Early clinical outcomes of two regimens of prophylactic antibiotics in cardiac surgical patients with delayed sternal closure.

BACKGROUND: Delayed sternal closure (DSC) can be a lifesaving approach for certain patients who have undergone cardiac surgery. The value of the type of prophylactic antibiotics in DSC is still debatable. AIM: To investigate clinical outcomes of different prophylactic antibiotic regimens in patients who had DSC after cardiac surgery. METHODS: This was a retrospective observational single-center study. Fifty-three consecutive patients who underwent cardiac surgery and had an indication for DSC were included. Patients were subjected to two regimens of antibiotics: Narrow-spectrum and broad-spectrum regimens. RESULTS: The main outcome measures were length of hospital and intensive care unit (ICU) stay, duration of mechanical ventilation, and mortality. Of the 53 patients, 12 (22.6%) received narrow-spectrum antibiotics, and 41 (77.4%) received broad-spectrum antibiotics. The mean age was 59.0 ± 12.1 years, without significant differences between the groups. The mean duration of antibiotic use was significantly longer in the broad-spectrum than the narrow-spectrum group (11.9 ± 8.7 vs 3.4 ± 2.0 d , P < 0.001). The median duration of open chest was 3.0 (2.0-5.0) d for all patients, with no difference between groups (P = 0.146). The median duration of mechanical ventilation was significantly longer in the broad-spectrum group [60.0 (Δ interquartile range (IQR) 170.0) h vs 50.0 (ΔIQR 113.0) h, P = 0.047]. Similarly, the median length of stay for both ICU and hospital were significantly longer in the broad-spectrum group [7.5 (ΔIQR 10.0) d vs 5.0 (ΔIQR 5.0) d, P = 0.008] and [27.0 (ΔIQR 30.0) d vs 19.0 (ΔIQR 21.0) d, P = 0.031]. Five (9.8%) patients were readmitted to the ICU and 18 (34.6%) patients died without a difference between groups. CONCLUSION: Prophylactic broad-spectrum antibiotics did not improve clinical outcomes in patients with DSC post-cardiac surgery but was associated with longer ventilation duration, length of ICU and hospital stays vs narrow-spectrum antibiotics.

Radical sternectomy for osteomyelitis without reconstruction post-coronary artery bypass graft: 10 years on.

Radical sternectomy with sternal reconstruction using synthetic mesh or titanium plates has been described before with excellent results. However, radical removal of the sternum without reconstruction is a rare surgical treatment for complicated deep sternal wound infections (DSWI). The long-term outcome following this radical operation is not well-known due to the limited number of cases in the literature. We report on a patient 10 years after a radical sternectomy for DSWI who presented with shortness of breath. We highlight some of the anatomical and physiological changes the chest cavity may undergo and the fact that this patient had a near normal quality of life in the 10 years following the sternectomy.

Infected Takayasu's arteritis presenting with aortic perforation.

We want to remind Physicians that unusual conditions can present in unusual ways and to keep an open mind always.

Left ventricular outflow tract cyst: What was it and where did it go?

Cyst or thrombus formation in the left ventricular outflow tract of a normal heart is very rare. We present a case of a male who presented with a major stroke and was found to have a freely mobile cystic mass in the left ventricular outflow tract, with an otherwise completely normal heart. He had some risks factors for hypercoagulability (reduced protein C activity and raised fibrinogen), but only received aspirin therapy due to his stroke severity (haemorrhagic transformation). Once his brain imaging suggested it was safe to proceed, repeat imaging showed the mass had gone, so cardiac surgery was avoided. What was it and where did it go?

Delivery of Acute Rehabilitation to a Postcoronary Artery Bypass Graft COVID-19 Patient in a Pandemic Environment.

During the first wave of the coronavirus disease (COVID-19) pandemic, a 57-year-old COVID-19 male patient was diagnosed with non-ST-elevation myocardial infarction and required urgent coronary artery bypass graft. In-patient cardiac rehabilitation following cardiac surgery was inevitable to limit or prevent various postoperative complications. A routine rehabilitation program was not feasible because of the strict COVID-19 isolation procedures, the high risk of cross infections, and the lack of various resources. Moreover, the detrimental effects of COVID-19 infection on multiple body systems reduced his exercise tolerance, limiting his engagement in physical activity. This case report highlights the various challenges encountered during the rehabilitation of these patients and strategies adopted to overcome them, illustrating the feasibility of a modified rehabilitation program to ensure early functional recovery.

Analysis of the Performance of Daily Cardiac Surgery Score (CASUS) in Patients with Mixed Racial Profile after Cardiac Surgery: A Single-Center Retrospective Study.

