Adoption of Technology by Healthcare Personnel: An Institutional Survey.

BACKGROUND: In the current era, technology has a significant influence on healthcare outcomes. Despite that, there are significant barriers and concerns toward the adoption of digital laboratory reporting systems among healthcare professionals in India. The aim of the study was to understand the overall attitude, barriers, and motivators toward the adoption of technology by healthcare personnel. METHODS: The study was conducted through a single-center and prospective questionnaire survey among physicians and surgeons of various specialities, with 107 participants. The electronic laboratory system at the institution, called "AADI," could be accessed across any computer terminal and through a web-based application that could be downloaded on any mobile device. RESULTS: The results of the study revealed that 98 out of 107 (91.59%) healthcare professionals used the digital platform regularly to access laboratory results, while only 9 (8.4%) did not use it. The mean satisfaction score of the users was 4.62 ± 0.51. The study showed that most users found the digital system to be more secure and reliable, which led to significant time savings compared to the paper-based system. The study also found that age was a determinant of usage, with younger healthcare professionals using the application more frequently. CONCLUSION: Overall, the study suggests that digital laboratory reporting systems have significant benefits, and further efforts are needed to increase adoption in healthcare establishments in India.

Levosimendan or Milrinone for Ventricular Septal Defect Repair With Pulmonary Arterial Hypertension.

OBJECTIVE: Both milrinone and levosimendan have been used in patients undergoing surgical closure of ventricular septal defects (VSD) with pulmonary artery hypertension (PAH); however, the evidence base for their use is limited. In the present study, the authors sought to compare the role of levosimendan and milrinone in the prevention of low-cardiac-output syndrome in the early postoperative period. DESIGN: A prospective, randomized, controlled trial. SETTING: At a tertiary-care center. PARTICIPANTS: Children between 1 month and 12 years presenting with VSD and PAH between 2018 and 2020. INTERVENTIONS: A total of 132 patients were randomized into the following 2 groups: Group L (levosimendan group) and Group M (milrinone group). MEASUREMENTS AND MAIN RESULTS: In addition to conventional hemodynamic parameters, the authors also included a myocardial performance index assessment to compare the groups. The levosimendan group had significantly lower mean arterial pressure while coming off cardiopulmonary bypass, after shifting to intensive therapy unit, as well as at 3 and 6 hours postoperatively. The duration of ventilation (29.6 ± 13.9 hours v 23.2 ± 13.3 hours; p = 0.012), as well as postoperative intensive care unit stay, were significantly prolonged in the levosimendan group (5.48 ± 1.2 v 4.7 ± 1.3 days, p = 0.003). There were 2 (1.6%) in-hospital deaths in the entire cohort, 1 in each arm. There was no difference in the myocardial performance index of the left or right ventricle. CONCLUSIONS: In patients undergoing surgical repair for VSD with PAH, levosimendan does not confer any additional benefit compared to milrinone. Both milrinone and levosimendan appear to be safe in this cohort.

Sacubitril-Valsartan in Patients with Ischemic Cardiomyopathy Undergoing Off-Pump Coronary Artery Bypass Grafting-Is It Safe?

Sacubitril-valsartan has been used selectively in patients undergoing coronary artery bypass grafting (CABG) and ischemic cardiomyopathy due to safety concerns. The aim of this prospective observational study was to assess the safety profile of sacubitril-valsartan in patients with reduced ejection fraction (EF <40%) undergoing CABG. Primary outcome was tolerability and safety profile. Thirty consecutive patients undergoing CABG with EF <40% were included. No mortality or readmissions occurred during 6 months follow-up. One (3.3%) patient experienced hypotension requiring discontinuation. Mild (8.9%) elevation in blood urea nitrogen, p = 0.35; along with a significant increase in serum creatinine (0.12mg/DL), p = 0.02; and potassium (0.23 mmol/L), p 0.003 was seen during follow-up. Sacubitril-valsartan is well tolerated in patients with reduced EF undergoing CABG.

