Pericardiotomy and atrial fibrillation after isolated coronary artery bypass grafting: A systematic review and meta-analysis of 16 randomised controlled trials.

BACKGROUND: Atrial fibrillation (AF) and pericardial effusion are notable complications following coronary artery bypass grafting (CABG), contributing to increased morbidity and healthcare costs. Posterior pericardiotomy has been proposed to mitigate these complications. This systematic review and meta-analysis aim to evaluate the efficacy of posterior pericardiotomy in reducing postoperative AF and pericardial effusion in isolated CABG patients. MATERIALS AND METHODS: A comprehensive literature search, adhering to PRISMA guidelines, was conducted across PubMed, MEDLINE via Ovid, Embase, Scopus, the Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov up to December 2023. Only randomised controlled trials (RCTs) comparing prophylactic posterior pericardiotomy to control treatments in adult CABG patients were included. The primary outcomes assessed were the incidences of postoperative AF and pericardial effusion. RESULTS: The meta-analysis incorporated 16 RCTs with a total of 2414 patients. The findings demonstrated a significant reduction in the incidence of postoperative AF (Odds Ratio = 0.34, 95 % CI: 0.25-0.48, P < 0.00001) and pericardial effusion (Odd Ratio = 0.24, 95 % CI: 0.15-0.38, P < 0.0001) in the group undergoing posterior pericardiotomy. However, the analysis revealed substantial heterogeneity and publication bias in the included studies. CONCLUSION: The posterior pericardiotomy is effective in reducing the incidences of AF and pericardial effusion in patients undergoing isolated CABG. Despite the positive outcomes, the presence of heterogeneity and publication bias warrants a cautious interpretation of the results and underscores the need for further multicentre RCTs in this area.

Patient-Specific Haemodynamic Analysis of Virtual Grafting Strategies in Type-B Aortic Dissection: Impact of Compliance Mismatch.

INTRODUCTION: Compliance mismatch between the aortic wall and Dacron Grafts is a clinical problem concerning aortic haemodynamics and morphological degeneration. The aortic stiffness introduced by grafts can lead to an increased left ventricular (LV) afterload. This study quantifies the impact of compliance mismatch by virtually testing different Type-B aortic dissection (TBAD) surgical grafting strategies in patient-specific, compliant computational fluid dynamics (CFD) simulations. MATERIALS AND METHODS: A post-operative case of TBAD was segmented from computed tomography angiography data. Three virtual surgeries were generated using different grafts; two additional cases with compliant grafts were assessed. Compliant CFD simulations were performed using a patient-specific inlet flow rate and three-element Windkessel outlet boundary conditions informed by 2D-Flow MRI data. The wall compliance was calibrated using Cine-MRI images. Pressure, wall shear stress (WSS) indices and energy loss (EL) were computed. RESULTS: Increased aortic stiffness and longer grafts increased aortic pressure and EL. Implementing a compliant graft matching the aortic compliance of the patient reduced the pulse pressure by 11% and EL by 4%. The endothelial cell activation potential (ECAP) differed the most within the aneurysm, where the maximum percentage difference between the reference case and the mid (MDA) and complete (CDA) descending aorta replacements increased by 16% and 20%, respectively. CONCLUSION: This study suggests that by minimising graft length and matching its compliance to the native aorta whilst aligning with surgical requirements, the risk of LV hypertrophy may be reduced. This provides evidence that compliance-matching grafts may enhance patient outcomes.

Early and mid-term outcomes after aortic valve replacement using a novel tissue bioprosthesis: a systematic review.

OBJECTIVES: While current data show a clear trend towards the use of bioprosthetic valves during aortic valve replacement (AVR), durability of bioprosthetic valves remains the most important concern. We conducted a 1st systematic review of all available evidence that analysed early and mid-term outcomes after AVR using the Inspiris RESILIA™ bioprosthesis. METHODS: A systematic literature search was performed to identify all relevant studies evaluating early and mid-term outcomes after AVR using the Inspiris RESILIA bioprosthesis and including at least 20 patients with no restriction on the publication date. Subgroup meta-analysis was performed to compare Inspiris RESILIA and PERIMOUNT Magna Ease bioprosthesis and to pool the early postoperative mortality and stroke rates. RESULTS: A total of 416 studies were identified, of which 15 studies met the eligibility criteria. The studies included a total of 3202 patients with an average follow-up of up to 5.3 years. The average age of patients across the studies was 52.2-75.1 years. Isolated AVR was performed in 39.0-86.4% of patients. In-hospital or 30-day postoperative mortality was 0-2.8%. At the mid-term follow-up, freedom from all-cause mortality was up to 85.4%. Among studies with mid-term follow-up, trace/mild paravalvular leak was detected in 0-3.0%, while major paravalvular leak was found only in up to 2.0% of patients. No statistically significant differences in terms of mortality (P = 0.98, odds ratio 1.02, 95% confidence interval 0.36-2.83) and stroke (P = 0.98, odds ratio 1.01, 95% confidence interval 0.38-2.73) between the Inspiris RESILIA bioprosthesis and PERIMOUNT Magna Ease bioprosthesis were observed in the subgroup meta-analysis. CONCLUSIONS: Mid-term data on the safety and haemodynamic performance of the novel aortic bioprosthesis are encouraging. Further comparative studies with other bioprostheses and longer follow-up are still required to endorse durability and safety of the novel bioprosthesis.

