Postponement of elective cardiac surgery: A prospective observational analysis of anxiety, depression, social support and clinical complications.

AIMS: To investigate patients' psychological reactions to postponement of elective cardiac surgery, and whether postponement was associated with increased complications post-operative and while waiting. DESIGN: A single-centre observational prospective cohort study. METHODS: All adult patients referred for elective cardiac surgery during the study period were considered for inclusion. Psychological data were collected using a survey distributed to patients prior to surgery and at 6 months post-operative. Clinical data were obtained from patient records. RESULTS: A total of 83 postponed and 132 non-postponed patients were included. Postponed patients displayed more avoidance behaviour, but only immediately before surgery. Postponed patients maintained their satisfaction with perceived social support, whereas non-postponed patients became more dissatisfied over time. Waiting 0-14 days was associated with increased symptoms of depression before surgery compared to non-postponed patients or those waiting more than 14 days. Surgical complications were the same in both groups. No patients experienced aggravation of their disease leading to urgent or emergent surgery while waiting for surgery. Hospital-related reasons were the most common cause for postponement of surgery. CONCLUSION: Postponement of selected patients is not associated with increased risk of psychological distress or complications related to the patient's disease. REPORTING METHOD: Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). IMPLICATIONS FOR PATIENT CARE: Pre- and post-psychological interventions may be relevant to consider in relation to elective cardiac surgery as it has been shown to positively affect outcome. Organisational/hospital-related reasons are still very common causes for postponement of elective surgeries, and hospital administrations should focus upon eliminating/decreasing this. PUBLIC CONTRIBUTION: Questionnaires filled by patients were used to understand an association between postponement of cardiac surgery and psychological distress.

Prediction of postoperative atrial fibrillation with postoperative epicardial electrograms.

Objectives. New-onset postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery. The arrhythmia often entails a longer hospital stay, greater risk of other complications, and higher mortality both short- and long-term. An investigation of the use of early atrial electrograms in predicting POAF in cardiac surgery was performed. Design. In this prospective observational study, a total of 99 consecutive adult patients undergoing coronary artery bypass grafting, valve surgery or both were included. On the first postoperative morning, standard 12-lead electrograms (ECG), unipolar atrial electrograms (aEG), and vital values were recorded. The outcome was new-onset POAF within one month postoperatively. Results. Three multivariable prediction models for POAF were formed using measurements derived from the ECG, aEG, and patient characteristics. Age, body mass index, and two unipolar electrogram measurements quantifying local activation time and fractionation were strongly associated with the outcome POAF. The performance of the POAF prediction models was assessed through receiver operating curve characteristics with cross-validation, and discrimination using the leave-one-out-method to internally validate the models. The cross-validated area under the receiver operating characteristic curve (AUC) was improved in a prediction model using atrial-derived electrogram variables (AUC 0.796, 95% CI 0.698-0.894), compared with previous ECG and clinical models (AUC 0.716, 95% CI 0.606-0.826 and AUC 0.718, 95% CI 0.613-0.822, respectively). Conclusions. This study found that easily obtainable measurements from atrial electrograms may be helpful in identifying patients at risk of POAF in cardiac surgery.

Using the C2HEST Score for Predicting Postoperative Atrial Fibrillation After Cardiac Surgery: A Report From the Western Denmark Heart Registry, the Danish National Patient Registry, and the Danish National Prescription Registry.

OBJECTIVES: New-onset postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery. A targeted approach is necessary for prophylactic handling of the complication. The authors tested the performance of the C2HEST score to predict POAF in patients undergoing cardiac surgery. DESIGN: Register-based cohort study. SETTING: Three cardiothoracic centers. PARTICIPANTS: All adult patients undergoing cardiac surgery in Western Denmark between January 1, 2010, and December 31, 2018, were included. Data on patient comorbidities before surgery were obtained from the Western Denmark Heart Registry, the Danish National Patient Registry, and the Danish National Prescription Registry. INTERVENTIONS: The C2HEST score (C2: Coronary Artery Disease/Chronic Obstructive Pulmonary Disease [1 point each]; H: Hypertension; E: Elderly [Age ≥75, 2 points]; S: Systolic Heart Failure [2 points]; T: Thyroid disease [hyperthyroidism]) was calculated for each patient. The primary outcome was POAF within the primary hospital stay. The C2HEST score's discriminative ability was evaluated and compared with an age-stratified version (mC2HEST) as well as 2 validated clinical risk models (CHADS2 and CHA2DS2-VASc). MEASUREMENTS AND MAIN RESULTS: Among the 14,279 patients included, 4,298 (30.1%) developed POAF. The C2HEST score's performance was not significantly better than the CHADS2 and CHA2DS2-VASc scores (area under the curve [AUC] 0.553 [95% confidence interval {CI} 0.543; 0.563] v 0.543 [95% CI 0.535; 0.552] and 0.565 [95% CI 0.555; 0.574], respectively). The age-modified (mC2HEST) score showed only modest improvement in the risk model, with an AUC of 0.580 (95% CI 0.570; 0.590). CONCLUSION: The discriminative ability of the C2HEST score, measured by the AUC, was limited in this population, and was not proven to be superior to the CHADS2, CHA2DS2-VASc, and mC2HEST scores in predicting POAF after cardiac surgery.