Valve choice for aortic valve replacement in patients between 50 and 70 years of age.

BACKGROUND AND AIM: There is a lack of clarity on whether to choose a mechanical or a bioprosthetic valve for aortic valve replacement in patients between the age of 50 and 70. METHODS: In this review, the existing evidence on the subject has been evaluated. RESULTS: Decision-making in this age group is heavily dependent on patient choice and patient-related factors. Mechanical valves in this age group are associated with an increased risk of bleeding while reoperations remain an important concern with bioprosthetic valves. Stroke rates have been reported to be largely similar in both valve types. CONCLUSION: There appears to be conflicting data on survival with some studies suggesting a survival benefit with mechanical valves.

To repair or replace-the root dilemma in aortic dissections.

Significant dilemma exists regarding the management of the aortic root pathology in acute aortic dissections. Several strategies for both repair and replacement exist and there is a lack of clarity on the superiority of one over the other. Important factors that influence management strategies include involvement of the sinuses, the competence of the aortic valve, the presence of Marfans syndrome, and connective tissue disorders, as well as availability of surgical expertise. The wide variability in these factors makes it unlikely for any one technique to be suitable for the management of all aortic roots pathology.

Robotic hybrid coronary revascularization-A need for strategy specific data.

Robotic totally endoscopic techniques to perform the left internal thoracic artery to left anterior descending graft, coupled with percutaneous coronary intervention (PCI), provide the least invasive option to achieve hybrid coronary revascularization (HCR). Shorter hospital stays and reduced need for blood transfusions have been consistently being reported by several studies along with similar long-term outcomes. Considerable variations exist in the definition of HCR which can be single or two-staged with surgical revascularization being carried out after PCI or vice versa. Variations also exist with respect to usage of cardiopulmonary bypass, surgical incisions, and the use of minimally invasive robotic techniques. The different strategies of HCR do not lead to similar outcomes and the findings of one strategy cannot be extrapolated to the entire group. Studies reporting different strategies of HCR should ideally provide more granular data when reporting outcomes.

Robotically assisted hybrid coronary revascularization-Masterly technique but is it for the masses?

Hybrid coronary revascularization consists of left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery and transcatheter revascularization of the non-LAD stenosis in specific settings to achieve complete coronary revascularization. Technique to perform the LITA to LAD graft has ranged from median sternotomy with cardiopulmonary bypass to robotically assisted totally endoscopic coronary bypass surgery using beating heart revascularization.

Octogenarians needing reoperative aortic valve surgery-Does one size fit all?

Early and midterm outcomes, rather than long-term outcomes, are perhaps more relevant in octogenarians undergoing transcatheter aortic valve replacement (TAVR) or redo-surgical aortic valve replacement. Considering that early and midterm outcomes are similar with both the interventions, TAVR appears to be an attractive option in these patients. However, decision-making should consider other factors like presence of porcelain aorta, or severe primary mitral regurgitation among others that may influence the strategy to be adopted. The philosophy of shared decision making, and heart team consultation is, therefore, ever most relevant in these high-risk and vulnerable groups of patients. The recommendations rather than being universal must be individualized based on the type of previous surgery carried out, need for isolated AVR or concomitant surgery, co-morbid conditions, available expertise, and patient choice.

Lactate levels: A reliable tool to predict mortality in acute type A aortic dissections?

Lactate levels are surrogate markers of malperfusion in patients presenting with type A aortic dissections. Lactate measurement is simple, easy to perform, universally available, and thus can be an important tool for predicting mortality. However, the discriminatory power varies between studies and no cut-off point has been defined that can determine outcomes in the most reliable fashion. The risk prediction based on lactate levels can be improved when combined with other clinical and laboratory prognostic factors. Further studies with a much larger sample size, need to be carried out using serial measurements at well-defined time points to try and identify a cut-off value. The addition of lactate values to existing risk prediction scores or developing a new score based on it should be the subject of future research.