Preoperative B-Type Natriuretic Peptides to Predict Postoperative Atrial Fibrillation in Cardiac Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Post-operative atrial fibrillation (AF) is the most common complication following cardiac surgery. There has been extensive exploration of clinical variables, imaging, and biomarkers to predict its occurrence after cardiac surgery. In this study, we examine the emerging biomarkers B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) to assess their pre-operative values and correlations with the occurrence of post-operative AF in patients undergoing cardiac surgery. METHODS: A comprehensive literature search was conducted using PubMed, EMBASE, MEDLINE via Ovid, ClinicalTrials.Gov, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify studies published until March 2023. The studies were included if they reported pre-operative BNP or NT-proBNP values and the development of post-operative AF in cardiac surgery patients. Subsequently, data were extracted, and a meta-analysis was performed using Review Manager 5.4 4 (The Cochrane Collaboration, 2020) and SPSS version 28 (IBM Corp, Armonk, NY, USA) to assess the difference between pre-operative BNP and NT-proBNP levels between patients with post-operative AF (AF group) and those without (No-AF group) using a random-effect model. Further analysis was performed in three subgroups: isolated coronary artery bypass grafting, isolated valve, and combined/mixed surgery group. RESULT: A total of 20 studies, including 9,079 participants were identified and included in the systematic review and meta-analysis. Pre-operative BNP levels were reported in 11 studies, and NT-proBNP levels were reported in 10 studies, of which one study reported both BNP and NT-proBNP levels. There is an overall significant difference between pre-operative levels of BNP (p=0.03, I2=95%) and NT-proBNP (p<0.001, I2=65%) when compared between AF and No-AF groups. Nonetheless, subgroup analysis showed there is no significant difference in pre-operative BNP levels, except in isolated valve surgery (p<0.001), whereas all subgroups showed significantly different pre-operative levels of NT-proBNP. CONCLUSIONS: Elevated levels of both BNP and NT-proBNP were observed in patients who developed post-operative AF after undergoing cardiac surgery. In particular, pre-operative NT-proBNP levels were elevated in all patients irrespective of the type of surgical procedure, but elevated pre-operative BNP was only seen in valve surgery patients. These findings suggest the potential usefulness of NT-proBNP as a promising biomarker for predicting the occurrence of post-operative AF following cardiac surgery.

Comment on Oehler et al. Outcome and Midterm Survival after Heart Transplantation Is Independent from Donor Length of Stay in the Intensive Care Unit. Life 2022, 12, 1053.

Oehler et al. described an interesting finding, stating that length of stay (LOS) of the donors in the intensive care unit (ICU) did not have an impact on the outcomes and survival of recipients up to 5 years after heart transplantation (HTx) [...].

Perioperative neuromonitoring during thoracoabdominal aortic aneurysm open repair: a systematic review.

OBJECTIVES: While open surgical repair remains the gold standard for thoracoabdominal aortic aneurysm (TAAA) treatment, there is still no consensus regarding perioperative neuromonitoring technique for prevention of spinal cord ischaemia. METHODS: In this systematic review, we aimed to explore the effects and practices of neuromonitoring during the open TAAA repair. A systematic literature search in PubMed, Embase via Ovid, Cochrane library and ClinicalTrialsGov until December 2022 was performed. RESULTS: A total of 535 studies were identified from the literature search, of which 27 studies including a total of 3130 patients met the eligibility criteria. Most studies (21 out of 27, 78%) investigated the feasibility of motor-evoked potentials (MEP), while 15 analysed somatosensory-evoked potentials (SSEP) and 2 studies analysed near-infrared spectroscopy during open TAAA repair. CONCLUSIONS: Current literature suggest that rates of postoperative spinal cord ischaemia can be kept at low levels after open TAAA repair with the adequate precautions and perioperative manoeuvres. Neuromonitoring with MEP provides the surgeon objective criteria to direct selective intercostal reconstruction or other protective anaesthetic and surgical manoeuvres. Simultaneous monitoring of MEP and SSEP is a reliable method that can rapidly detect important findings and direct adequate protective manoeuvres during open TAAA repair.

Resternotomy aortic root and arch replacement following previous complex type A aortic dissection requiring endovascular repair for malperfusion.