Metabolic changes during carbon monoxide poisoning: An experimental study.

Carbon monoxide (CO) is the leading cause of death by poisoning worldwide. The aim was to explore the effects of mild and severe poisoning on blood gas parameters and metabolites. Eleven pigs were exposed to CO intoxication and had blood collected before and during poisoning. Mild CO poisoning (carboxyhaemoglobin, COHb 35.2 ± 7.9%) was achieved at 32 ± 13 minutes, and severe poisoning (69.3 ± 10.2% COHb) at 64 ± 23 minutes from baseline (2.9 ± 0.5% COHb). Blood gas parameters and metabolites were measured on a blood gas analyser and nuclear magnetic resonance spectrometer, respectively. Unsupervised principal component, analysis of variance and Pearson's correlation tests were applied. A P-value ≤ .05 was considered statistically significant. Mild poisoning resulted in a 28.4% drop in oxyhaemoglobin (OHb) and 12-fold increase in COHb, while severe poisoning in a 65% drop in OHb and 24-fold increase in COHb. Among others, metabolites implicated in regulation of metabolic acidosis (lactate, P < .0001), energy balance (pyruvate, P < .0001; 3-hydroxybutyrc acid, P = .01), respiration (citrate, P = .007; succinate, P = .0003; fumarate, P < .0001), lipid metabolism (glycerol, P = .002; choline, P = .0002) and antioxidant-oxidant balance (glutathione, P = .03; hypoxanthine, P < .0001) were altered, especially during severe poisoning. Our study adds new insights into the deranged metabolism of CO poisoning and leads the way for further investigation.

Incidence of Stroke After Pneumonectomy and Lobectomy.

Background and Purpose- After pneumonectomy or lobectomy, at least 1 blind pulmonary vein is left with potential risk of postoperative thromboembolic incidents. We investigated the risk of stroke within this population compared with background and pulmonary wedge resections controls. Methods- We identified 12 965 patients with pneumonectomy or lobectomy and 6400 patients with wedge resection using data from Danish nationwide registries from 1996 to 2016. In multivariate Poisson regression analysis, we estimated incidence rate ratios of stroke for patients undergoing lobectomy or pneumonectomy versus background population controls and patients who underwent wedge resection. We stratified our analysis by days: 0 to 30, 31 to 90, 91 to 180, and 180 to 365 after surgery and performed a subgroup analysis in patients with lung cancer. Results- The incidence rate of stroke was 10.6 per 1000 person-years for time exposed for pneumonectomy or lobectomy and 2.3 per 1000 person-years for patients not exposed for pneumonectomy or lobectomy. In the 0- to 30-day multivariate Poisson regression analysis, compared with the background population, pneumonectomy or lobectomy was associated with an increased risk of stroke both patients with and without atrial fibrillation (incidence rate ratios [IRR]) of 4.66 (95% CI, 2.04-7.12) and 5.43 (95% CI, 3.99-7.41), respectively. Similarly, in patients with lung cancer, the first 30 days after pneumonectomy or lobectomy remained a risk factor for stroke for patients with (IRR, 2.94; 95% CI, 1.39-6.25) and for patients without atrial fibrillation (IRR, 2.56; 95% CI, 1.86-3.59).When compared with wedge resection, 0 to 30 days after lobectomy or pneumonectomy was also associated with increased risk of stroke (IRR, 2.63; 95% CI, 1.19-5.81); however, this association was insignificant in patients with lung cancer (IRR, 2.98; 95% CI, 0.72-12.29). Conclusions- Patients undergoing pneumonectomy or lobectomy had an increased 30 days risk of stroke. Whether the pulmonary vein stump is a risk factor for stroke and whether preventive strategies are relevant require further investigation.

Integration of Rehabilitation Activities Into Everyday Life Through Telerehabilitation: Qualitative Study of Cardiac Patients and Their Partners.

