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1.
J Am Coll Cardiol ; 79(7): 682-694, 2022 02 22.
Article in English | MEDLINE | ID: mdl-35177198

ABSTRACT

Autonomic neuromodulation therapies (ANMTs) (ie, ganglionated plexus ablation, epicardial injections for temporary neurotoxicity, low-level vagus nerve stimulation [LL-VNS], stellate ganglion block, baroreceptor stimulation, spinal cord stimulation, and renal nerve denervation) constitute an emerging therapeutic approach for arrhythmias. Very little is known about ANMTs' preventive potential for postoperative atrial fibrillation (POAF) after cardiac surgery. The purpose of this review is to summarize and critically appraise the currently available evidence. Herein, the authors conducted a systematic review of 922 articles that yielded 7 randomized controlled trials. In the meta-analysis, ANMTs reduced POAF incidence (OR: 0.37; 95% CI: 0.25 to 0.55) and burden (mean difference [MD]: -3.51 hours; 95% CI: -6.64 to -0.38 hours), length of stay (MD: -0.82 days; 95% CI: -1.59 to -0.04 days), and interleukin-6 (MD: -79.92 pg/mL; 95% CI: -151.12 to -8.33 pg/mL), mainly attributed to LL-VNS and epicardial injections. Moving forward, these findings establish a base for future larger and comparative trials with ANMTs, to optimize and expand their use.


Subject(s)
Atrial Fibrillation/physiopathology , Atrial Fibrillation/therapy , Autonomic Nervous System/physiopathology , Cardiac Surgical Procedures/adverse effects , Postoperative Complications/physiopathology , Postoperative Complications/therapy , Atrial Fibrillation/etiology , Autonomic Nerve Block/methods , Autonomic Nerve Block/trends , Cardiac Surgical Procedures/trends , Humans , Postoperative Complications/etiology , Radiofrequency Ablation/methods , Radiofrequency Ablation/trends , Vagus Nerve Stimulation/methods , Vagus Nerve Stimulation/trends
5.
Prog Cardiovasc Dis ; 69: 101-109, 2021.
Article in English | MEDLINE | ID: mdl-34843811

ABSTRACT

Percutaneous left atrial appendage closure (LAAC) has become an important non-pharmacological intervention for stroke prevention in patients with non-valvular atrial fibrillation (AF). LAAC aims to reduce the risk of thromboembolism without increasing the risk of bleeding, a crucial strategy for patients at high risk for bleeding. Over the last few decades, the safety and long-term efficacy of the procedure in specific populations have grown, and more patients are being treated with these devices. Current and future studies focus on expanding the target population as well as the iteration of current technology. This article reviews recent, present, and future LAAC studies on the two most common devices, the Watchman device (Boston Scientific Corporation) and the Amplatzer cardiac plug (ACP) (St. Jude Medical, Minneapolis, MN), and their subsequent next generations, the Watchman FLX, and the Amulet, respectively.


Subject(s)
Atrial Appendage , Atrial Fibrillation , Cardiac Surgical Procedures , Atrial Appendage/surgery , Atrial Fibrillation/surgery , Cardiac Surgical Procedures/adverse effects , Cardiac Surgical Procedures/trends , Hemorrhage/chemically induced , Humans , Stroke/prevention & control , Treatment Outcome
7.
Circ Cardiovasc Imaging ; 14(11): e013134, 2021 11.
Article in English | MEDLINE | ID: mdl-34743527

ABSTRACT

There is continued interest in surgical repair of both the congenitally malformed aortic valve, and the valve with acquired dysfunction. Aortic valvar repair based on a geometric approach has demonstrated improved durability and outcomes. Such an approach requires a thorough comprehension of the complex 3-dimensional anatomy of both the normal and congenitally malformed aortic root. In this review, we provide an understanding of this anatomy based on the features that can accurately be revealed by contrast-enhanced computed tomographic imaging. We highlight the complimentary role that such imaging, with multiplanar reformatting and 3-dimensional reconstructions, can play in selection of patients, and subsequent presurgical planning for valvar repair. The technique compliments other established techniques for perioperative imaging, with echocardiography maintaining its central role in assessment, and enhances direct surgical evaluation. This additive morphological and functional information holds the potential for improving selection of patients, surgical planning, subsequent surgical repair, and hopefully the subsequent outcomes.


