Implementing a Preoperative Anemia Optimization Protocol for Cardiovascular Surgery Patients: A Quality Improvement Project.

BACKGROUND: Patients with anemia have poorer outcomes following cardiac surgery than do those without anemia. To improve outcomes, the Enhanced Recovery After Surgery cardiac recommendations include optimizing patients' condition, including treating anemia, before surgery. LOCAL PROBLEM: Despite implementing Enhanced Recovery After Surgery initiatives, a midwestern cardiothoracic surgery group recognized a care gap in preoperative patients with anemia. No standardized protocol was in use. METHODS: An anemia optimization protocol was developed for perioperative care of patients with anemia. Data from retrospective medical record review were analyzed to determine relationships between protocol use and secondary outcomes. The protocol was created using best evidence and expert consensus. Cardiac surgery and hematology specialists revised the protocol and agreed on a final version. The protocol was integrated into the consultation process for cardiac surgery patients. RESULTS: During the implementation period, 23 of 55 patients with anemia (42%) received interventions via the anemia optimization protocol. The mean quantity of packed red blood cells transfused perioperatively per patient was 1.9 U in the protocol group and 3.5 U in the nonprotocol group. In the subgroup of patients experiencing postoperative acute kidney injury, the mean increase in creatinine level was 0.65 mg/dL in the protocol group and 1.52 mg/dL in the nonprotocol group. Four patients in the protocol group (17%) and 6 patients in the nonprotocol group (19%) experienced postoperative acute kidney injury. CONCLUSION: Preoperative anemia is associated with poorer cardiac surgical outcomes. Incorporating the anemia optimization protocol into practice may mitigate the risk of postoperative complications for patients with anemia. Continued use of the protocol is recommended.

Perioperative serum syndecan-1 concentrations in patients who underwent cardiovascular surgery with cardiopulmonary bypass and its association with the occurrence of postoperative acute kidney injury: a retrospective observational study.

BACKGROUND: Various factors can cause vascular endothelial damage during cardiovascular surgery (CVS) with cardiopulmonary bypass (CPB), which has been suggested to be associated with postoperative complications. However, few studies have specifically investigated the relationship between the degree of vascular endothelial damage and postoperative acute kidney injury (pAKI). The objectives of this study were to measure perioperative serum syndecan-1 concentrations in patients who underwent CVS with CPB, evaluate their trends, and determine their association with pAKI. METHODS: This was a descriptive and case‒control study conducted at the National University Hospital. Adult patients who underwent CVS with CPB at a national university hospital between March 15, 2016, and August 31, 2020, were included. Patients who were undergoing preoperative dialysis, had preoperative serum creatinine concentrations greater than 2.0 mg dl-1, who were undergoing surgery involving the descending aorta were excluded. The perioperative serum syndecan-1 concentration was measured, and its association with pAKI was investigated. RESULTS: Fifty-two patients were included. pAKI occurred in 18 (34.6%) of those patients. The serum syndecan-1 concentration increased after CPB initiation and exhibited bimodal peak values. The serum syndecan-1 concentration at all time points was significantly elevated compared to that after the induction of anesthesia. The serum syndecan-1 concentration at 30 min after weaning from CPB and on postoperative day 1 was associated with the occurrence of pAKI (OR = 1.10 [1.01 to 1.21], P = 0.03]; OR = 1.16 [1.01 to 1.34], P = 0.04]; and the cutoff values of the serum syndecan-1 concentration that resulted in pAKI were 101.0 ng ml-1 (sensitivity = 0.71, specificity = 0.62, area under the curve (AUC) = 0.67 (0.51 to 0.83)) and 57.1 ng ml-1 (sensitivity = 0.82, specificity = 0.56, AUC = 0.71 (0.57 to 0.86)). Multivariate logistic regression analysis revealed that the serum syndecan-1 concentration on postoperative day 1 was associated with the occurrence of pAKI (OR = 1.02 [1.00 to 1.03]; P = 0.03). CONCLUSION: The serum syndecan-1 concentration at all time points was significantly greater than that after the induction of anesthesia. The serum syndecan-1 concentration on postoperative day 1 was significantly associated with the occurrence of pAKI. TRIAL REGISTRATION: This study is not a clinical trial and is not registered with the registry.

