Expert Opinions on the Debate of Pericardial Reconstruction in Cardiovascular Surgery: To Close or Not to Close?

BACKGROUND: As of 2019, pericardial closure was performed in only a small portion of the over 320,000 cardiac surgeries performed annually. However, evidence regarding the benefits of pericardial closure or reconstruction has been accruing, particularly with the publication of the RECON study in 2019.  Methods: This group of authors convened to try to arrive at consensus expert opinion regarding pericardial reconstruction. Structured topic questions initially were used to stimulate discussion. Subsequently, a survey of proposed expert opinion statements was conducted among the authors. Based on that survey, consensus expert opinion statements and recommendations were compiled. RESULTS: The expert opinions encompass various topics relating to pericardial reconstruction, including definitions, benefits/risks, and technique. Observed benefits include reductions in: (1) adhesions; (2) postoperative pericardial effusion, atrial fibrillation, and bleeding; and (3) readmissions and length of hospital stay. Expert opinion recommendations regarding surgical technique are compiled into a single chart. Complete pericardial reconstruction should be performed, using native pericardial tissue if available and viable; if not feasible, a patch may be used. Patches that stimulate the formation of site-specific tissue in situ (such as natural extracellular matrix) may have additional benefits (including bioregenerative properties and lack of inflammatory response). Closure should be taut, but tension-free. Adequate drainage of the closed pericardium must be ensured. CONCLUSIONS: Based on available data and collective surgical experience, we endorse pericardial reconstruction as standard approach in appropriately selected patients. We also endorse adoption of standardized pericardial reconstruction techniques to optimize patient outcomes and improve evidence quality in future studies.

Pericardial closure with extracellular matrix scaffold following cardiac surgery associated with a reduction of postoperative complications and 30-day hospital readmissions.

BACKGROUND: A prospective, multi-center study (RECON) was conducted to evaluate the clinical outcomes of pericardial closure using a decellularized extracellular matrix (ECM) graft derived from porcine small intestinal submucosa. METHODS: Patients indicated for open cardiac surgery with pericardial closure using ECM were eligible for the RECON study cohort. Postoperative complications and readmission of the RECON patients were compared to the patient cohort in the Nationwide Readmissions Database (NRD). Inverse probability of treatment weighting was used to control the differences in patient demographics, comorbidities, and risk factors. RESULTS: A total of 1420 patients at 42 centers were enrolled, including 923 coronary artery bypass grafting (CABG) surgeries and 436 valve surgeries. Significantly fewer valve surgery patients in the RECON cohort experienced pleural effusion (3.1% vs. 13.0%; p < 0.05) and pericardial effusion (1.5% vs. 2.6%; p < 0.05) than in the NRD cohort. CABG patients in the RECON cohort were less likely to suffer bleeding (1.2% vs. 2.9%; p < 0.05) and pericardial effusion (0.2% vs. 2.2%, p < 0.05) than those in the NRD cohort. The 30-day all-cause hospital readmission rate was significantly lower among RECON patients than NRD patients following both valve surgery (HR: 0.34; p < 0.05) and CABG surgery (HR: 0.42; p < 0.05). In the RECON study, 14.4% of CABG patients and 27.0% of valve patients had postoperative atrial fibrillation as compared to previously reported risks, which generally ranges from 20 to 30% after CABG and from 35 to 50% after valve surgery. CONCLUSIONS: Pericardial closure with ECM following cardiac surgery is associated with a reduction in the proportion of patients with pleural effusion, pericardial effusion, and 30-day readmission compared to a nationwide database. TRIAL REGISTRATION: NCT02073331 , Registered on February 27, 2014.

Alternative Implantation Technique for Rapid Deployment Valve.

We present a simpler and faster way of implanting the Edwards Intuity Elite rapid deployment valve system. Annular sizing and guiding suture placement are performed in the usual manner. After the valve is parachuted down to the annulus, the balloon catheter is detached and a vent catheter is placed through the center hole to maximize exposure of the valve. The guiding sutures are tied down using an automated suture fastening device instead of securing snares. Visualization of the tip of the suture fastener on the annulus ensures proper valve seating. The sealing frame is ballooned, and the valve is deployed.

Sistema automatizado para la evaluación de la calidad en los laboratorios de diagnóstico con tecnología SUMA / Automated system for quality assessment in the diagnosis laboratories with SUMA technology

El Centro de Inmunoensayo (CIE) es una institución dedicada a investigación-producción orientada al desarrollo y producción de reactivos e instrumentos para el diagnóstico médico, basados en técnicas inmunoenzimáticas que aprovechan la gran especificidad de la interacción antígeno-anticuerpo y las ventajas de las reacciones catalizadas por enzimas. Su línea principal es el Sistema Ultra Micro Analítico (SUMA), que consiste en una tecnología integrada por equipos y reactivos para la realización de los análisis inmunoenzimáticos a un bajo costo de ejecución, lo cual lo hace particularmente adecuado para los programas de prevención de la salud, en los que se requiere el procesamiento de un gran número de muestras. Con el objetivo de lograr la garantía de la calidad se han desarrollado durante más de una década diferentes sistemas de software que se han utilizado en el proceso de evaluación de la calidad en el trabajo de los laboratorios. Con el nombre de SAC 2.0, el CIE desarrolló un sistema para el control de la calidad que puede realizar el proceso evaluativo de forma totalmente automatizada, que ofrece prestaciones similares a los sistemas más avanzados que existen actualmente. En este trabajo se describen elementos considerados en su concepción, así como las ventajas obtenidas con la automatización, las cuales demuestran cómo la herramienta desarrollada constituye un componente de vital importancia para el adecuado funcionamiento de los laboratorios de la tecnología SUMA, ubicados en Cuba y en el exterior(AU)

The Center of Immunoassay (CIE) is a research-production complex aiming at the development and production of reagents and instrumentation for medical diagnosis based on immunoenzymatic techniques using the great specificity of the antigen-antibody interactions and the advantages of the reactions catalyzed by enzymes. Its main line is the Ultra Micro Analytical System (SUMA), consists of a technology of equipments and reagents to perform immunoenzymatic analyses at a low cost, which makes it particularly adequate for prevention health programs that require the processing of a big number of samples. In order to achieve a desirable quality warrant, different software systems have been developed for more than a decade, that have been used in the quality assessment process in the laboratories. Under the name of SAC 2.0, the CIE has developed a version of a system for quality control that is able to perform the assessment process totally automated. This paper describes the elements considered in its conception as well as the advantages obtained from automation, which show how important the developed tools are for the proper functioning of the SUMA laboratories allocated not only in Cuba but in other countries as well(AU)

Institutional variability of intraoperative red blood cell utilization in coronary artery bypass graft surgery.

The variability in frequency of allogeneic blood transfusion during coronary artery bypass surgery (CABG) is a concern. Evidence-based guidelines support minimizing the use of blood during open heart surgery. The Hospital Clinical Services Group quality indicator database was queried for intraoperative red blood cell (RBC) transfusions in 17 252 isolated CABG surgery cases during 2007. Institutional variability was observed in the frequency of intraoperative RBC transfusion rates, which ranged from 0% to 85.7%. The institution mean RBC transfusion rate was 40.8%. Regional geographic and cardiac program size variations were observed in RBC transfusion rates and volume with significant variation. Notable institutional variability persists with respect to intraoperative RBC transfusion in isolated CABG surgery despite clear evidence and guidelines to support techniques to minimize RBC transfusion. Such results support the hypothesis that incorporating evidence-based transfusion-related practices in open heart surgery are not uniformly adopted.