Subject(s)
Aortic Valve/diagnostic imaging , Cardiac Surgical Procedures/trends , Heart Valve Diseases/diagnosis , Imaging, Three-Dimensional/methods , Tomography, X-Ray Computed/methods , Aortic Valve/abnormalities , Aortic Valve/surgery , Cardiac Surgical Procedures/methods , Echocardiography , Heart Valve Diseases/congenital , Heart Valve Diseases/surgery , Humans
8.
Best Pract Res Clin Anaesthesiol ; 35(3): 321-332, 2021 Oct.
Article in English | MEDLINE | ID: mdl-34511222

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has potentiated the need for implementation of strict safety measures in the medical care of surgical patients - and especially in cardiac surgery patients, who are at a higher risk of COVID-19-associated morbidity and mortality. Such measures not only require minimization of patients' exposure to COVID-19 but also careful balancing of the risks of postponing nonemergent surgical procedures and providing appropriate and timely surgical care. We provide an overview of current evidence for preoperative strategies used in cardiac surgery patients, including risk stratification, telemedicine, logistical challenges during inpatient care, appropriate screening capacity, and decision-making on when to safely operate on COVID-19 patients. Further, we focus on perioperative measures such as safe operating room management and address the dilemma over when to perform cardiovascular surgical procedures in patients at risk.


Subject(s)
COVID-19/prevention & control , Cardiac Surgical Procedures/standards , Patient Safety/standards , Perioperative Care/standards , COVID-19/epidemiology , COVID-19/surgery , Cardiac Surgical Procedures/trends , Humans , Pandemics/prevention & control , Perioperative Care/trends , Risk Factors
9.
BMC Cardiovasc Disord ; 21(1): 434, 2021 09 14.
Article in English | MEDLINE | ID: mdl-34521355

ABSTRACT

BACKGROUND: The coronavirus-disease 2019 (COVID-19) pandemic imposed an unprecedented burden on the provision of cardiac surgical services. The reallocation of workforce and resources necessitated the postponement of elective operations in this cohort of high-risk patients. We investigated the impact of this outbreak on the aortic valve surgery activity at a single two-site centre in the United Kingdom. METHODS: Data were extracted from the local surgical database, including the demographics, clinical characteristics, and outcomes of patients operated on from March 2020 to May 2020 with only one of the two sites resuming operative activity and compared with the respective 2019 period. A similar comparison was conducted with the period between June 2020 and August 2020, when operative activity was restored at both institutional sites. The experience of centres world-wide was invoked to assess the efficiency of our services. RESULTS: There was an initial 38.2% reduction in the total number of operations with a 70% reduction in elective cases, compared with a 159% increase in urgent and emergency operations. The attendant surgical risk was significantly higher [median Euroscore II was 2.7 [1.9-5.2] in 2020 versus 2.1 [0.9-3.7] in 2019 (p = 0.005)] but neither 30-day survival nor freedom from major post-operative complications (re-sternotomy for bleeding/tamponade, transient ischemic attack/stroke, renal replacement therapy) was compromised (p > 0.05 for all comparisons). Recommencement of activity at both institutional sites conferred a surgical volume within 17% of the pre-COVID-19 era. CONCLUSIONS: Our institution managed to offer a considerable volume of aortic valve surgical activity over the first COVID-19 outbreak to a cohort of higher-risk patients, without compromising post-operative outcomes. A backlog of elective cases is expected to develop, the accommodation of which after surgical activity normalisation will be crucial to monitor.


Subject(s)
Aortic Valve/surgery , COVID-19 , Cardiac Surgical Procedures/trends , Heart Valve Diseases/surgery , Outcome and Process Assessment, Health Care/trends , Practice Patterns, Physicians'/trends , Surgeons/trends , Aged , Aged, 80 and over , Cardiac Surgical Procedures/adverse effects , Cardiac Surgical Procedures/mortality , Databases, Factual , Elective Surgical Procedures/trends , Female , Heart Valve Diseases/mortality , Humans , London , Male , Middle Aged , Patient Safety , Postoperative Complications/etiology , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome
10.
Int Heart J ; 62(5): 1153-1155, 2021 Sep 30.
Article in English | MEDLINE | ID: mdl-34544965

ABSTRACT

A 60-year old male with paroxysmal atrial fibrillation underwent a combined procedure of left atrial appendage occlusion and pulmonary vein isolation. However, an acute intraprocedural 24-mm Watchman device dislodgement occurred, and thus a decision for urgent surgery was made. However, it was noted during the surgery that the device had migrated further to the descending aorta, just distal to the left subclavian artery. Since a right sternotomy access for retrieval was not feasible, a percutaneous approach was justified. A homemade snare was created using a combination of a long sheath, J-wire, and a regular snare, and the device was successfully retrieved without significant difficulty.