Assessment of Aspirin and Clopidogrel Resistance in Patients Undergoing Cardiovascular Surgery: A Single-Center Cross-Sectional Study

Objective: We aimed to investigate antiplatelet drug resistance utilizing light transmission-lumiaggregometry (LT-LA) and the Platelet Function Analyzer-100 (PFA-100) in patients undergoing cardiovascular surgery. Materials and Methods: The study included 60 patients diagnosed with stable coronary artery disease and peripheral vascular diseases that required surgery. Participants were divided into three groups: patients receiving aspirin (ASA) (n=21), patients receiving clopidogrel (CLO) (n=19), and patients receiving dual therapy (ASA+CLO) (n=20). Aggregation and secretion tests by LT-LA and closure time by the PFA-100 were used to measure antiplatelet drug resistance. Results: Based on the adenosine diphosphate (ADP)-induced aggregation test, 43% of patients were resistant to ASA, 22% to CLO, and 15% to dual therapy. Diabetes, hypertension, and hyperlipidemia were the most commonly identified comorbid disorders. In patients with comorbid risk factors, the median value of platelet aggregation response to ADP was significantly higher in the ASA group than in the CLO and dual therapy groups (p=0.0001). In patients receiving ASA monotherapy, the maximum amplitude of aggregation response to platelet agonists was ≥70% in 43% of patients for ADP and 28% for collagen by LT-LA. Elevated ADP (≥0.29 nmol) and collagen (≥0.41 nmol)-induced adenosine triphosphate release were found by LT-LA in 66% of patients utilizing an ADP agonist and 80% of patients using a collagen agonist undergoing ASA therapy. Closure times obtained with the PFA-100 were normal in 28% of patients using collagen-ADP cartridges and 62% of patients using collagen-epinephrine (CEPI) cartridges who received ASA. Recurrent thrombosis and bleeding were observed in 12 (20%) patients with cardiovascular disease. Three of these individuals (25%) showed ASA resistance with normal responses to ADP-induced aggregation (≥70%) and secretion (≥0.29 nmol), as well as normal CEPI closure times. Conclusion: Our findings suggest that antiplatelet drug monitoring by LT-LA and PFA-100 may be useful for high-risk and complicated cardiovascular patients.

Definition, Staging, and Role of Biomarkers in Acute Kidney Injury in the Context of Cardiovascular Interventions.

Acute kidney injury (AKI) is a frequently occurring complication of cardiovascular interventions, and associated with adverse outcomes. Therefore, a clear definition of AKI is of paramount importance to enable timely recognition and treatment. Historically, changes in the serum creatinine and urine output have been used to define AKI, and the criteria have evolved over time with better understanding of the impact of AKI on the outcomes. However, the reliance on serum creatinine for these AKI definitions carries numerous limitations including delayed rise, inability to differentiate between hemodynamics versus structural injury and assay variability to name a few.

Efectividad de intervención de Enfermería para disminuir la depresión de personas en el preoperatorio cardiovascular / Effectiveness of a Nursing Intervention to Reduce Depression in Individuals during the Preoperative Period of Cardiovascular Surgery

Introducción: Durante el preoperatorio cardiovascular, las personas presentan con frecuencia niveles altos de depresión, los que se asocian a resultados quirúrgicos poco favorables y, por ende, a la necesidad de una intervención de Enfermería para disminuir estos niveles. Objetivo: Evaluar la efectividad de una intervención de Enfermería para disminuir la depresión de personas en el preoperatorio cardiovascular. Métodos: Estudio preexperimental con pretest y protest, en una población de 88 personas en el Servicio de Cirugía Cardiovascular en el Centro de Investigaciones Médico Quirúrgicas, La Habana, Cuba, desde marzo de 2019 a junio de 2020. La depresión fue medida con el test de Inventario de Depresión Rasgo-Estado. Se realizó una intervención de Enfermería sustentada en el Modelo de Adaptación de Sor Callista Roy, el Proceso de Atención de Enfermería y las taxonomías NANDA, NOC, NIC, para disminuir la depresión de personas en el preoperatorio cardiovascular. Los resultados se confrontaron y expresaron en porcentajes, media y números absolutos. Se utilizó la prueba de Chi cuadrado y probabilidad exacta de Fisher. La asociación de variables se obtuvo con la prueba no paramétrica de Wilcoxon, con regla de disociación: si p≤ 0,05 se rechaza HO. Resultados: El sexo masculino constituyó el 57,92 por ciento de los casos y la edad media fue de 57 años. Luego de la intervención se redujo la depresión en un 27,27 por ciento (p= 0,000). Conclusiones: La implementación de una intervención de Enfermería para disminuir la depresión de personas en el preoperatorio cardiovascular, sustentada en el Modelo de Adaptación de Sor Callista Roy, el PAE y las Taxonomías NANDA, NOC, NIC mostró efectividad, ya que se logró modificar de forma positiva y significativa la depresión, en tanto, optimizó los resultados posoperatorios(AU)