OBJECTIVE: The aim was to look at the Cardiac Surgery Score (CASUS) assessment after cardiac surgery, and compare it with the intensive care unit (ICU) mortality and morbidity, in a racially diverse group of patients, in a single center. DESIGN: Clinical retrospective study analyzing data from 319 patients over a 1-year duration. SETTING: Cardiothoracic intensive care unit (CTICU) of a tertiary care center. PARTICIPANTS: All patients who underwent cardiac surgery between January 1 and December 31, 2017. INTERVENTIONS: Review of electronic patient records. MEASUREMENTS AND RESULTS: Daily CASUS assessments (calculated on an online application and recorded on patient electronic records) were retrieved. The variables of CASUS used for the study were CASUS value on postoperative day 1 (POD1-CASUS), on death/discharge from CTICU (Dis-CASUS), mean of all CASUS values during CTICU stay (M-CASUS), and differential CASUS (Dif- CASUS) [CASUS POD 1 - CASUS on discharge]. The receiver operating characteristic (ROC) curve for the diagnostic level of POD 1-CASUS, indicating mortality, was calculated. A value of >6.5 for POD 1 CASUS had 80% sensitivity and 84% specificity, with area under the curve value 0.756 (95% confidence interval: 0.46 to 1). The mean values of POD1-CASUS (8.6 ± 6), M-CASUS (8.2 ± 5.2), and Dis-CASUS (7.8 ± 5.7) were significantly higher in cases of mortality, compared to the others. POD1-CASUS, M-CASUS, and Dis-CASUS were found to be statistically significantly elevated in patients with acute kidney injury (AKI) and postoperative stroke, and in those who were readmitted to the CTICU after initial discharge. Patients with POD1-CASUS ≥6.5 had a statistically significant association with mortality and postoperative morbidity (p < 0.05). Findings from multivariate logistic regression indicated that body mass index (BMI), ICU readmission, length of mechanical ventilation, and length of ICU stay remained associated significantly with POD1 CASUS ≥6.5. CONCLUSION: This study found that CASUS on POD 1, mean values of CASUS during CTICU stay, and CASUS at death/discharge from CTICU predicted ICU mortality after cardiac surgery in this racially diverse group. The CASUS derivatives can be used to predict unfavorable outcomes after cardiac surgery. A POD1-CASUS value of 6.5 or more could signify mortality and postoperative morbidity.

Successful Surgical Embolectomy for a Rapidly Deteriorating Patient with Pulmonary Embolism and Hemorrhagic Stroke.

Pulmonary embolism (PE) is a life-threatening condition. High-risk PE is defined as pulmonary embolism with either hemodynamic collapse, persistent hypotension, and/or organ hypoperfusion. The overall mortality rate associated with high-risk PE remains at approximately 30%. Intermediate-high risk PE is a new term introduced to identify hemodynamically stable PE patients with evidence of right ventricular dysfunction. Thrombolytics therapy is the first choice for treatment of high-risk PE with hemodynamic instability; however, in a patient who failed thrombolytics or have contraindication to thrombolytics, thrombus removal either with open surgical or catheter embolectomy is a good alternative. We report a case of a patient who presented with hemorrhagic stroke complicated by intermediate-high-risk PE that rapidly deteriorated before undergoing successful surgical embolectomy.

Right aortic arch with mirror image branching found incidentally during coronary surgery.

Right aortic arch with a left innominate (brachiocephalic) artery with mirror image branching (RAMI) is a rare congenital anomaly, and it is unusual to diagnose it in adulthood. There are very few cases of cardiac surgery being performed for acquired cardiac disease on a congenital RAMI patient. We present a patient who had an incidental finding of a RAMI anomaly found during coronary artery bypass surgery. Post-operatively computerised tomography showed both his congenital lesions and his bypass grafts.

Periprocedural Anticoagulation Management of Patients receiving Warfarin in Qatar: A Prospective Cohort Study.

BACKGROUND: The use of anticoagulant bridging remains controversial. This study was conducted to evaluate our warfarin periprocedural management in Qatar and investigate the associated clinical outcomes with such management. METHODS: A prospective cohort study was designed to describe the periprocedural clinical practice in warfarin patients in Qatar and to compare clinical safety and efficacy outcomes between anticoagulant bridging and nonbridging. RESULTS: 103 patients were recruited. Bridging occurred in 82% of the participants. No thromboembolic events were observed, while 39.1% of patients experienced bleeding events during the study period. The incidence of overall bleeding and major bleeding were numerically higher for bridging group compared to nonbridging but did not reach statistical significance ([30.6% vs 22.2%, P = 0.478] and [12.9% vs 5.6%, P = 0.375], respectively). CONCLUSION: Warfarin interruption and bridging are overwhelmingly used in warfarin-treated patients in Qatar. While bridging was numerically associated with increased bleeding events, there is no statistical difference in reported clinical events between bridging and nonbridging strategies.

