ERAS® Cardiac Society Turnkey Order Set for Surgical Site Infection Prevention: Proceedings from the AATS ERAS Conclave 2023.

OBJECTIVES: Surgical site infections (SSIs) after cardiac surgery increase morbidity and mortality, consume healthcare resources, impair recovery, and diminish patients' quality of life. Numerous guidelines and expert consensus documents have been published to address the prevention and management of SSIs. Our objective is to integrate these documents into an order set that will facilitate the adoption and implementation of evidence-based best practices for preventing and managing SSIs following cardiac surgery. METHODS: Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for SSI reduction. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistent Class I or IIA, Class IIB or otherwise supported by published evidence, were also included in italicized type. RESULTS: Preventative care begins with the preoperative identification of both modifiable and non-modifiable SSI risks by healthcare providers. Assessment tools can be utilized to assist in identifying patients at a high risk of SSI. Preoperative recommendations include screening for and treating Staphylococcus aureus nasal carriage. Intraoperatively, tailored prophylactic intravenous antibiotics and maintaining blood glucose levels below 180 mg/dL are essential elements. Postoperative care includes maintaining normothermia, glucose control and patient engagement. CONCLUSION: Despite the well-documented advantages of a multidisciplinary care pathway for SSI in cardiac surgery, there are inconsistencies in its adoption and implementation. This manuscript provides an order set that incorporates recommendations from existing guidelines to prevent SSI in the cardiac surgical population.

Closing the care gap: combining enhanced recovery with minimally invasive valve surgery.

PURPOSE OF REVIEW: Patients with advanced age and frailty require interventions for structural heart disease at an increasing rate. These patients typically experience higher rates of postoperative morbidity, mortality and prolonged hospital length of stay, loss of independence as well as associated increased costs to the healthcare system. Therefore, it is becoming critically important to raise awareness and develop strategies to improve clinical outcomes in the contemporary, high-risk patient population undergoing cardiacprocedures. RECENT FINDINGS: Percutaneous options for structural heart disease have dramatically improved the therapeutic options for some older, frail, high-risk patients; however, others may still require cardiac surgery. Minimally invasive techniques can reduce some of the physiologic burden experienced by patients undergoing surgery and improve recovery. Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) is a comprehensive, interdisciplinary, evidence-based approach to perioperative care. It has been shown to improve recovery and patient satisfaction while reducing complications and length of stay. SUMMARY: Combining minimally invasive cardiac surgery with enhanced recovery protocols may result in improved patient outcomes for a patient population at high risk of morbidity and mortality following cardiac surgery.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS).

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

ERAS Cardiac Society turnkey order set for patient blood management: Proceedings from the AATS ERAS Conclave 2023.

OBJECTIVES: There are multiple published guidelines on comprehensive patient blood management (PBM), centered on the 3 pillars of PBM: managing preoperative anemia, minimizing blood loss, and tolerating intraoperative/postoperative anemia. We sought to create an order set to facilitate widespread implementation of evidence-based PBM for cardiac surgery patients. METHODS: Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for PBM. Orders derived from consistent class I, class IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence are presented in italic type. RESULTS: Preoperatively, there are strong recommendations to screen and treat preoperative anemia with iron replacement and erythropoietin and to discontinue dual antiplatelet therapy if the patient can safely wait for surgery. Intraoperative orders outline the routine use of an antifibrinolytic agent, cell saver, point of care viscoelastic testing, and use of a standard transfusion algorithm. The order set also reflects strong recommendations intraoperatively and postoperatively for agreed-upon hemoglobin thresholds to consider transfusion of packed red blood cells. A hemoglobin threshold should be adopted according to local team consensus and should trigger a discussion regarding transfusion. CONCLUSIONS: The benefit of a multidisciplinary PBM care pathway in cardiac surgery has been well established, yet implementation remains variable. Using recommendations from existing guidelines, we have created a TKO to facilitate the implementation of PBM.

Methemoglobin as a marker of acute anemic stress in cardiac surgery.