Introduction: During the preoperative period of cardiovascular surgery, people frequently present high levels of depression, associated with little favorable surgical outcomes and, therefore, with the need for a nursing intervention to reduce such levels. Objective: To evaluate the effectiveness of a nursing intervention to reduce depression in preoperative cardiovascular patients. Methods: A preexperimental study with pretest and protest was carried out in a population of 88 people in the cardiovascular surgery service at Centro de Investigaciones Médico-Quirúrgicas, in Havana, Cuba, from March 2019 to June 2020. Depression was measured using the State/Trait Depression Inventory test. A nursing intervention was performed, based on the Adaptation Model of Sister Callista Roy, the Nursing Care Process, as well as the NANDA, NOC and NIC taxonomies, in order to reduce depression in preoperative cardiovascular patients. The results were compared and expressed as percentages, mean and absolute numbers. The chi-square and Fisher's exact probability tests were used. The association of variables was obtained with the nonparametric Wilcoxon test, with the dissociation rule if p ≤ 0.05, H O is rejected. Results: The male sex accounted for 57.92 percent of the cases and the mean age was 57-years. After the intervention, depression was reduced by 27.27 percent (p= 0.000). Conclusions: The implementation of a nursing intervention to reduce depression in preoperative cardiovascular patients, based on the Adaptation Model of Sister Callista Roy, the Nursing Care Process, as well as NANDA, NOC and NIC taxonomies, showed effectiveness, since it was possible to modify depression in a positive and significant way, while optimizing postoperative outcomes(AU)

Intervención de enfermería durante la circulación extracorpórea en cirugía cardiovascular / Nursing intervention during extracorporeal circulation in cardiovascular surgery

Introducción: Una intervención de enfermería durante la circulación extracorpórea en cirugía cardiovascular puede reducir la aparición de complicaciones, la estadía en unidad de cuidados intensivos, hospitalaria y la mortalidad. Se ofrecen cuidados articulando los dominios de atención a personas en estado crítico establecidos por Patricia Benner, el Proceso de Atención de Enfermería y las taxonomías. Objetivo: Exponer el desarrollo de una intervención de enfermería durante la circulación extracorpórea. Métodos: Se realizó un estudio experimental, que incluyó 159 personas, distribuidas en dos grupos, que acudieron al Servicio de Cardiología, del Centro de Investigaciones Médico Quirúrgicas desde enero de 2018 hasta enero de 2021. Los grupos fueron escogidos mediante la aleatorización simple (1:1). El primero se conformó por 79 personas, abordadas con el procedimiento convencional; y el segundo, por 80, atendidas con la intervención de enfermería diseñada por el equipo de investigación. Se compararon y expresaron los resultados en números absolutos, porcentajes y media. Resultados: Predominaron los hombres (79,7 por ciento). La edad media fue 60 años. En el grupo al que se le aplicó la intervención de enfermería se redujeron la aparición de complicaciones, la estadía en Unidades de Cuidados Intensivos, hospitalaria, y la mortalidad (p = 0,04). Conclusiones: La implementación de la Intervención de Enfermería por el enfermero perfusionista ayudó a mejorar las respuestas humanas de esas personas. Los resultados finales obtenidos mostraron su validez, al evidenciar la disminución en la aparición de complicaciones y, por ende, la reducción de la estadía en UCI, hospitalaria y la mortalidad(AU)

