hypofibrinogenemia in cardiac surgery for nearly 50 years. More recently, fibrinogen concentrate has been used off-label in the United States and is the standard in European countries and Canada to treat the acquired hypofibrinogenemia during cardiac surgery. Fibrinogen concentrate has multiple potential advantages including rapid reconstitution, greater dose predictability, viral inactivation during processing, and reduced transfusion-related adverse events. However, because fibrinogen concentrate lacks the other components contained in the cryoprecipitate, it may not be the "ideal" product for replacing fibrinogen in all cardiac surgical patients, particularly those with longer cardiopulmonary bypass duration. In this Pro-Con commentary article, we discuss the advantages and disadvantages of using fibrinogen concentrate and cryoprecipitate to treat acquired hypofibrinogenemia in cardiac surgical patients.

Transcatheter mitral valve repair: an overview of current and future devices.

The field of transcatheter mitral valve repair (TMVr) for mitral regurgitation (MR) is rapidly evolving. Besides the well-established transcatheter mitral edge-to-edge repair approach, there is also growing evidence for therapeutic strategies targeting the mitral annulus and mitral valve chordae. A patient-tailored approach, careful patient selection and an experienced interventional team is crucial in order to optimise procedural and clinical outcomes. With further data from ongoing clinical trials to be expected, consensus in the Heart Team is needed to address these complexities and determine the most appropriate TMVr therapy, either single or combined, for patients with severe MR.

Patient-reported outcome measures after mitral valve repair: a comparison between minimally invasive and sternotomy.

OBJECTIVES: To compare patient-reported outcome measures of minimally invasive (MI) to sternotomy (ST) mitral valve repair. METHODS: We included all patients undergoing isolated mitral valve surgery via either a right mini-thoracotomy (MI) or ST over a 36-month period. Patients were asked to complete a modified Composite Physical Function questionnaire. Intraoperative and postoperative outcomes, and patient-reported outcome measures were compared between 2 propensity-matched groups (n = 47/group), assessing 3 domains: 'Recovery Time', 'Postoperative Pain' (at day 2 and 1, 3, 6 and 12 weeks) and 'Treatment Satisfaction'. Composite scores for each domain were subsequently constructed and multivariable analysis was used to determine whether surgical approach was associated with domain scores. RESULTS: The response rate was 79%. There was no mortality in either group. In the matched groups, operative times were longer in the MI group (P < 0.001), but postoperative outcomes were similar. Composite scores for Recovery Time [ST 51.7 (31.8-62.1) vs MI 61.7 (43.1-73.9), P = 0.03] and Pain [ST 65.7 (40.1-83.1) vs MI 79.1 (65.5-89.5), P = 0.02] significantly favoured the MI group. Scores in the Treatment Satisfaction domain were high for both surgical approaches [ST 100 (82.5-100) vs MI 100 (95.0-100), P = 0.15]. The strongest independent predictor of both faster recovery parameter estimate 12.0 [95% confidence interval (CI) 5.7-18.3, P < 0.001] and less pain parameter estimate 7.6 (95% CI 0.7-14.5, P = 0.03) was MI surgery. CONCLUSIONS: MI surgery was associated with faster recovery and less pain; treatment satisfaction and safety profiles were similar.