BACKGROUND: Implementation of cardiac rehabilitation has not been optimal, with patient participation rates below 50%. Factors that contribute to cardiac patients' lack of participation in rehabilitation programs are patient motivation, logistical difficulties in getting to the rehabilitation facilities, lack of psychosocial elements, and individualization of activities in the rehabilitation programs. Telerehabilitation has been proposed as a new way to address the challenge of engaging and motivating cardiac patients and their partners to participate in rehabilitation. OBJECTIVE: The aim of this study was to explore the experiences of cardiac patients and their partners of participating in the Teledialog Telerehabilitation Program (TTP). The Teledialog program consisted of a digital rehabilitation plan, transmission of health data from patient's home to hospital and health care center, and an interactive Web portal with information and training videos. METHODS: This case study used a theoretical approach combining the "community of practice" approach and self-determination theory. A triangulation of data collection techniques was used, including documents, participant observation (72 hours), and qualitative interviews with cardiac patients and their partners enrolled in the telerehabilitation group. A total of 14 cardiac patients, 12 patient spouses/partners, and 1 son participated in the study. The participants were interviewed at enrollment in the telerehabilitation program and after 12 weeks of participation in the program. Interview data were analyzed using NVivo 11.0. RESULTS: Patients and their partners found the Web portal ActiveHeart.dk and the electronic rehabilitation (e-rehabilitation) plan to be helpful tools for health education, coordinating rehabilitation goals, creating an overview of the data, and ensuring continuity in the rehabilitation process. The patients felt that the TTP treated them as individuals, gave them a sense of autonomy, and provided enhanced relatedness to health care professionals and partners and a sense of competence as active participants in their own rehabilitation process. Some patients missed being part of a community of practice with other cardiac patients and did not use the Web forum. Patients' partners found that the telerehabilitation program gave them a sense of security and helped them balance their involvement as a partner to the patient and not push the patient too hard. CONCLUSIONS: Cardiac patients and their partners found telerehabilitation technologies a useful digital toolbox in the rehabilitation process. Telerehabilitation motivated the patients to integrate rehabilitation activities into their work schedule and everyday life and made them feel like unique individuals. Participating in the Teledialog Telerehabilitation Program might not be a suitable strategy for all cardiac patients. Being a patient's partner in the telerehabilitation program was associated with a heightened sense of security, navigation between active involvement in the rehabilitation process, being an equal partner, and not pushing the patient too hard.

Regional muscle tissue saturation is an indicator of global inadequate circulation during cardiopulmonary bypass: a randomized porcine study using muscle, intestinal and brain tissue metabolomics.

BACKGROUND: Muscle tissue saturation (StO2) measured with near-infrared spectroscopy has generally been considered a measurement of the tissue microcirculatory condition. However, we hypothesized that StO2 could be more regarded as a fast and reliable measure of global than of regional circulatory adequacy and tested this with muscle, intestinal and brain metabolomics at normal and two levels of low cardiopulmonary bypass blood flow rates in a porcine model. METHODS: Twelve 80 kg pigs were connected to normothermic cardiopulmonary bypass with a blood flow of 60 mL/kg/min for one hour, reduced randomly to 47.5 mL/kg/min (Group I) or 35 mL/kg/min (Group II) for one hour followed by one hour of 60 mL/kg/min in both groups. Regional StO2 was measured continuously above the musculus gracilis (non-cannulated leg). Metabolomics were obtained by brain tissue oxygen monitoring system (Licox) measurements of the brain and microdialysis perfusate from the muscle, intestinal mucosa and brain. A non-parametric statistical method was used. RESULTS: The systemic parameters showed profound systemic ischaemia during low CPB blood flow. StO2 did not change markedly in Group I, but in Group II, StO2 decreased immediately when blood flow was reduced and, furthermore, was not restored despite blood flow being normalized. Changes in the metabolomics from the muscle, colon and brain followed the changes in StO2. CONCLUSION: We found, in this experimental cardiopulmonary bypass model, that StO2 reacted rapidly when the systemic circulation became inadequate and, furthermore, reliably indicate insufficient global tissue perfusion even when the systemic circulation was restored after a period of systemic hypoperfusion.

No Effect of Rapamycin on Cardiac Adhesion Formation: A Drug-Loaded Bioresorbable Polylactone Patch in a Porcine Cardiac Surgical Model.