Introduction: A nursing intervention during extracorporeal circulation in cardiovascular surgery can reduce the occurrence of complications, the stay in intensive care units, in hospitals, and mortality. Care is offered by articulating the domains of care for people in critical condition established by Patricia Benner, the Nursing Care Process and taxonomies. Objective: To present the development of a nursing intervention during extracorporeal circulation. Methods: An experimental study was conducted, which included 159 people, divided into two groups, who attended the Cardiology Service of the Center for Medical and Surgical Research from January 2018 to January 2021. Groups were chosen using simple randomization (1:1). The first group was made up of 79 people, approached with the conventional procedure; and the second, by 80 people, attended with the nursing intervention designed by the research team. The results were compared and expressed in absolute numbers, percentages and mean. Results: Men predominated (79.7 percent). The median age was 60 years. In the group to which the nursing intervention was applied, the occurrence of complications, the stay in Intensive Care Units, in hospitals, and mortality were reduced (p = 0.04). Conclusions: The implementation of the Nursing Intervention by the perfusionist nurse helped to improve the human responses of these people. The final results obtained showed their validity, as they showed the decrease in the onset of complications and, therefore, the reduction of ICU and hospital stay and mortality(AU)

Incidence and outcomes of surgical site infection after cardiovascular surgery (complete republication).

OBJECTIVES: Surgical site infection in cardiovascular surgery had a great effect on postoperative outcomes. This study examined the current status of surgical site infection and postoperative outcomes used the registered data of the Japan Cardiovascular Surgery Database. METHODS: From the registry, we extracted 53,186 cases of thoracic cardiovascular surgery performed under median sternotomy in 2018. According to Japanese Healthcare Associated Infections Surveillance (JHAIS), patients were divided into three groups: coronary artery bypass graft (CABG) with saphenous vein graft (SVG) (SVG+ ; n = 14,246), CABG without SVG (SVG-; n = 5535), and operations other than CABG (no CABG; n = 33,405). The incidence of deep sternal wound infection, leg wound infection, hospital death, and hospitalization more than 90 days was examined. RESULTS: The incidence of deep sternal wound infection is 1.4% in all cases and 1.7% in SVG+ , 1.2% in SVG-, and 1.4% in no CABG. In deep sternal wound infection cases, incidence of hospital death was 24.7% and was higher than no infection cases. Especially, in no CABG group, incidence of hospital death was 30.1%. The long-term hospitalization rate and readmission rate within 30 days of patients with deep sternal wound infection were also high. CONCLUSIONS: The incidence of deep sternal wound infection was low, but it has not decreased. Postoperative outcomes in patients with surgical site infection were still bad.

Combined serum free light chain predicts prognosis in acute kidney injury following cardiovascular surgery.

OBJECTIVES: Increased polyclonal free light chains (FLCs) are found in inflammatory conditions. Inflammation is recognized in the progression of acute kidney injury (AKI). This study was aimed to determine whether polyclonal combined FLC (cFLC) was associated with prognosis of AKI patients. METHODS: This prospective cohort included 145 adults with hospital-acquired AKI following cardiovascular surgery between 2014 and 2016, according to the KDIGO creatinine criteria. The primary end point of the study was all-cause death during follow-up. RESULTS: The median of serum cFLC concentration in the cohort was 42.0 (31.9-60.3 mg/L) and levels of cFLC in patients with AKI stage 3 were higher than those in AKI stage 1 and stage 2. cFLC levels correlated significantly with renal function biomarkers, high sensitivity C-reactive protein (hsCRP), and sequential organ failure assessment (SOFA) score. Patients were organized into the following two groups: the low-cFLC group (cFLC <43.3 mg/L) and the high-cFLC group (cFLC ≥ 43.3 mg/L). A total of 17 (11.0%) patient deaths occurred within 90 d, 13 (18.8%) in the high-cFLC group. Kaplan-Meier analysis revealed that the two groups differed significantly with respect to 90-d survival (log-rank p = .012), and Cox regression analysis showed that an cFLC level ≥43.3 mg/L was significantly associated with a 5.0-fold increased risk of death (adjusted hazard ratio [HR], 5.95; 95% confidence interval [CI], 1.04- 33.91; p = .045) compared with an cFLC level <43.3 mg/L. CONCLUSIONS: Serum cFLC levels were significantly elevated and might be an independent predictor of mortality in patients with AKI following cardiovascular surgery.

Long-term outcomes of truncus arteriosus repair: A modulated renewal competing risks analysis.

