Perioperative Risk Factors of Acute Kidney Injury After Heart Transplantation and One-Year Clinical Outcomes: A Retrospective Cohort Study.

OBJECTIVES: This study aimed to identify perioperative risk factors of acute kidney injury after heart transplantation and to evaluate 1-year clinical outcomes. DESIGN: A retrospective single-center cohort study. SETTING: At a university hospital. PARTICIPANTS: All patients who underwent heart transplantation from January 2015 to December 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors recorded acute kidney injury after heart transplantation. One-year mortality and renal function also were recorded. Risk factors of acute kidney injury were evaluated using a multivariate logistic regression model. Long-term survival was compared between patients developing acute kidney injury and those who did not, using a log-rank test. Among 209 patients included in this study, 134 patients (64% [95% CI (58; 71)]) developed posttransplantation acute kidney injury. Factors independently associated with acute kidney injury were high body mass index (odds ratio [OR]: 1.18 [1.02-1.38] per kg/m2; p = 0.030), prolonged duration of cold ischemic period (OR: 1.11 [1.01-1.24] per 10 minutes; p = 0.039), and high dose of intraoperative dobutamine support (OR: 1.24 [1.06-1.46] per µg/kg/min; p = 0.008). At 1 year, patients who developed postoperative acute kidney injury had higher mortality rates (20% v 8%, p = 0.015). Among 172 survivors at 1 year, 82 survivors (48%) had worsened their renal function compared with preheart transplantation. CONCLUSIONS: This study highlighted the high incidence of acute kidney injury after heart transplantation and its impact on patient outcomes. Risk factors such as body mass index, prolonged cold ischemic period duration, and level of inotropic support with dobutamine were identified, providing insights for preventive strategies.

Association between vasoactive-inotropic score, morbidity and mortality after heart transplantation.

OBJECTIVES: The aim of this study was to evaluate the association between vasoactive-inotropic score (VIS), calculated in the 24 h after heart transplantation, and post-transplant mortality and morbidity. METHODS: This was an observational single-centre retrospective study. Patients admitted to surgical intensive care unit after transplantation, between January 2015 and December 2018, were reviewed consecutively. VISmax was calculated as dopamine+ dobutamine+ 100 × epinephrine + 100 × norepinephrine + 50 × levosimendan + 10 × milrinone (all in µg/kg/min) + 10 000 × vasopressin (units/kg/min), using the maximum dosing rates of vasoactive and inotropic medications in the 24 h after intensive care unit admission. The primary outcome was mortality at 1 year post-transplant. The secondary outcomes included length of stay, duration of mechanical ventilation and inotropic support and the occurrence of septic shock, ventilator-associated pneumonia, bloodstream infection or renal replacement therapy. RESULTS: A total of 151 patients underwent heart transplantation and admitted to intensive care unit. The median VISmax was 39.2 (interquartile range = 19.4-83.0). VISmax was independently associated with 1-year post-transplant mortality, as well as recipient age [hazard ratio (HR) = 1.004, P-value = 0.013], recipient gender (female to male: hazard ratio = 2.23, P-value = 0.047) and combined transplantation (hazard ratio = 2.85, P-value = 0.048). There was a significant association between VISmax and duration of mechanical ventilation (P-value < 0.001), length of stay (P-value = 0.002), duration of infused inotropes (P-value < 0.001), occurrence of bloodstream infections, septic shocks, ventilation-acquired pneumonia and renal replacement therapy. CONCLUSIONS: VISmax calculated during the first 24 h after postoperative intensive care unit admission in transplanted patients is independently associated with 1-year mortality. In addition, length of stay, duration of mechanical ventilation and infused inotropes increased with increasing VISmax.

Levosimendan in patients undergoing extracorporeal membrane oxygenation after cardiac surgery: an emulated target trial using observational data.