Subject(s)
Atrial Appendage/surgery , Atrial Fibrillation/surgery , Cardiac Surgical Procedures/trends , Device Removal/instrumentation , Septal Occluder Device/adverse effects , Aorta, Thoracic/surgery , Cardiac Catheterization/methods , Cardiac Surgical Procedures/methods , Combined Modality Therapy/methods , Humans , Male , Middle Aged , Pulmonary Veins/surgery , Subclavian Artery/surgery , Treatment Outcome
11.
J Pediatr ; 239: 206-211.e1, 2021 12.
Article in English | MEDLINE | ID: mdl-34363815

ABSTRACT

OBJECTIVE: To evaluate the trends in hospitalizations for children with trisomy 18 over time and to determine the rate of invasive procedures on these children, using a large inpatient database. STUDY DESIGN: A retrospective analysis using the Kids' Inpatient Database from 1997 to 2016 was performed for trisomy 18. We evaluated survival to discharge as well as the presence of pulmonary, skeletal, neurologic, gastrointestinal, renal, and hematologic/bleeding problems. We also searched for the following interventions, if performed: gastrostomy tube placement, tracheostomy, or cardiac procedure. RESULTS: Over this period 10 151 admissions occurred in children with a diagnosis of trisomy 18. Between 1997 and 2016, the number of children admitted annually with trisomy 18 increased 74% from 1036 to 1798. The proportion of patients born prematurely remained stable at 14%-16% throughout the study. Gastrostomy tube placement increased 12-fold during the study period, tracheostomy increased 11-fold, and cardiac intervention increased 5-fold. The overall mortality rate decreased in those with trisomy 18 from 32% in 1997 to 21% in 2016. CONCLUSIONS: We highlight a decreased inpatient mortality rate during the study period. The number of children undergoing interventions such as gastrostomy tube and tracheostomy increased, as did the number of children undergoing cardiac intervention. Although the number of procedures has increased with the mortality rate decreasing, it is unclear at present whether the 2 are related.


Subject(s)
Cardiac Surgical Procedures/trends , Gastrostomy/trends , Hospitalization/trends , Practice Patterns, Physicians'/trends , Tracheostomy/trends , Trisomy 18 Syndrome/surgery , Adolescent , Child , Child, Preschool , Databases, Factual , Female , Humans , Infant , Infant, Newborn , Male , Retrospective Studies , Trisomy 18 Syndrome/complications , Trisomy 18 Syndrome/mortality , United States
13.
Anesth Analg ; 133(1): 19-28, 2021 07 01.
Article in English | MEDLINE | ID: mdl-34127586

ABSTRACT

Cryoprecipitate has been the gold standard for treating acquired hypofibrinogenemia in cardiac surgery for nearly 50 years. More recently, fibrinogen concentrate has been used off-label in the United States and is the standard in European countries and Canada to treat the acquired hypofibrinogenemia during cardiac surgery. Fibrinogen concentrate has multiple potential advantages including rapid reconstitution, greater dose predictability, viral inactivation during processing, and reduced transfusion-related adverse events. However, because fibrinogen concentrate lacks the other components contained in the cryoprecipitate, it may not be the "ideal" product for replacing fibrinogen in all cardiac surgical patients, particularly those with longer cardiopulmonary bypass duration. In this Pro-Con commentary article, we discuss the advantages and disadvantages of using fibrinogen concentrate and cryoprecipitate to treat acquired hypofibrinogenemia in cardiac surgical patients.