BACKGROUND: The fusing of the epicardium and sternum due to adhesion is a common problem during repeated cardiac surgery and carries with it an increased risk of bleeding. The use of barriers and patches has been tested to prevent the formation of adhesions, but the very presence of a patch can provoke adhesion formation. The objective of this study was, therefore, to investigate both biodegradable and bioresorbable polylactone patches [(polycaprolactone-poly(ethylene oxide)-polycaprolactone tri-block copolymer (PCE)]. The patches were also tested with a controlled release of rapamycin, which prevents cell migration and extracellular matrix deposition. The clinical effectiveness of rapamycin in pericardial patches has not previously been examined. MATERIALS AND METHODS: Three groups of 6 female Danish Landrace pigs underwent sternotomy and abrasion of the epicardium, before being randomized to either group 1--the control group (with no patch), group 2--PCE patch implanted between the sternum and epicardium, or group 3--PCE patch and slow-release 1.6-mg rapamycin. After a median time period of 26 days, the pigs were euthanized and their hearts removed en bloc with the sternum, for macroscopic, histological and pathological examination. RESULTS: Upon macroscopic examination, a significantly lower degree of adhesion in group 2, as compared to group 1 (p < 0.05), was found. Histological analysis of the tissues showed significantly more fibrosis, inflammation and foreign body granulomas (p < 0.05) in both group 2 and group 3, when compared to group 1. CONCLUSION: A PCE patch following sternotomy in animal subjects reduces postoperative macroscopic adhesions without reducing microscopic fibrosis or inflammation. Loading the patch with rapamycin was found not to increase the antifibrotic effect.

Cardiac Patients' Walking Activity Determined by a Step Counter in Cardiac Telerehabilitation: Data From the Intervention Arm of a Randomized Controlled Trial.

BACKGROUND: Walking represents a large part of daily physical activity. It reduces both overall and cardiovascular diseases and mortality and is suitable for cardiac patients. A step counter measures walking activity and might be a motivational tool to increase and maintain physical activity. There is a lack of knowledge about both cardiac patients' adherence to step counter use in a cardiac telerehabilitation program and how many steps cardiac patients walk up to 1 year after a cardiac event. OBJECTIVE: The purpose of this substudy was to explore cardiac patients' walking activity. The walking activity was analyzed in relation to duration of pedometer use to determine correlations between walking activity, demographics, and medical and rehabilitation data. METHODS: A total of 64 patients from a randomized controlled telerehabilitation trial (Teledi@log) from Aalborg University Hospital and Hjoerring Hospital, Denmark, from December 2012 to March 2014 were included in this study. Inclusion criteria were patients hospitalized with acute coronary syndrome, heart failure, and coronary artery bypass grafting or valve surgery. In Teledi@log, the patients received telerehabilitation technology and selected one of three telerehabilitation settings: a call center, a community health care center, or a hospital. Monitoring of steps continued for 12 months and a step counter (Fitbit Zip) was used to monitor daily steps. RESULTS: Cardiac patients walked a mean 5899 (SD 3274) steps per day, increasing from mean 5191 (SD 3198) steps per day in the first week to mean 7890 (SD 2629) steps per day after 1 year. Adherence to step counter use lasted for a mean 160 (SD 100) days. The patients who walked significantly more were younger (P=.01) and continued to use the pedometer for a longer period (P=.04). Furthermore, less physically active patients weighed more. There were no significant differences in mean steps per day for patients in the three rehabilitation settings or in the disease groups. CONCLUSIONS: This study indicates that cardiac telerehabilitation at a call center can support walking activity just as effectively as telerehabilitation at either a hospital or a health care center. In this study, the patients tended to walk fewer steps per day than cardiac patients in comparable studies, but our study may represent a more realistic picture of walking activity due to the continuation of step counter use. Qualitative studies on patients' behavior and motivation regarding step counter use are needed to shed light on adherence to and motivation to use step counters. TRIAL REGISTRATION: ClinicalTrials.gov NCT01752192; https://clinicaltrials.gov/ct2/show/NCT01752192 (Archived by WebCite at http://www.webcitation.org/6fgigfUyV).

Cost-Utility Analysis of a Cardiac Telerehabilitation Program: The Teledialog Project.