Moderately dilated ascending aorta-The right wrap?

External reinforcement of the dilated or thin-walled aorta has been tried for nearly half a century. A range of materials has been used as external support. This commentary assesses the evidence that exists regarding the efficacy of wrapping the aorta as well as compares the different options available with a particular focus on the usage of the autologous pericardium.

Determinant of outcome in late presenting type A aortic dissection.

BACKGROUND: Early repair is recommended in type A aortic dissection repair, however, this is not often possible. The aim of this study was to assess the time delays, examine the effect of timing and malperfusion on outcomes, and identify other independent risk factors for mortality. METHODS: This was a retrospective study on data collected prospectively. Primary outcome was 30-day mortality. Secondary outcome was adverse postoperative outcomes. All patients who arrived at the hospital with a type A aortic dissection, irrespective of the timing, were included in the study. Univariate as well as multivariate analysis was carried out. RESULTS: A total of 81 patients presented to our institution during the study period. Half the patients got operated within 86 h of symptom onset and 75% were operated within 183 h. With regards to malperfusion, 6 (8.8%) patients had cerebral malperfusion, 10 (14.7%) had features of myocardial ischemia, and 13 (19.1%) had renal malperfusion. One (1.5%) patient had mesenteric ischemia and 9 (13.2%) had limb ischemia. The duration between symptom onset and operative repair was longer in survivors (152 ± 167 vs. 75 ± 102, p = .29). A total of 29 (42.6%) patients presented with features of one or more organ malperfusion and the mortality in these patients was significantly higher at 10 (34.5%) versus 5 (12.5%); p = .04. Multivariable logistic regression identified CPB time as an independent risk factor in our cohort for 30-day mortality (odds ratio: 1.03; 95% confidence interval: 1.007-1.06). CONCLUSION: In cases of predominantly delayed presentation and operative repair, the outcome is significantly influenced by presence of malperfusion. Surgical repair still produces satisfactory outcomes and should be undertaken at the earliest in most cases.

Effect of preoperative statins on respiratory complications after coronary artery bypass grafting.

OBJECTIVES: Limited data exist on the effect of preoperative statin therapy on postoperative respiratory complications. Machine learning algorithms (MLA) can process large, heterogenous data, and have immensely improved the ability for risk prediction. In this study, we sought to examine the role of preoperative statins on respiratory complications in patients undergoing coronary artery bypass grafting (CABG) using MLA. METHODS: The study population contained the data of patients who underwent CABG between the years 2015 and 2019 (n = 5638). Three hundred and thirty-seven independent variables were recorded and the data was randomly split with stratified sampling into training and testing data with 20% of the data (1113 records) reserved for model testing. Various models including linear models, Random forest, SVM, and XGboost were trained to predict the incidence of postoperative respiratory complications. Forty-seven important features were found to impact model prediction (p ≤ .05) using the global surrogate model method. A conventional multivariable linear regression model was then used to identify predictors of respiratory complications. RESULTS: One thousand three hundred sixty-two (24.5%) patients developed a respiratory complication in our series. The respiratory complication was seen in 561 (29.7%) of the patients who were not on statin compared to only 801 (21.8%) who were on a statin, p < .0001. The area under the curve for receiver operating characteristic curve using statins and respiratory complications was 0.706. Statins showed positive feature importance in all the MLA models. CONCLUSIONS: MLA showed that statins impacted the prediction of respiratory complications in all the models studied. The study confirmed that preoperative statins reduced the risk of respiratory complications by 21%.

Cardiothoracic surgery leadership and learning are indispensable to each other.