Subject(s)
Afibrinogenemia/drug therapy , Cardiac Surgical Procedures/adverse effects , Fibrinogen/administration & dosage , Fibronectins/administration & dosage , Hemostatics/administration & dosage , Postoperative Complications/drug therapy , Afibrinogenemia/blood , Afibrinogenemia/etiology , Cardiac Surgical Procedures/trends , Factor VIII/administration & dosage , Factor VIII/chemistry , Fibrinogen/chemistry , Fibronectins/chemistry , Hemostatics/chemistry , Humans , Postoperative Complications/blood , Postoperative Complications/etiology , Treatment Outcome
14.
Pacing Clin Electrophysiol ; 44(7): 1236-1252, 2021 Jul.
Article in English | MEDLINE | ID: mdl-34085712

ABSTRACT

The thromboembolic complications of Atrial fibrillation (AF) remain a major problem in contemporary clinical practice. Despite advances and developments in anticoagulation strategies, therapy is complicated by the high risk of bleeding complications and need for meticulous medication compliance. Over the past few decades, the left atrial appendage has emerged as a promising therapeutic target to prevent thromboembolic events while mitigating bleeding complications and compliance issues. Emerging data indicates that it is a safe, effective and feasible alternative to systemic anticoagulation in patients with non-valvular AF. A number of devices have been developed for endocardial or epicardial based isolation of the left atrial appendage. Increasing experience has improved overall procedural safety and ease while simultaneously reducing device related complication rates. Furthermore, increasing recognition of the non-mechanical advantages of this procedure has led to further interest in its utility for further indications beyond the prevention of thromboembolic complications. In this review, we present a comprehensive overview of the evolution of left atrial appendage occlusion, commercially available devices and the role of this modality in the current management of AF. We also provide a brief outline of the landmark trials supporting this approach as well as the ongoing research and future prospects of left atrial appendage occlusion.


Subject(s)
Atrial Appendage/surgery , Atrial Fibrillation/surgery , Thromboembolism/prevention & control , Atrial Fibrillation/complications , Cardiac Surgical Procedures/methods , Cardiac Surgical Procedures/trends , Forecasting , Humans , Thromboembolism/etiology
16.
Interact Cardiovasc Thorac Surg ; 32(3): 433-440, 2021 04 08.
Article in English | MEDLINE | ID: mdl-33831215

ABSTRACT

OBJECTIVES: To compare patient-reported outcome measures of minimally invasive (MI) to sternotomy (ST) mitral valve repair. METHODS: We included all patients undergoing isolated mitral valve surgery via either a right mini-thoracotomy (MI) or ST over a 36-month period. Patients were asked to complete a modified Composite Physical Function questionnaire. Intraoperative and postoperative outcomes, and patient-reported outcome measures were compared between 2 propensity-matched groups (n = 47/group), assessing 3 domains: 'Recovery Time', 'Postoperative Pain' (at day 2 and 1, 3, 6 and 12 weeks) and 'Treatment Satisfaction'. Composite scores for each domain were subsequently constructed and multivariable analysis was used to determine whether surgical approach was associated with domain scores. RESULTS: The response rate was 79%. There was no mortality in either group. In the matched groups, operative times were longer in the MI group (P < 0.001), but postoperative outcomes were similar. Composite scores for Recovery Time [ST 51.7 (31.8-62.1) vs MI 61.7 (43.1-73.9), P = 0.03] and Pain [ST 65.7 (40.1-83.1) vs MI 79.1 (65.5-89.5), P = 0.02] significantly favoured the MI group. Scores in the Treatment Satisfaction domain were high for both surgical approaches [ST 100 (82.5-100) vs MI 100 (95.0-100), P = 0.15]. The strongest independent predictor of both faster recovery parameter estimate 12.0 [95% confidence interval (CI) 5.7-18.3, P < 0.001] and less pain parameter estimate 7.6 (95% CI 0.7-14.5, P = 0.03) was MI surgery. CONCLUSIONS: MI surgery was associated with faster recovery and less pain; treatment satisfaction and safety profiles were similar.


Subject(s)
Minimally Invasive Surgical Procedures/methods , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/surgery , Patient Reported Outcome Measures , Sternotomy/methods , Aged , Cardiac Surgical Procedures/methods , Cardiac Surgical Procedures/trends , Cohort Studies , Female , Humans , Male , Middle Aged , Minimally Invasive Surgical Procedures/trends , Operative Time , Pain, Postoperative/diagnostic imaging , Pain, Postoperative/etiology , Prospective Studies , Sternotomy/trends , Thoracotomy/methods , Thoracotomy/trends , Treatment Outcome
17.
Open Heart ; 8(1)2021 04.
Article in English | MEDLINE | ID: mdl-33911022

ABSTRACT

The field of transcatheter mitral valve repair (TMVr) for mitral regurgitation (MR) is rapidly evolving. Besides the well-established transcatheter mitral edge-to-edge repair approach, there is also growing evidence for therapeutic strategies targeting the mitral annulus and mitral valve chordae. A patient-tailored approach, careful patient selection and an experienced interventional team is crucial in order to optimise procedural and clinical outcomes. With further data from ongoing clinical trials to be expected, consensus in the Heart Team is needed to address these complexities and determine the most appropriate TMVr therapy, either single or combined, for patients with severe MR.