BACKGROUND: Cardiac rehabilitation can reduce mortality of patients with cardiovascular disease, but a frequently low participation rate in rehabilitation programs has been found globally. The objective of the Teledialog study was to assess the cost-utility (CU) of a cardiac telerehabilitation (CTR) program. The aim of the intervention was to increase the patients' participation in the CTR program. At discharge, an individualized 3-month rehabilitation plan was formulated for each patient. At home, the patients measured their own blood pressure, pulse, weight, and steps taken for 3 months. MATERIALS AND METHODS: The analysis was carried out together with a randomized controlled trial with 151 patients during 2012-2014. Costs of the intervention were estimated with a health sector perspective following international guidelines for CU. Quality of life was assessed using the 36-Item Short Form Health Survey. RESULTS: The rehabilitation activities were approximately the same in the two groups, but the number of contacts with the physiotherapist was higher among the intervention group. The mean total cost per patient was €1,700 higher in the intervention group. The quality-adjusted life-years (QALYs) gain was higher in the intervention group, but the difference was not statistically significant. The incremental CU ratio was more than €400,000 per QALY gained. CONCLUSIONS: Even though the rehabilitation activities increased, the program does not appear to be cost-effective. The intervention itself was not costly (less than €500), and increasing the number of patients may show reduced costs of the devices and make the CTR more cost-effective. Telerehabilitation can increase participation, but the intervention, in its current form, does not appear to be cost-effective.

Acute Kidney Injury and Long-term Risk of Cardiovascular Events After Cardiac Surgery: A Population-Based Cohort Study.

OBJECTIVE: To examine the impact of postoperative acute kidney injury (AKI) on the long-term risk of myocardial infarction, heart failure, stroke, and all-cause mortality after elective cardiac surgery. The authors investigated whether time of onset of AKI altered the association between AKI and the adverse events. DESIGN: Population-based cohort study in 2006-2011. SETTING: Two university hospitals. PARTICIPANTS: Adult elective cardiac surgical patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: AKI was defined as an increase in baseline creatinine according to the Kidney Disease Improving Global Outcomes criteria. AKI was defined within 30 days of surgery, and also analyzed as early- or late-onset AKI. The authors followed patients from postoperative day 30 until hospitalization with myocardial infarction, heart failure, stroke, or death. Adjustment for confounding factors was done using propensity scores and standardized-mortality-ratio weights. A total of 1,457 (30.7%) of 4,742 patients developed AKI within 30 days of surgery and 470 (9.9%) patients experienced a composite cardiovascular endpoint. Comparing patients with and without postoperative AKI, weighted hazard ratio (HR) and 95% confidence intervals (CI) of 5-year risk of the composite cardiovascular endpoint was 1.41 (95% CI: 1.11-1.80). For each endpoint separately the weighted HR was similarly increased. Ninety-one days to 5-year weighted HR of all-cause mortality was 1.37 (95% CI: 1.05-1.80). The effect of AKI was similar for early- and late-onset AKI. CONCLUSIONS: Early- and late-onset AKI within 30 days of elective cardiac surgery was associated with a similarly increased 5-year risk of myocardial infarction, heart failure, stroke, and increased all-cause mortality.

Exercise-based real-time telerehabilitation for older patients recently discharged after transcatheter aortic valve implantation: An extended feasibility study.

OBJECTIVES: To assess the extended feasibility of a telerehabilitation program and its effects on physical performance in older adults who have recently undergone transcatheter aortic valve implantation (TAVI). METHODS: In this single-center feasibility study, patients underwent an eight-week telerehabilitation program, involving web-based home exercise training twice weekly, an activity tracker, access to an informative website, and one online session with a nurse, starting one-week postoperative. Data collection was performed before surgery and three months postoperative. The feasibility of the intervention was based on recruitment and adherence to the program. As a secondary outcome, we evaluated the change in six-minute walk distance from before surgery to three months postoperative. RESULTS: Forty-one patients scheduled for TAVI were assessed for eligibility; 15 patients (37%) were enrolled. Of these, eight were excluded after surgery due to tiredness (n = 2), non-cardiac related hospital readmission (n = 2), fluctuating health (n = 1), death during hospital stay (n = 1), and reduced cognition (n = 2). Seven patients completed the eight-week web-based intervention and were evaluated three months postoperative. Their median (IQR) age was 83 [81, 87] years, and the sample comprised three men and four women. Their walked distance improved from median (IQR) 262 [199, 463] before surgery, to 381 [267, 521] meters three months postoperative. No adverse events were reported. CONCLUSION: Web-based telerehabilitation, including supervised exercise training, in older adults who have recently undergone TAVI was feasible for a small number of patients who completed the eight-week intervention. This was reflected in an improvement in their walked distance three months after the surgery. However, the low recruitment and retention rates do question the overall feasibility of this intervention in a frail, older population of post-TAVI patients.

Chronic post-thoracotomy pain after lung cancer surgery: a prospective study of preoperative risk factors.