OBJECTIVE: In this study, we sought to identify independent risk factors for mortality and reintervention after early surgical correction of truncus arteriosus using a novel statistical method. METHODS: Patients undergoing neonatal/infant truncus arteriosus repair between January 1984 and December 2018 were reviewed retrospectively. An innovative statistical strategy was applied integrating competing risks analysis with modulated renewal for time-to-event modeling. RESULTS: A total of 204 patients were included in the study. Mortality occurred in 32 patients (15%). Smaller right ventricle to pulmonary artery conduit size and truncal valve insufficiency at birth were significantly associated with overall mortality (right ventricle to pulmonary artery conduit size: hazard ratio, 1.34; 95% confidence interval, 1.08-1.66, P = .008; truncal valve insufficiency: hazard ratio, 2.5; 95% confidence interval, 1.13-5.53, P = .024). truncal valve insufficiency at birth, truncal valve intervention at index repair, and number of cusps (4 vs 3) were associated with truncal valve reoperations (truncal valve insufficiency: hazard ratio, 2.38; 95%, confidence interval, 1.13-5.01, P = .02; cusp number: hazard ratio, 6.62; 95% confidence interval, 2.54-17.3, P < .001). Right ventricle to pulmonary artery conduit size 11 mm or less was associated with a higher risk of early catheter-based reintervention (hazard ratio, 1.54; 95% confidence interval, 1.04-2.28, P = .03) and reoperation (hazard ratio, 1.96; 95% confidence interval, 1.33-2.89, P = .001) on the right ventricle to pulmonary artery conduit. CONCLUSIONS: Smaller right ventricle to pulmonary artery conduit size and truncal valve insufficiency at birth were associated with overall mortality after truncus arteriosus repair. Quadricuspid truncal valve, the presence of truncal valve insufficiency at the time of diagnosis, and truncal valve intervention at index repair were associated with an increased risk of reoperation. The size of the right ventricle to pulmonary artery conduit at index surgery is the single most important factor for early reoperation and catheter-based reintervention on the conduit.

Perioperative outcomes of combined heart surgery and lung tumor resection: a systematic review and meta-analysis.

OBJECTIVE: The prevalence of patients with concomitant heart and lung lesions requiring surgical intervention is increasing. Simultaneous cardiac surgery and pulmonary resection avoids the need for a second operation. However, there are concerns regarding the potentially increased mortality and complication rates of simultaneous surgery and the adequacy of lung exposure during heart surgery. Therefore, we performed a meta-analysis to evaluate the perioperative mortality and complication rates of combined heart surgery and lung tumor resection. METHODS: A comprehensive literature search was performed in July 2020. The PubMed, Embase, and Web of Science databases were searched to identify studies that reported the perioperative outcomes of combined heart surgery and lung tumor resection. Two reviewers independently screened the studies, extracted data, and assessed the risk of bias of included studies. Pooled proportions and 95% confidence intervals (95% CI) were calculated by R version 3.6.1 using the meta package. RESULTS: A total of 536 patients from 29 studies were included. Overall, the pooled proportion of operative mortality was 0.01 (95% CI: 0.00, 0.03) and the pooled proportion of postoperative complications was 0.40 (95% CI: 0.24, 0.57) for patients who underwent combined cardiothoracic surgery. Subgroup analysis by lung pathology revealed that, for patients with lung cancer, the pooled proportion of anatomical lung resection was 0.99 (95% CI: 0.95, 1.00) and the pooled proportion of systematic lymph node dissection or sampling was 1.00 (95% CI: 1.00, 1.00). Subgroup analysis by heart surgery procedure found that the pooled proportion of postoperative complications of patients who underwent coronary artery bypass grafting (CABG) patients using the off-pump method was 0.17 (95% CI: 0.01, 0.43), while the pooled proportion of complications after CABG using the on-pump method was 0.61 (95% CI: 0.38, 0.82). CONCLUSION: Combined heart surgery and lung tumor resection had a low mortality rate and an acceptable complication rate. Subgroup analyses revealed that most patients with lung cancer underwent uncompromised anatomical resection and mediastinal lymph node sampling or dissection during combined cardiothoracic surgery, and showed off-pump CABG may reduce the complication rate compared with on-pump CABG. Further researches are still needed to verify these findings.

Selective Inhibition of NLRP3 Inflammasome Reverses Pressure Overload-Induced Pathological Cardiac Remodeling by Attenuating Hypertrophy, Fibrosis, and Inflammation.