Subject(s)
Cardiac Catheterization/adverse effects , Cardiac Surgical Procedures/instrumentation , Heart Valve Prosthesis Implantation/adverse effects , Mitral Valve Insufficiency/surgery , Mitral Valve/surgery , Cardiac Surgical Procedures/trends , Cardiac Valve Annuloplasty/methods , Chordae Tendineae/pathology , Chordae Tendineae/surgery , Humans , Mitral Valve/pathology , Patient Selection , Treatment Outcome
18.
Expert Rev Med Devices ; 18(3): 245-260, 2021 Mar.
Article in English | MEDLINE | ID: mdl-33624569

ABSTRACT

Introduction: During the past five years the approach to procedural planning, operative techniques and perfusion strategies for minimally invasive mitral valve surgery (MIMVS) has evolved. With the goal to provide a maximum of patient safety the procedure has been modified according to individual patient characteristics and is largely based on preoperative imaging.Areas covered: In this review article we describe the important factors in image based therapy planning and simulation, different access strategies, the operative key-steps, a rationale use of devices, and highlight a few future developments in the field of MIMVS. Published studies were identified through pearl growing, citation chasing, a search of PubMed using the systematic review methods filter, and the authors' topic knowledge.Expert opinion: With the help of expert teams including surgeons specialized in mitral repair, anesthesiologists and perfusionists a broad spectrum of mitral valve pathologies and related pathologies can be treated with excellent functional outcomes. Avoiding procedure related complications is the key for success for any MIMVS program.


Subject(s)
Cardiac Surgical Procedures/trends , Minimally Invasive Surgical Procedures/trends , Mitral Valve/surgery , Computer Simulation , Humans , Mitral Valve/diagnostic imaging , Robotics , Tomography, X-Ray Computed
20.
J Thorac Cardiovasc Surg ; 161(3): 733-744, 2021 Mar.
Article in English | MEDLINE | ID: mdl-33431207

ABSTRACT

BACKGROUND: Increased attention has been dedicated to gender inequity at scientific meetings. This study evaluated the gender distribution of session leaders at cardiothoracic surgery national and regional meetings. METHODS: This is a descriptive study of the gender of peer-selected session leaders at 4 cardiothoracic surgery organizations' annual meetings from 2015 to 2019. Session leaders included moderators, panelists, and invited discussants. Data from publicly available programs were used to generate a list of session leaders and organization leaders. The primary outcome measure was the proportion of female session leaders at annual meetings. Descriptive analyses were performed, including the Cochran-Armitage trend test for linear trends of proportions. RESULTS: A total of 679 sessions over 20 meetings were examined. Of the 3662 session leaders, 480 (13.1%) were women. The proportion of total female session leaders trended positively over time from 9.6% (56 of 581) in 2015 to 15.9% (169 of 1060) in 2019 (P = .001). Among specialty topic sessions, female session leaders were distributed as follows: adult cardiac, 6.9% (81 of 1172); congenital cardiac, 10.8% (47 of 437); and thoracic, 23.2% (155 of 668). The proportion of female session leaders trended significantly only for thoracic sessions (20.6% [21 of 102] in 2015 to 29.2% [58 of 199] in 2019; P = .02). More than one-half of the sessions (57.4%; 390 of 679) featured all-male session leadership. CONCLUSIONS: Women remain underrepresented in leadership roles at cardiothoracic surgery organizational meetings. This may deter female applicants and has implications for female surgeons' career trajectories; therefore, attention must be given to the potential for unconscious bias in leadership in cardiothoracic surgery.


Subject(s)
Congresses as Topic/trends , Gender Equity , Leadership , Physicians, Women/trends , Surgeons/trends , Thoracic Surgery/trends , Thoracic Surgical Procedures/trends , Cardiac Surgical Procedures/trends , Cultural Diversity , Female , Humans , Male , Sexism , Time Factors
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