OBJECTIVES: The objective of this longitudinal cohort study was to investigate if preoperative pain mechanisms, anxiety, and depression increase risk of developing chronic post-thoracotomy pain (CPTP) after lung cancer surgery. METHODS: Patients with suspected or confirmed lung cancer undergoing surgery by either video-assisted thoracoscopic surgery or anterior thoracotomy were recruited consecutively. Preoperative assessments were conducted by: quantitative sensory testing (QST) (brush, pinprick, cuff pressure pain detection threshold, cuff pressure tolerance pain threshold, temporal summation and conditioned pain modulation), neuropathic pain symptom inventory (NPSI), and the Hospital Anxiety and Depression Scale (HADS). Clinical parameters in relation to surgery were also collected. Presence of CPTP was determined after six months and defined as pain of any intensity in relation to the operation area on a numeric rating scale form 0 (no pain) to 10 (worst pain imaginable). RESULTS: A total of 121 patients (60.2 %) completed follow-up and 56 patients (46.3 %) reported CPTP. Development of CPTP was associated with higher preoperative HADS score (p=0.025), higher preoperative NPSI score (p=0.009) and acute postoperative pain (p=0.042). No differences were observed in relation to preoperative QST assessment by cuff algometry and HADS anxiety and depression sub-scores. CONCLUSIONS: High preoperative HADS score preoperative pain, acute postoperative pain intensity, and preoperative neuropathic symptoms were was associated with CPTP after lung cancer surgery. No differences in values of preoperative QST assessments were found. Preoperative assessment and identification of patients at higher risk of postoperative pain will offer opportunity for further exploration and development of preventive measures and individualised pain management depending on patient risk profile.

Fewer transfusions are still more-red blood cell transfusions affect long-term mortality in cardiac surgery.

OBJECTIVES: Previous studies indicated higher long-term mortality after the transfusion of allogeneic red blood cells (RBC); newer recommendations emphasize lower transfusion rates. The consequences of the transfusion of RBCs in cardiac surgery are unclear because later studies focused on transfusion triggers and short-term outcomes. Reports on long-term complications after cardiac surgery are few. MATERIAL AND METHODS: The mandatory Western Denmark Heart Registry was used to identify all adult cardiac operations performed in 4 centres from 2000 to 2019. Patients with multiple entries or previous cardiac operations, special/complex procedures, dying within 30 days and not eligible for follow-up were excluded. RESULTS: A total of 32,581 adult cardiac operations performed in 4 centres from 2000 to 2019 were included. The Kaplan-Meier survival plot for low-risk patients undergoing simple cardiac operations showed a significantly lower 15-year survival (0.384 vs 0.661) of patients who received perioperative RBC transfusions [odds ratio 2.43 (confidence level 2.23-2.66)]. The risk decreased with increasing comorbidity or age. No difference was found in high-risk patients. The adjusted risk ratio after an RBC transfusion, including age, sex, comorbidity and surgery, was 1.62 (1.48-1.77). CONCLUSIONS: Despite reduced transfusion rates, long-term follow-up on especially low-risk patients undergoing comparable cardiac operations still demonstrates substantially more deaths of patients receiving perioperative RBC transfusions. Even transfusion of 1-2 units is associated with increased long-term mortality.

Efforts to change transfusion practice and reduce transfusion rates are effective in coronary artery bypass surgery.

OBJECTIVES: Efforts to decrease allogeneic blood transfusion and avoid unnecessary transfusions in cardiac surgery are important because transfusions are associated with increased postoperative morbidity and mortality. The purpose of the present study was to evaluate the long-term effects of multidisciplinary efforts to reduce allogeneic blood transfusion rates and avoid unnecessary red blood cell (RBC) transfusions in primary elective coronary artery bypass graft (CABG) surgery. DESIGN: A retrospective observational study. SETTING: A single center study in a university-affiliated hospital. PARTICIPANTS: A total of 450 patients undergoing primary elective CABG surgery during 2004, 2008, or 2010. INTERVENTIONS: The application of systematic multimodal perioperative blood-sparing techniques and interventions directed to change transfusion behaviors. MEASUREMENTS AND MAIN RESULTS: The results from an audit on transfusion practices in 2004 were compared with similar audits performed in 2008 and 2010 using a before-and-after study design. The patient populations were comparable throughout the years. The median postoperative chest tube bleeding was decreased from 950 mL in 2004 to 750 mL in 2010. The proportion of patients transfused with allogeneic blood products was decreased from 64% to 47%. Overtransfusion with allogeneic RBCs defined as the proportion of patients transfused with RBCs discharged with hemoglobin >7 mmol/L (11.3 g/dL) was reduced from 36% to 16%. CONCLUSIONS: Multimodal efforts to change transfusion behaviors and decrease transfusion rates in CABG surgery have persistent effects for several years.

Exercise-Based Real-time Telerehabilitation for Older Adult Patients Recently Discharged After Transcatheter Aortic Valve Implantation: Mixed Methods Feasibility Study.