Biological evidence supports plasma methemoglobin as a biomarker for anemia-induced tissue hypoxia. In this translational planned substudy of the multinational randomized controlled transfusion thresholds in cardiac surgery (TRICS-III) trial, which included adults undergoing cardiac surgery requiring cardiopulmonary bypass with a moderate-to-high risk of death, we investigated the relationship between perioperative hemoglobin concentration (Hb) and methemoglobin; and evaluated its association with postoperative outcomes. The primary endpoint was a composite of death, myocardial infarction, stroke, and severe acute kidney injury at 28 days. We observe weak non-linear associations between decreasing Hb and increasing methemoglobin, which were strongest in magnitude at the post-surgical time point. Increased levels of post-surgical methemoglobin were associated with a trend toward an elevated risk for stroke and exploratory neurological outcomes. Our generalizable study demonstrates post-surgical methemoglobin may be a marker of anemia-induced organ injury/dysfunction, and may have utility for guiding personalized approaches to anemia management. Clinicaltrials.gov registration NCT02042898.

Perioperative Optimization of the Cardiac Surgical Patient.

Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.

Mitral repair with leaflet preservation versus leaflet resection and ventricular reverse remodeling from a randomized trial.

OBJECTIVES: In the Canadian Mitral Research Alliance (CAMRA) Trial CardioLink-2 leaflet resection versus preservation techniques for posterior leaflet prolapse was investigated and no difference was shown in their effect on mean mitral gradient at peak exercise at 12 months postoperatively. The purpose of this subanalysis was to evaluate the effect of the 2 strategies on left ventricular (LV) reverse remodeling after repair. METHODS: A total of 104 patients were randomized to either a leaflet resection or leaflet preservation strategy. Echocardiograms, performed at baseline (preoperative), predischarge, and 12 months postoperatively, were analyzed in a blinded fashion at a core laboratory. RESULTS: All patients underwent successful mitral repair. At discharge, 3 patients showed moderate mitral regurgitation, whereas the remainder showed mild or less regurgitation. Compared with the baseline echocardiogram, the indexed end diastolic volume was reduced at the discharge echocardiogram (P < .0001) and was further reduced at the 12-month echocardiogram (P = .01). In contrast, the indexed end systolic volume did not significantly change from baseline assessed at the predischarge echocardiogram (P = .32) but improved at 12 months postoperatively (P < .0001), resulting in a corresponding improvement in ejection fraction at 12 months (P < .0001). The type of mitral repair strategy had no significant effect on LV reverse remodeling trends. CONCLUSIONS: The mitral repair strategies used did not influence postoperative LV reverse remodeling, which occurred in stages. Although LV end diastolic dimensions recovered before discharge, improvements in LV end systolic dimension were evident 12 months after repair.

Regional analgesia for cardiac surgery.

PURPOSE OF REVIEW: Regional anesthesia is gaining attention as a valuable component of multimodal, opioid-sparing analgesia in cardiac surgery, where improving the patient's quality of recovery while minimizing the harms of opioid administration are key points of emphasis in perioperative care. This review serves as an outline of recent advancements in a variety of applications of regional analgesia for cardiac surgery. RECENT FINDINGS: Growing interest in regional analgesia, particularly the use of newer "chest wall blocks", has led to accumulating evidence for the efficacy of multiple regional techniques in cardiac surgery. These include a variety of technical approaches, with results consistently demonstrating optimized pain control and reduced opioid requirements. Regional and pain management experts have worked to derive consensus around nerve block nomenclature, which will be foundational to establish best practice, design and report future research consistently, improve medical education, and generally advance our knowledge in this vital area of perioperative patient care. SUMMARY: The field of regional analgesia for cardiac surgery has matured over the last several years. A variety of regional techniques have been described and shown to be efficacious as part of the multimodal, opioid-sparing approach to pain management in the cardiac surgical setting.

Neuroanatomy and severity of stroke in patients with type A aortic dissection.