Activation of the NLRP3 inflammasome promotes pathological cardiac remodeling induced by pressure overload. However, the therapeutic effects of NLRP3 inhibition after cardiac remodeling remain unknown. The present study aimed to investigate whether the selective NLRP3 inhibitor, MCC950, could reverse transverse aortic constriction (TAC)-induced cardiac remodeling. Mice were divided into four groups based on the treatment given: sham, sham + MCC950, TAC, and TAC + MCC950. MCC950 (10 mg/kg, intraperitoneal injection, once per day) was administered from two weeks after TAC or sham surgery for four weeks. Echocardiography, histological analysis, RT-PCR, and Western blotting were performed to explore the function of MCC950 after TAC. We found that MCC950 reversed cardiac dysfunction after TAC. MCC950 attenuated cardiac hypertrophy by down-regulating calcineurin expression and inhibiting MAPK activation. Further, it also alleviated cardiac fibrosis post-TAC by inhibiting the TGF-ß/Smad4 pathway, and reduced cardiac inflammation and macrophage infiltration post-TAC, including both M1 and M2 macrophages. Taken together, MCC950 can attenuate cardiac remodeling due to pressure overload by inhibiting hypertrophy, fibrosis, and inflammation. Our study provides a basis for the clinical application of NLRP3 inhibitors in the treatment of non-ischemic heart failure.

Postoperative Cardiovascular Surgery Delirium: Interrater Agreement Between Nurses and Clinical Nurse Specialist and Factors Associated With Prevalence.

PURPOSE: The aims of this study were to examine interrater agreement of delirium between clinical nurses and a clinical nurse specialist, determine delirium subtype prevalence, and examine associated patient, procedure, and hospital factors. DESIGN: A descriptive cross-sectional design and a convenience sample of nurses and patients on progressive care units were used in this study. METHODS: Clinical nurse specialist data were collected on a case report form, and clinician and patient data were obtained from electronic databases. Interrater agreement of delirium prevalence was assessed by κ statistic, and logistic regression models were used to determine patient factors associated with delirium. RESULTS: Of 216 patients, 23 had delirium; clinical nurses identified fewer cases than the clinical nurse specialist: 1.8% versus 10.7%; κ agreement, 0.27 (0.06, 0.49). By delirium subtype, hypoactive delirium was more frequent (n = 10). Factors associated with delirium were history of cerebrovascular disease (odds ratio [95% confidence interval], 2.8 [1.01-7.7]; P = .044), history of mitral valve disease (odds ratio [95% confidence interval], 0.31 [0.09-0.90]; P = .041), and longer perfusion time (odds ratio [95% confidence interval], 1.7 [1.1-2.7]; P = .016). One factor was associated with hypoactive delirium, longer perfusion time (odds ratio [95% confidence interval], 2.2 [1.3-4.2]; P = .008). CONCLUSIONS: Because clinician-clinical nurse specialist delirium agreement was low and hypoactive delirium was common, clinical interventions are needed.

Decreased activities of daily living at discharge predict mortality and readmission in elderly patients after cardiac and aortic surgery: A retrospective cohort study.

ABSTRACT: Recently, activities of daily living (ADL) were identified as a prognostic factor among elderly patients with heart disease; however, a specific association between ADL and prognosis after cardiac and aortic surgery is not well established. We aimed to clarify the impact of ADL capacity at discharge on prognosis in elderly patients after cardiac and aortic surgery.This retrospective cohort study included 171 elderly patients who underwent open operation for cardiovascular disease in a single center (median age: 74 years; men: 70%). We used the Barthel Index (BI) as an indicator for ADL. Patients were classified into 2 groups according to the BI at discharge, indicating a high (BI ≥ 85) or low (BI < 85) ADL status. All-cause mortality and unplanned readmission events were observed after discharge.Thirteen all-cause mortality and 44 all-cause unplanned readmission events occurred during the median follow-up of 365 days. Using Kaplan-Meier analysis, a low ADL status was determined to be significantly associated with all-cause mortality and unplanned readmission. In the multivariable Cox proportional hazard models, a low ADL status was an independent predictor of all-cause mortality and unplanned readmission after adjusting for age, sex, length of hospital stay, and other variables (including preoperative status, surgical parameter, and postoperative course).A low ADL status at discharge predicted all-cause mortality and unplanned readmission in elderly patients after cardiac and aortic surgery. A comprehensive approach from the time of admission to postdischarge to improve ADL capacity in elderly patients undergoing cardiac and aortic surgery may improve patient outcomes.