BACKGROUND: Retrospective cohorts have suggested that levosimendan may facilitate the weaning of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We therefore studied this clinical question by emulating a randomized trial with observational data. METHODS: All patients with refractory postcardiotomy cardiogenic shock and assisted with VA-ECMO, admitted to a surgical intensive care unit at La Pitié-Salpêtrière Hospital between 2016 and 2019, were eligible. To avoid immortal-time bias, we emulated a target trial sequentially comparing levosimendan administration versus no levosimendan administration in patients treated with VA-ECMO. The primary outcome was time to successful ECMO weaning. The secondary outcomes were 30-day and 1-year mortality. We performed a multivariable analysis to adjust for confounding at baseline. RESULTS: Two hundred and thirty-nine patients were included in the study allowing building a nested trials cohort of 1434 copies of patients. No association of levosimendan treatment and VA-ECMO weaning was found (HR = 0.91, [0.57; 1.45], p = 0.659 in multivariable analysis), or 30-day mortality (OR = 1.03, [0.52; 2.03], p = 0.940) and 1-year mortality (OR = 1.00, [0.53; 1.89], p = 0.999). CONCLUSIONS: Using the emulated target trial framework, this study did not find any association of levosimendan treatment and ECMO weaning success after postcardiotomy cardiogenic shock. However, the population of interest remains heterogeneous and subgroups might benefit from levosimendan.

Effects of ferric carboxymaltose on hemoglobin level after cardiac surgery: A randomized controlled trial.

BACKGROUND: Perioperative anemia is common in cardiac surgery. Few studies investigated the effect of postoperative intravenous (IV) iron supplementation and were mostly inconclusive. METHODS: Design: A randomized single-center, double-blind, placebo-controlled, parallel-group trial. PARTICIPANTS: 195 non-anemic patients were recruited from December 2018 to December 2020: 97 patients received 1 g of ferric carboxymaltose (FCM) and 98 patients received 100 mL of physiological serum on postoperative day 1. MEASUREMENTS: hemoglobin levels, reticulocyte count, serum iron, serum ferritin, and transferrin saturation were measured at induction of anesthesia, postoperative days 1, 5, and 30. Transfusion rate, duration of mechanical ventilation, critical care unit length of stay, and side effects associated with IV iron administration were measured. The primary outcome was hemoglobin level on day 30. Secondary outcomes included iron balance, transfused red cell packs, and critical care unit length of stay. RESULTS: At day 30, the hemoglobine level was higher in the FCM group than in the placebo group (mean 12.9 ± 1.2 vs. 12.1 ± 1.3 g/dL (95%CI 0.41-1.23, p-value <0.001)). Patients in the FCM group received fewer blood units (median 1[0-2] unit vs. 2 [0-3] units, p-value = 0.037) and had significant improvement in iron balance compared to the control group. No side effects associated with FCM administration were reported. CONCLUSION: In this randomized controlled trial, administration of FCM on postoperative day 1 in non-anemic patients undergoing cardiac surgery increased hemoglobin levels by 0.8 g/dL on postoperative day 30, leading to reduced transfusion rate, and improved iron levels on postoperative day 5 and 30. CLINICAL TRIAL REGISTRY NUMBER: NCT03759964.

Preoperative oral magnesium loading to prevent postoperative atrial fibrillation following coronary surgery: a prospective randomized controlled trial.

OBJECTIVES: Postoperative atrial fibrillation (POAF) is common following coronary artery bypass grafting (CABG) surgery. Hypomagnesemia is frequent after CABG surgery. No previous trials have assessed the effect of preoperative magnesium (Mg) loading on POAF incidence. METHODS: This was a single-centre, double-blind, placebo-controlled, parallel-group trial, with balanced randomization [1:1]. The participants were recruited from November 2018 until May 2019. Patients received either 3.2 g of Mg daily (4 tablets of 0.4 g each twice daily) for 72 h preoperatively and 1.6 g of Mg (4 tablets) on the day of surgery or placebo tablets. RESULTS: The primary outcome was the incidence of POAF. Secondary outcomes included time to extubation, transfusion rate, critical care unit and hospital length of stay. Of the 210 randomized participants, 200 (100 in each group) completed the study. A total of 10 (10%) and 22 (22%) subjects developed POAF in the Mg and placebo groups, respectively (RR = 0.45, 95% confidence interval: 0.23-0.91). Hospital and critical care unit length of stay were comparable between the 2 groups. No side effects related to Mg administration were documented. CONCLUSIONS: In this randomized controlled trial, preoperative loading with oral administration of Mg for 3 days in patients admitted for CABG surgery decreases the incidence of POAF compared to placebo. CLINICAL TRIAL REGISTRATION NUMBER: NCT03703349.

Weaning-Related Shock in Patients With ECMO: Incidence, Mortality, and Predisposing Factors.