BACKGROUND: The use of telehealth technology to improve functional recovery following transcatheter aortic valve implantation (TAVI) has not been investigated. OBJECTIVE: In this study, we aimed to examine the feasibility of exercise-based cardiac telerehabilitation after TAVI. METHODS: This was a single-center, prospective, nonrandomized study using a mixed methods approach. Data collection included testing, researchers' observations, logbooks, and individual patient interviews, which were analyzed using a content analysis approach. The intervention lasted 3 weeks and consisted of home-based web-based exercise training, an activity tracker, a TAVI information website, and 1 web-based session with a nurse. RESULTS: Of the initially included 13 patients, 5 (40%) completed the study and were interviewed; the median age was 82 (range 74-84) years, and the sample comprised 3 men and 2 women. Easy access to supervised exercise training at home with real-time feedback and use of the activity tracker to count daily steps were emphasized by the patients who completed the intervention. Reasons for patients not completing the program included poor data coverage, participants' limited information technology skills, and a lack of functionality in the systems used. No adverse events were reported. CONCLUSIONS: Exercise-based telerehabilitation for older people after TAVI, in the population as included in this study, and delivered as a web-based intervention, does not seem feasible, as 60% (8/13) of patients did not complete the study. Those completing the intervention highly appreciated the real-time feedback during the web-based training sessions. Future studies should address aspects that support retention rates and enhance patients' information technology skills.

Perspectives on Participation in a Feasibility Study on Exercise-Based Cardiac Telerehabilitation After Transcatheter Aortic Valve Implantation: Qualitative Interview Study Among Patients and Health Professionals.

BACKGROUND: Aortic valve stenosis affects approximately half of people aged ≥85 years, and the recommended surgical treatment for older patients is transcatheter aortic valve implantation (TAVI). Despite strong evidence for its advantages, low attendance rate in cardiac rehabilitation is observed among patients after TAVI. Cardiac telerehabilitation (CTR) has proven comparable with center-based rehabilitation; however, no study has investigated CTR targeting patients after TAVI. On the basis of participatory design, an exercise-based CTR program (TeleTAVI) was developed, which included a web-based session with a cardiac nurse, a tablet containing an informative website, an activity tracker, and supervised home-based exercise sessions that follow the national recommendations for cardiac rehabilitation. OBJECTIVE: This study aims to explore patients' and health professionals' experiences with using health technologies and participating in the exercise-based CTR program, TeleTAVI. METHODS: This study is a part of a feasibility study and will only report patients' and health professionals' experiences of being a part of TeleTAVI. A total of 11 qualitative interviews were conducted using a semistructured interview guide (n=7, 64% patients and n=4, 36% health professionals). Patient interviews were conducted after 8 weeks of participation in TeleTAVI, and interviews with health professionals were conducted after the end of the program. The analysis was conducted as inductive content analysis to create a condensed meaning presented as themes. RESULTS: Reticence toward using the website was evident with reduced curiosity to explore it, and reduced benefit from using the activity tracker was observed, as the patients' technical competencies were challenged. This was also found when using the tablet for web-based training sessions, leading to patients feeling worried before the training, as they anticipated technical problems. Disadvantages of the TeleTAVI program were technical problems and inability to use hands-on guidance with the patients. However, both physiotherapists and patients reported a feeling of improvement in patients' physical fitness. The home training created a feeling of safety, supported adherence, and made individualization possible, which the patients valued. A good relationship and continuity in the contact with health professionals seemed very important for the patients and affected their positive attitude toward the program. CONCLUSIONS: The home-based nature of the TeleTAVI program seems to provide the opportunity to support individualization, autonomy, independence, and adherence to physical training in addition to improvement in physical capability in older patients. Despite technological challenges, basing the relationship between the health professionals and patients on continuity may be beneficial for patients. Prehabilitation may also be considered, as it may create familiarity toward technology and adherence to the training.

Distress and anxiety following postponed cardiac surgery prior to and during the COVID-19 pandemic.