Large cardiac wall hematoma with rapid growth: a case report of a potentially catastrophic complication during cardiac surgery.

BACKGROUND: Rapid growth of cardiac wall hematoma is a rare but potentially fatal complication of cardiac surgery. However, its pathophysiology and optimal management remain undefined. CASE PRESENTATION: Here we present a rare case of a large cardiac wall hematoma in the right ventricle during a thoracic aortic and valvular surgery. The hematoma expanded rapidly with epicardial rupture during cardiopulmonary bypass. We could establish non-surgical hemostasis and prevent further expansion of hematoma by early weaning of the cardiopulmonary bypass, followed by the administration of protamine and manual compression by hemostatic agent application. His postoperative recovery was uneventful and upon computed tomography analysis, the hematoma was observed to have absorbed completely at 1 week postoperatively. The patient is doing well 1 year after the surgery without evidence of recurrent cardiac wall hematoma on follow-up computed tomography. CONCLUSIONS: Cardiovascular surgeons should bear in mind this potentially catastrophic complication during cardiac surgery. Because of the vulnerability of the cardiac wall at the area of the hematoma, we believe that a hemostatic approach without sutures may be effective for this lethal complication.

Association between glucose variability and postoperative delirium in acute aortic dissection patients: an observational study.

BACKGROUND: Blood glucose variability is associated with poor prognosis after cardiac surgery, but the relationship between glucose variability and postoperative delirium in patients with acute aortic dissection is unclear. The study aims to investigate the association of blood glucose variability with postoperative delirium in acute aortic dissection patients. METHODS: We prospectively analyzed 257 patients including 103 patients with delirium. The patients were divided into two groups according to whether delirium was present. The outcome measures were postoperative delirium, the length of the Intensive Care Unit stay, and the duration of hospital stay. Multivariable Cox competing risk survival models was used to assess. RESULTS: A total of 257 subjects were enrolled, including 103 patients with delirium. There were statistically significant differences between the two groups in body mass index, history of cardiac surgery, first admission blood glucose, white blood cell counts, Acute Physiology and Chronic Health Evaluation II score, hypoxemia, mechanical ventilation duration, and the length of Intensive Care Unit stay(P < 0.05). The delirium group exhibited significantly higher values of the mean of blood glucose (MBG) and the standard deviation of blood glucose (SDBG) than in the non-delirium group(P < 0.05). In model 1, the adjusted hazard ratio (AHR) of the standard deviation of blood glucose was 1.436(P < 0.05). In Model 2, the standard deviation of blood glucose (AHR = 1.418, 95%CI = 1.195-1.681, P < 0.05) remained significant after adjusting for confounders. The area under the curve of the SDBG was 0.763(95%CI = 0.704-0.821, P < 0.01). The sensitivity was 81.6%, and the specificity was 57.8%. CONCLUSIONS: Glucose variability is associated with the risk of delirium in patients after aortic dissection surgery, and high glycemic variability increases the risk of postoperative delirium.

Should We Postpone Elective Cardiovascular Procedures and Percutaneous Coronary Interventions During the COVID-19 Pandemic?