OBJECTIVE: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) commonly is used to manage refractory cardiogenic shock after cardiac surgery, with 31% to 76% of patients successfully weaned off their ECMO. However, it is associated with high mortality rates, and 20% to 65% of weaned patients do not survive to hospital discharge. This study aimed to assess the incidence of ECMO weaning-related shock, the risk factors, and prognosis in the intensive care unit (ICU). DESIGN: Retrospective observational cohort study. SETTING: Surgical ICU of Cardiology Institute of Pitié-Salpêtrière University Hospital (Paris-France). PARTICIPANTS: Patients who were assisted with a peripheral VA-ECMO from January 2015 to December 2017 were included. Patients with venovenous, central, or right ECMO were excluded. MEASUREMENTS: The authors collected data on patients' characteristics, during and after surgery. The indications for VA-ECMO implantation were ventricular dysfunction, primary graft dysfunction, and refractory cardiac arrest. Weaning-related shock was defined as the need to introduce or increase the dose of catecholamine at ECMO explantation or in the following week. RESULTS: After weaning off VA-ECMO, 56 of 146 patients (38.4%) presented weaning-related shock: 55% were septic shocks, 12.5 % were caused by right ventricle failure, and 7.1% by hemorrhage. ICU mortality was 42% versus 8% in patients who did not present shock. Multivariate analysis showed that patients with pulmonary hypertension and those with norepinephrine before weaning were more likely to develop shock. CONCLUSION: ECMO weaning-related shock is frequent in patients with refractory cardiogenic shock after cardiac surgery. This is most commonly caused by sepsis and causes higher mortality rates, calling for further evaluation.

Preoperative fasting: Assessment of the practices of Lebanese Anesthesiologists.

BACKGROUND: Although new guidelines developed by the American Society of Anesthesiologists (ASA) recommend a liberalized preoperative nutrition, authorized clinical practice guidelines or recommendations have not yet been proposed by the Lebanese Society of Anesthesia (LSA). OBJECTIVE: The purpose of this study was to examine Lebanese anesthesiologists' preoperative fasting routines and determine their knowledge and acceptance of the ASA recommendations, their attitude toward liberalized fasting, and the factors favoring their nonadherence to the new recommendations. MATERIALS AND METHODS: This study was conducted in university hospitals, affiliated hospitals, and nonuniversity hospitals located in different regions of Lebanon. The survey was approved by the local ethics committee. A written questionnaire was emailed to all anesthesiologist members of the LSA which was completed anonymously. RESULTS: Out of the 294 anesthesiologists registered in the LSA and who read the email, 118 (40.1%) completed the questionnaire. Of respondents, 90% are aware of the latest ASA practice guidelines for preoperative fasting, and 78.7% claim to apply them in their practices; however, 75% of respondents still require adult patients to stop eating after midnight, and only 45% allow them to drink clear fluids up to 2 h preoperatively. One of the main reasons for not complying with the ASA guidelines was "to allow flexibility for changes in the operating schedule." CONCLUSION: A long preoperative fasting period is still the common practice for Lebanese anesthesiologists. National guideline for preoperative fasting as liberal as that recommended by the ASA should be considered.

Inferior vena cava filter migration during the prone position for spinal surgery: a case report.

PURPOSE: Inferior vena cava (IVC) filters have been used as an alternative therapy for patients with a contraindication to anticoagulation. We present a case of an IVC filter migration to the right ventricle occurring while a trauma patient was undergoing spinal surgery in the prone position. The patient provided written consent to describe this case. CLINICAL FEATURES: A 54-yr-old multiple trauma male patient with an unstable fracture of the T6 vertebra and a stable fracture of the T10 vertebra developed a pulmonary embolism secondary to a left common femoral deep vein thrombosis. An IVC filter was placed so that an intravenous unfractionated heparin infusion could be stopped two days before scheduled spinal surgery. Intraoperatively, the patient was placed in the prone position on conventional convex support pads. At the end of the procedure, he developed ventricular trigeminy which lasted three minutes. During the next 48 hr, the patient developed a fever of 39°C. An echocardiogram was performed to rule out endocarditis, and results showed that the IVC filter had migrated into the right ventricle. After a failed attempt at percutaneous removal of the filter in the catheterization laboratory, the patient was transferred to the operating room and the IVC filter was extracted through a midline sternotomy under cardiopulmonary bypass. CONCLUSIONS: The prone position during surgery can induce anatomic and hemodynamic changes in the IVC. This may contribute to the migration of IVC filters--especially flexible retrievable filters. Careful handling and positioning of patients with IVC filters is recommended to avoid a sudden increase in IVC pressure that may predispose to IVC filter migration.