Cardiothoracic surgery is facing a multitude of challenges in leadership and training on the global scale, these being a complex and aging patient population, shortage of cardiac surgeons, diminishing student interest and trainee enthusiasm, increasingly challenging training obstacles and work-life imbalances, suboptimal job prospects, reports of discrimination and bullying and lack of diversity as well as gap between innovation and technology, clinical application, and training of future surgeons. The survival of cardiac surgery hinges on the leadership attracting and retaining young surgeons into the specialty. Mentoring, leading through example, recognizing the work-life imbalances, adapting to diverse and modern training models and embracing diversity with respect to gender and race, will ultimately be required to create and cultivate a nurturing environment of training and preparing future leaders. The vision for training future generations of cardiothoracic surgeons must rely heavily on strengthening the unity of the heart team. In doing so we can provide the best possible care for our patients and a most fulfilling career for the future generation of cardiac surgeons.

Rare presentation of transposition of great arteries and total anomalous pulmonary venous connection in an 18-year-old.

Transposition of great arteries (TGA) in association with total anomalous Pulmonary venous connection (TAPVC) is a rare anomaly, that is seldom reported in adulthood. While both the conditions are life threatening on their own, in combination they compensate for each other and can often present after weeks or months after birth. Transthoracic Echocardiography (TTE) can reliably diagnose this anomaly. Cardiac MRI can also be used to confirm the diagnosis. We describe a rare combination of TGA and TAPVC in an 18-year-old patient.

Role of peri-operative exercise in patients undergoing coronary artery bypass grafting.

Peri-operative exercise regimes are important to minimize complications in patients undergoing coronary artery bypass grafting (CABG). Apart from inspiratory muscle training, aerobics, resistance training, and stretching have all been reported with the potential to promote recovery after cardiac surgery. In the postoperative period, breathing exercises, aerobic and resistance exercises walking, and yoga have all been practiced. However, there is no clarity on the ideal physiotherapy regime in patients undergoing CABG or the intensity of exercise these patients can be subjected to. Future studies need to focus on these unanswered questions.

Structural valve degeneration in the transcatheter mitral valve implantation era.

Structural valve degeneration of biological valves continues to be a persistent problem and has assumed greater importance with the advent of transcatheter valve implantation techniques. Considerable variability exists among different studies in reporting the incidence of structural valve degeneration and differentiation with nonstructural valve degeneration and bio-prosthetic valve failures is important. Moreover, the pathological basis of structural valve degeneration is still not completely understood. Theoretically, trans-catheter implanted valves may be more prone to degeneration compared to surgically implanted biological valves. Measures to reduce structural valve degeneration are imperative, irrespective of the technique of valve implantation.

"Turn downs" in aortic emergencies: Reassurance or uncertainty?

"Turn-down" rate has been reported to have a significant influence on outcomes, and being turned down for an operation is associated with significant short-term mortality risk. A study examining the impact of the pandemic on the "turn-down" rates of acute aortic syndromes in the United Kingdom reported an overall "turn-down" rate of  7.3% in the early part of the pandemic. This review examines the significance of "turn-downs" in this setting and scrutinizes the adequacy of reporting this complex variable.

Skin Testing before Antibiotic Administration - Is there a Scientific basis?

The practice of skin testing prior to administration of antibiotics in the absence of a history of allergy is non-existent in the western world. Reports on skin testing in the absence of known allergy are unheard of in the medical literature. The practice of giving a test dose prior to administration of the antibiotic is also practiced very sporadically and has no scientific basis. Despite this In India in most major institutions both in government and private hospitals , general practice set up and small and medium nursing homes, skin testing prior to administration of antibiotics remain extremely common and is even considered to be negligent if not practiced. In this review the evidence for skin testing and test dose before antibiotic administration has been examined. Based on the evidence available skin testing should be restricted to patients with a history of prior penicillin allergy for whom penicillin or other B-lactam antibiotic is the drug of choice and there is no suitable alternative.1 There is no need to do skin testing without a history of penicillin allergy even if the drug is to be administered parenterally. Test dose administration does not protect patients from anaphylactic reactions and hence the practice has no scientific basis.