INTRODUCTION: Recently, the COVID-19 pandemic has caused postponements of elective cardiac surgery. We hypothesised that postponements due to the pandemic were associated with higher levels of psychological distress than prepandemic postponements. METHODS: A prospective, observational cohort study was conducted among patients in whom elective cardiac surgery was postponed. Patients who received information regarding a new date of surgery prior to the pandemic were compared with patients postponed during the pandemic without information regarding a new date of surgery. Data were collected from patient records, validated questionnaires and interviews. RESULTS: Out of 55 postponed patients, 21 experienced prepandemic postponement. No significant differences were observed between groups regarding the psychological measures before their rescheduled operation. However, patients in both groups reported high levels of anxiety and depression with > 60% indicative of potentially positive diagnoses. No differences were found in mortality across groups and no patients developed severe complications. Interviews showed that patients in the COVID-19 group felt immediate relief at postponement and engaged in a meaning-making process with respect to their ability to tolerate postponement in order to reassure themselves and their relatives. CONCLUSIONS: No significant differences were found in psychological distress between the patients of the two groups. However, both groups experienced high levels of psychological distress. It remains unknown whether these results may be extrapolated to other surgical fields. FUNDING: none. TRIAL REGISTRATION: not relevant.

Health-Related Quality of Life and Angina in Fractional Flow Reserve- Versus Angiography-Guided Coronary Artery Bypass Grafting: FARGO Trial (Fractional Flow Reserve Versus Angiography Randomization for Graft Optimization).

BACKGROUND: In coronary artery bypass grafting (CABG), the use of fractional flow reserve (FFR) is insufficiently investigated. Stenosis assessment usually relies on visual estimates of lesion severity. This study evaluated health-related quality of life (HRQoL) and angina after FFR- versus angiography-guided CABG. METHODS: One hundred patients referred for CABG were randomized to FFR- or angiography-guided CABG. In the FFR group, lesions with FFR>0.80 were deferred, while the surgeon was blinded to the FFR values in the angiography group. Before and 6 months after CABG, HRQoL was assessed by the health state classifier EQ-5D of the EuroQoL 5-level instrument and angina status based on the Canadian Cardiovascular Society classification system were registered. RESULTS: Six-month angiography included FFR evaluations of deferred lesions. In total, completed EQ-5D of the EuroQoL 5-level instrument questionnaires were available in 86 patients (43 in the FFR versus 43 in the angiography-guided group). HRQoL was significantly improved and angina significantly decreased from baseline to 6 months after CABG with no difference between the randomization groups. Graft failure rates and clinical outcomes were similar in both groups. Patients with graft failure or FFR<0.80 of the previous deferred lesions had significantly lower visual analogue scale scores (78.7±14.2 versus 86.8±14.7, P=0.004) and more angina compared with patients without graft failure or FFR≥0.80 at 6-month follow-up. CONCLUSIONS: FFR- versus angiography-guided CABG demonstrated similar improvements in HRQoL and angina 6 months after CABG. Graft failure or low FFR in deferred lesions were associated with low HRQoL and angina. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02477371.

Peroperative epicardial ultrasonography of distal coronary artery bypass graft anastomoses using a stabilizing device. A feasibility study.

BACKGROUND: Widespread use of intraoperative epicardial ultrasonography (ECUS) for quality assessment of coronary artery bypass graft anastomoses during coronary artery bypass grafting (CABG) has not occurred - presumably due to technological and practical challenges including the need to maintain stable and optimal acoustic contact between the ultrasound probe and the target without the risk of distorting the anastomosis. We investigated the feasibility of using a stabilizing device during ultrasound imaging of distal coronary bypass graft anastomoses in patients undergoing on-pump CABG. Imaging was performed in both the longitudinal and transverse planes. METHODS: Single-centre, observational prospective feasibility study among 51 patients undergoing elective, isolated on-pump CABG. Ultrasonography of peripheral coronary bypass anastomoses was performed using a stabilizing device upon which the ultrasound transducer was connected. Transit-time flow measurement (TTFM) was also performed. Descriptive statistical tests were used. RESULTS: Longitudinal and transverse images from the heel, middle and toe were obtained from 134 of 155 coronary anastomoses (86.5%). After the learning curve (15 patients), all six projections were obtained from 100 of 108 anastomoses scanned (93%). Failure to obtain images were typical due to a sequential curved graft with anastomoses that could not be contained in the straight cavity of the stabilizing device, echo artefacts from a Titanium clip located in the roof of the anastomoses, and challenges in interpreting the images during the learning curve. No complications were associated with the ECUS procedure. The combined ECUS and TTFM resulted in immediate revision of five peripheral anastomoses. CONCLUSIONS: Peroperative use of a stabilizing device during ultrasonography of coronary artery bypass anastomoses in on-pump surgery facilitates imaging and provides surgeons with non-deformed longitudinal and transverse images of all parts of the anastomoses in all coronary territories. Peroperative ECUS in addition to flow measurements has the potential to increase the likelihood of detecting technical errors in constructed anastomoses. TRIAL REGISTRATION: The study was registered on September 29, 2016, ClinicalTrials.gov ID: NCT02919124.