A redo sternotomy, aortic root, and arch replacement in a patient following previous complex surgical and endovascular type A aortic dissection repair is presented in this video case report. Shortly after having the initial type A aortic dissection repair with replacement of the ascending aorta, the patient developed severe visceral malperfusion due to a compressed distal true lumen and underwent emergency endovascular repair with ascending arch and descending thoracic aorta stents and chimney grafts for the aortic arch vessels as well as fenestration of the intimal flap of the abdominal aorta. Unfortunately, the patient developed permanent paraplegia and progressive symptomatic severe aortic regurgitation. The patient underwent a redo sternotomy, aortic root, and arch replacement with explantation of the ascending stent graft and chimney stent grafts. Antegrade cerebral perfusion was maintained throughout the procedure. The aortic arch was replaced using a Terumo Aortic Plexus multibranched graft distally anastomosed to the endovascular stent graft, and the innominate and left common carotid arteries were reimplanted onto the graft. The aortic root was replaced with a Bioconduit graft, using a modified Cabrol technique to reimplant the left coronary artery. A satisfactory postoperative course and computed tomography imaging highlight the feasibility of this highly complex aortic arch repair with careful preoperative planning.

Delirium, dementia, and depression (3D) assessment of older patients in the emergency department: 5-year survival analysis.

BACKGROUND: While physicians tend to emphasize on physical medical problems, behavioral and cognitive disorders of geriatric patients are usually missed, especially in emergency settings. The aim of the study was to determine the prevalence of delirium, dementia, and depression (3D) among older patients (≥65 years old) in the Emergency Department (ED) and to evaluate the effect of geriatric 3D on the 6-month and 5-year mortality. METHODS: This was a prospective, observational cohort study, including 415 patients from eligible 512 consecutive older patients, who are 65 years of age or older, presenting to the ED of a tertiary care university hospital. Geriatric delirium, dementia, and depression were prospectively evaluated using Confusion Assessment Method, Quick Confusion Scale, and Geriatric Depression Scale-15, respectively. Premorbid functional status was determined by Barthel Index. The Charlson Comorbidity Index was used to measure the comorbid burden. After enrollment, patients were screened for 6-month and 5-year survival rates via the Government Death Reporting System records. The Kaplan-Meier method and Cox proportional hazards analysis was used for survival analysis. RESULTS: Among the study population, the prevalence of geriatric 3D was found as 10.6% (n = 44/415) for delirium, 45.6% (n = 160/351) for dementia, and 35.1% (n = 123/350) for depression. Delirium, dementia, and depression all had higher mortality rates among older ED patients covering the 5-year period. However, only delirium was predictive of both 6-month and 5-year mortality rates. DISCUSSION: Aside from the medical and surgical issues of geriatric patients, the prevalences of dementia and depression are much higher than expected in the emergency department. Delirium was a predictor for 6-month and 5-year mortality. We suggest that EDs should have screening tools for geriatric 3D mental health disorders to increase the quality of life for the geriatric population.

Can adequate hemodynamic management of brain-dead donors improve donor organ procurement?

There is increasing evidence that adequate donor management with a goal of optimization of organ function is essential to maximize the number of organs that can be procured. Therefore, identification of the cause of hemodynamic instability is crucial in order to direct the right therapy. Several donor management goals for better hemodynamic management including serial echocardiography can guide hemodynamic management in potential donors to increase both number and quality of donor hearts.

Ministernotomy repair of inadvertent proximal right subclavian artery injury following right internal jugular central venous catheter insertion.

A man in his 60s was referred for urgent coronary artery bypass grafting (CABG) procedure following acute coronary syndrome. After induction of general anaesthesia, right jugular venous catheterisation under two-dimensional ultrasound guidance was planned as part of perioperative management. While obtaining vascular access, the pulsatile flow was noted once the dilator was inserted, having to abandon the procedure and immediately apply manual pressure. CT angiogram showed proximal right subclavian artery injury with active contrast extravasation and resultant large haematoma in the neck. The patient underwent urgent exploration of the injured vessel through a J-shaped ministernotomy, and primary repair of the artery was performed. The patient recovered from the procedure without any complications. He continued to stay in the hospital for a few days, afterwards, he underwent the initially planned CABG surgery. He was discharged home on day 5 after surgery without further concerns.

Migration of PFO closure device and entrapment within tricuspid valve leading to tricuspid regurgitation: surgical correction of an extremely rare complication after transcutaneous PFO closure.

A 41-year-old woman was referred to tertiary cardiothoracic surgery centre following embolisation of the Amplatzer patent foramen ovale (PFO) closure device to septal leaflet of tricuspid valve with reopening of PFO. Two years earlier, she presented with thalamic stroke, and she was found to have a PFO following investigations. The following year she underwent transcatheter closure. Six months after the percutaneous closure, she presented again with significant periods of shortness of breath. Imaging studies revealed the migration and embolisation of PFO closure device to the septal leaflet of tricuspid valve with reopening of the foramen and significant tricuspid valve regurgitation. She underwent open heart surgery using cardiopulmonary bypass for retrieval of the device, closure of the foramen and repair of the tricuspid valve. The patient recovered well without any significant issues following surgery.