BACKGROUND: Strokes are a longstanding complication of acute type A aortic dissection (ATAAD) repair. Understanding the neuroanatomy, mechanism, and severity of stroke will facilitate efforts to improve prediction, prevention, and treatment strategies. METHODS: Retrospective review of patients who sustained stroke from a consecutive series of patients undergoing ATAAD repair. Neuroimaging was interpreted by two stroke neurologists blinded to clinical results. Severity of stroke was assessed by the National Institutes of Health Stroke Scale (NIHSS). Residual disability at 30 days was assessed using the modified Rankin Scale (mRS). RESULTS: Twenty percent (38/189) of patients undergoing repair for ATAAD had stroke (unilateral 58%, bi-hemispheric 42% [p = .33]). All strokes were ischemic. No significant lateralization (right vs. left) was noted with unilateral strokes (26% vs. 32%, p = .67). Etiology of stroke was embolic (58%), hypoperfusion (26%), mixed (11%), and unknown (5%). There were no intraoperative variables that correlated with the neuroanatomy or mechanism of stroke. Preoperative carotid dissection was seen in 40% (n = 15), while postoperatively 10% (n = 4) sustained intracranial large vessel occlusion (LVO). Strokes were moderate or severe (NIHSS ≥ 9) in 97% of cases, with 66% incidence of moderate residual disability (mRS ≥ 3) at 1 month postoperatively. CONCLUSIONS: Strokes associated with ATAAD are severe at presentation resulting in significant disability. One in 10 strokes is due to LVO and potentially amenable to endovascular treatment. Heterogeneity in both location and etiology of stroke makes prevention challenging. Future trials may evaluate the role of early neuroimaging and simultaneous treatment of stroke given advancements in endovascular therapy.

Restrictive versus liberal transfusion in patients with diabetes undergoing cardiac surgery: An open-label, randomized, blinded outcome evaluation trial.

AIM: To characterize the association between diabetes and transfusion and clinical outcomes in cardiac surgery, and to evaluate whether restrictive transfusion thresholds are harmful in these patients. MATERIALS AND METHODS: The multinational, open-label, randomized controlled TRICS-III trial assessed a restrictive transfusion strategy (haemoglobin [Hb] transfusion threshold <75 g/L) compared with a liberal strategy (Hb <95 g/L for operating room or intensive care unit; or <85 g/L for ward) in patients undergoing cardiac surgery on cardiopulmonary bypass with a moderate-to-high risk of death (EuroSCORE ≥6). Diabetes status was collected preoperatively. The primary composite outcome was all-cause death, stroke, myocardial infarction, and new-onset renal failure requiring dialysis at 6 months. Secondary outcomes included components of the composite outcome at 6 months, and transfusion and clinical outcomes at 28 days. RESULTS: Of the 5092 patients analysed, 1396 (27.4%) had diabetes (restrictive, n = 679; liberal, n = 717). Patients with diabetes had more cardiovascular disease than patients without diabetes. Neither the presence of diabetes (OR [95% CI] 1.10 [0.93-1.31]) nor the restrictive strategy increased the risk for the primary composite outcome (diabetes OR [95% CI] 1.04 [0.68-1.59] vs. no diabetes OR 1.02 [0.85-1.22]; Pinteraction  = .92). In patients with versus without diabetes, a restrictive transfusion strategy was more effective at reducing red blood cell transfusion (diabetes OR [95% CI] 0.28 [0.21-0.36]; no diabetes OR [95% CI] 0.40 [0.35-0.47]; Pinteraction  = .04). CONCLUSIONS: The presence of diabetes did not modify the effect of a restrictive transfusion strategy on the primary composite outcome, but improved its efficacy on red cell transfusion. Restrictive transfusion triggers are safe and effective in patients with diabetes undergoing cardiac surgery.

Expert Consensus of Data Elements for Collection for Enhanced Recovery After Cardiac Surgery.

BACKGROUND: Despite the emergence of Enhanced Recovery Protocols (ERPs) in cardiac surgery, there is no consensus on the essential elements for data reporting for quality improvement efforts, as well as accountability and standardization of outcome reporting across institutions. The aim of this study was to establish a consensus on essential data elements for cardiac ERAS®. METHODS: A 2-round modified Delphi technique was utilized based on existing recommendations from the recently published ERAS® cardiac surgery consensus guidelines. Round 1 included a steering committee of 10 experts who oversaw formulation of a focused list of data elements into 3 main areas: Preoperative, intraoperative and postoperative. Round 2 consisted of a multidisciplinary, multinational, heterogenous group of 50 voting experts from across the United States and Europe. All participants evaluated their level of agreement with each data element using a 5-point Likert scale with consensus threshold of 70%. RESULTS: In round 1, 17 data elements were considered essential (consensus > = 70%, either positive or negative) and 6 were considered marginal (consensus < = 70%, either positive or negative). In round 2, positive consensus was achieved for 15/17 (88.2%) data elements in the essential category, and all six data elements (100%) in the marginal category, indicating a high level of overall agreement. CONCLUSION: This initial study, which identified 21 key data elements for collection in an ERAS® cardiac program, will aid clinicians in establishing a framework for evaluating the quality of their contemporary ERP processes and will allow acquisition of data to help benchmark performance metrics between hospitals.