BACKGROUND: Prioritization among patients with coronary artery disease represents a difficult issue during the SARS-CoV-2 pandemic. We present our clinical practices and patients' outcomes after elective, emergent, and urgent cardiovascular surgery and percutaneous coronary interventions (PCI). We also investigated the rate of nosocomial infection of SARS-CoV-2 in health workers (HWs), including surgeons after cardiovascular procedures and percutaneous interventions (PCI). MATERIAL AND METHODS: We performed 186 cardiovascular operations and PCI between March 15 and October 15. According to the level of priority (LoP), we performed urgent and emergent coronary artery bypass grafting (CABG) and cardiac valve repair or replacement surgery in 44 patients. In one patient with acute chordae rupture with pulmonary edema, we performed mitral valve replacement. We performed the aortic arch repair in two patients with type-I aortic dissection in urgent situations. Therefore, in 47 patients we performed cardiac operations in urgent or emergent situations. Elective CABG (N = 28) and elective cardiac valve (N = 10) surgeries were performed (total: 38). While rescue PCI was urgently performed in 47 patients with ST-segment elevation myocardial infarction (STEMI), it was performed in elective or emergent situations in 40 patients with myocardial ischemia. Endovascular treatment was performed in four patients with deep venous thrombosis (DVT) and in four patients with chronic arterial occlusion, respectively. Surgical vascular repair and embolectomy were performed in patients with peripheral artery injury (N = 6) and acute arterial embolic events (N = 4), respectively. We performed thoracic computed tomography followed by reverse transcriptase-polymerase chain reaction (RT-PCR) test in patients with irregular diffuse reticular opacities with or without consolidation on chest X-ray. Blood coagulation disorders including d-dimer, thromboplastin time (TT), and partial thromboplastin time (aPTT) were measured prior to procedures. RESULTS: No mortality and morbidity was seen after percutaneous and surgical arterial or venous procedures. The total mortality rate was 4.1% (8 of 186 CAD patients or valve surgery) after urgent and emergent CABG (N = 4), an urgent valve replacement (N = 1), and PCI (N = 3). Low cardiac output syndrome (LOS) and major adverse cardiac cerebrovascular event (MACCE) were the mortality factors after cardiac surgery. The reasons for death after PCI were sudden cardiac arrest related to the dissection of the left main coronary artery during procedure and pneumonia due to COVID-19 (N = 2). Ground-glass opacities in combination with pulmonary consolidations were detected in seven patients. Interlobular septal and pleural thickening with patchy bronchiectasis in the bilateral lower lobe involvement was found after thoracic computed tomography in these patients. We confirmed in-hospital COVID-19 using a PCR test in two patients with STEMI prior to PCI. PT and aPTT increased, but fibrin degradation products did not in those two patients. We confirmed COVID-19 via phone call in six CABG patients and one PCI patient after discharge from the hospital. None of the patients diagnosed with COVID-19 died after being discharged from the hospital. CONCLUSION: Cardiovascular surgery and PCI can safely be performed with acceptable complications and mortality rates in elective situations, during the COVID-19 pandemic. Preoperative control of OR traffic, careful evaluation of the patient's history, consultation, and precautions taken by healthcare professionals are important, during and after procedures. Also important is wearing a mask and face shield and careful disinfection of equipment and space.

The modified water swallowing test score is the best predictor of postoperative pneumonia following extubation in cardiovascular surgery: A retrospective cohort study.

ABSTRACT: No guidelines have been established for the evaluation of swallowing function following extubation. The factors of bedside swallowing evaluations (BSEs) that are associated with the development of pneumonia have not been fully elucidated. This study aimed to retrospectively investigate the most appropriate measurements of BSEs for predicting pneumonia.The study subjects were 97 adults who underwent BSEs following cardiovascular surgery. Patients were divided into the pneumonia onset group (n = 21) and the non-onset group (n = 76). Patient characteristics, intraoperative characteristics, complications, BSE results, and postoperative progress were compared between the groups. BSEs were composed of consciousness level, modified water swallowing test (MWST) score, repetitive saliva swallowing test score, speech intelligibility score, and risk of dysphagia in the cardiac surgery score. Univariate and multivariate analyses with the BSE as the independent variable and pneumonia onset as the dependent variable were also performed to identify factors that predict pneumonia. For factors that became significant in univariate analysis, the incidence of pneumonia was shown using the Kaplan-Meier curve.No significant differences were found in patient characteristics, intraoperative characteristics, and complications between the 2 groups. The postoperative progress was significantly different between the 2 groups, the pneumonia-onset group had a significantly longer time until the start of oral intake and a significantly lower median value of Food Intake Level Scale at the time of discharge. According to univariate and multivariate analyses, MWST score was a significant factor for predicting the onset of pneumonia even after adjusting for patient characteristics and surgical factors, and the incidence of pneumonia increased approximately 3 times when the MWST score was 3 points or less.The MWST score after extubation in cardiovascular surgery was the strongest predictor of postoperative pneumonia in BSEs. Furthermore, the incidence of pneumonia increased approximately 3 times when the MWST score was 3 points or less. Predicting cases with a high risk of developing pneumonia allows nurses and attending physicians to monitor the progress carefully and take aggressive preventive measures.