Multidimensional Analysis of Descending Aortic Growth After Acute Type A Aortic Dissection.

BACKGROUND: After repair of acute type A aortic dissection, typical geometric variables of conventional aortic surveillance focus on maximum diameter and its rate of growth, potentially missing important geometric changes elsewhere. We determined additional information provided by a semiautomated, 3-dimensional (3D), nonlinear growth model of the descending thoracic aorta after repair of type A aortic dissection. METHODS: Computed tomographic angiography data were retrospectively collected after hemiarch repair of type A aortic dissection. The descending aorta was systematically reconstructed to generate a 3D model made up of individual segments. The baseline and follow-up diameters were measured semiautomatically for each segment, and the nonlinear interval growth was determined. RESULTS: The fastest growing segment expanded at a rate of 3.8 mm/y (interquartile range, 2.2 to 5.4 mm/y) vs 0.6 mm/y (interquartile range, -0.3 to 1.7 mm/y) when measured at the original site of maximum diameter (P < .01). The maximum baseline diameter was a poor predictor of location with fastest growth (r = 0.10, P > .1). Using the society recommended growth limits, a greater proportion of patients would be considered "at risk" when assessed by our method vs conventional surveillance measures. CONCLUSIONS: Our model identifies areas of rapid aortic growth after repair of type A dissection that would likely be missed using current surveillance techniques. The increased precision, resolution, and reproducibility provided by our technique may improve on limitations of current surveillance techniques, provide novel geometric data on aortic remodeling, and contribute to the pursuit of a comprehensive patient-specific approach to aortic risk stratification.

Randomized, Controlled Trial Comparing Mitral Valve Repair With Leaflet Resection Versus Leaflet Preservation on Functional Mitral Stenosis: The CAMRA CardioLink-2 Study.

BACKGROUND: Equipoise exists between the use of leaflet resection and preservation for surgical repair of mitral regurgitation caused by prolapse. We therefore performed a randomized, controlled trial comparing these 2 techniques, particularly in regard to functional mitral stenosis. METHODS: One hundred four patients with degenerative mitral regurgitation surgically amenable to either leaflet resection or preservation were randomized at 7 specialized cardiac surgical centers. Exclusion criteria included anterior leaflet or commissural prolapse, as well as a mixed cause for mitral valve disease. Using previous data, we determined that a sample size of 88 subjects would provide 90% power to detect a 5-mm Hg difference in mean mitral valve gradient at peak exercise, assuming an SD of 6.7 mm with a 2-sided test with α=5% and 10% patient attrition. The primary end point was the mean mitral gradient at peak exercise 12 months after repair. RESULTS: Patient age, proportion who were female, and Society of Thoracic Surgeons risk score were 63.9±10.4 years, 19%, and 1.4±2.8% for those who were assigned to leaflet resection (n=54), and 66.3±10.8 years, 16%, and 1.9±2.6% for those who underwent leaflet preservation (n=50). There were no perioperative deaths or conversions to replacement. At 12 months, moderate mitral regurgitation was observed in 3 subjects in the leaflet resection group and 2 in the leaflet preservation group. The mean transmitral gradient at 12 months during peak exercise was 9.1±5.2 mm Hg after leaflet resection and 8.3±3.3 mm Hg after leaflet preservation (P=0.43). The participants had similar resting peak (8.3±4.4 mm Hg versus 8.4±2.6 mm Hg; P=0.96) and mean resting (3.2±1.9 mm Hg versus 3.1±1.1 mm Hg; P=0.67) mitral gradients after leaflet resection and leaflet preservation, respectively. The 6-minute walking distance was 451±147 m for those in the leaflet resection versus 481±95 m for the leaflet preservation group (P=0.27). CONCLUSIONS: In this adequately powered randomized trial, repair of mitral prolapse with either leaflet resection or leaflet preservation was associated with similar transmitral gradients at peak exercise at 12 months postoperatively. These data do not support the hypothesis that a strategy of leaflet resection (versus preservation) is associated with a risk of functional mitral stenosis. Registration: URL: https://www.clinicaltrials.gov; Unique identifier NCT02552771.