A tale of three pumps and a mechanical heart.

Temporary mechanical circulatory support device (tMCS) failure could qualify patients with advanced heart failure to receive a long-term solution. We report on a patient who presented with cardiorespiratory arrest that required a tMCS and developed acute type A aortic dissection. Data Sources: our case adds further evidence regarding the support of a patient with a second (or more) incidence of tMCS. This patient subsequently underwent left ventricular assist device insertion and type A aortic dissection repair, as a combined procedure, with a satisfactory outcome.

SARS-CoV-2 (COVID-19) PCR cycle threshold: can it help in the timing of urgent cardiac surgery?

BACKGROUND: The COVID-19 pandemic has resulted in a significant reduction in urgent cardiac surgery due to concerns about safety for both patients and care givers. The timing of safe cardiac surgery is yet to be clarified in the setting of COVID-19 diagnosis. METHODS: Due to the urgency of the cardiac conditions on presentation, we have operated on four patients who exhibited the spectrum of COVID-19 disease from asymptomatic to severe COVID-19 pneumonia. With the evolving knowledge about SARS-CoV-2 and its genetic determinants as well as the cycle threshold levels obtained from real-time reverse transcription polymerase chain reaction, we have attempted to develop a strategy to deal with these patients. RESULTS: All four patients underwent urgent cardiac surgery following a thorough evaluation and multidisciplinary team approach with guidance based on the virus cycle threshold values obtained by reverse transcription polymerase chain reaction. CONCLUSION: We have shown that, with thorough preparations, consideration of the significance of the cycle threshold obtained on reverse transcription polymerase chain reaction and meticulous timing, COVID-19 diagnosed patients may undergo open heart surgery safely.

Molecular and clinical roles of incretin-based drugs in patients with heart failure.

Glucagon-like peptide-1 (GLP-1) agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors produce some beneficial and deleterious effects in diabetic patients not mediated by their glycemic lowering effects, and there is a need for better understanding of the molecular basis of these effects. They possess antioxidant and anti-inflammatory effects with some direct vasodilatory action (animal and human trial data) that may indirectly influence heart failure (HF). Unlike GLP-1R agonists, signaling for HF adverse effects was observed with two DPP-4 inhibitors, saxagliptin and alogliptin. Accordingly, these drugs should be used with caution in heart failure patients.

Coronary artery anomalies: Unusually high incidence of anomalies with a malignant course in an Asian population.

OBJECTIVES: Coronary artery anomalies are uncommon, but important cardiac malformations, representing the second commonest cause of death in young athletes. METHODS: We utilized computerized tomographic angiography to screen and precisely delineate coronary artery anomalies in patients with minimal cardiac symptoms. RESULTS: During 3.5-year period, we performed 2888 computerized tomographic angiographies. A total of 33 (1.1%; 95% confidence interval = 0.7-1.5) cases of coronary artery anomalies were identified (mean age = 44 ± 13.5 (15-70) years). In total, 23 patients (mean age = 43 years) had malignant coronary artery anomalies with an inter-arterial course of the aberrant vessel: of which 3 had left main coronary artery arising from right coronary sinus and 20 right coronary artery from left sinus; 19 patients were of Asian and 14 were of Arab origins. Of interest, 21 out of 33 patients had chest pain, 5 had palpitations, and 2 had breathlessness. There were no examples of sudden cardiac death. All patients received appropriate advice regarding physical exertion and medical management, and remained well for 2-5 years of follow-up. Of 33 patients, 4 had significant symptomatic coronary artery disease requiring intervention: 1 percutaneous coronary intervention and 3 coronary artery bypass graft surgery. CONCLUSION: There is a relatively high incidence of coronary artery anomalies with malignant course in Asians. The vast majority were managed conservatively.

Mechanical approach in the management of advanced acute and chronic heart failure: the state of the art.

Despite the progress in medical therapy, advanced heart failure (AHF) remains a global epidemic with high morbidity and mortality. Novel cardiac support strategies such as pharmacologic agents, mechanical circulatory support (MCS), and cell- or matrix-based therapies are promising for these patients. The indications, types, and timing of MCS implantation depend to a large extent on the presentation, clinical status of the patient, underlying etiology, and long-term prospects. The presence or absence of end-organ damage has a significant impact on prognosis following MCS initiation. Although many patients with acute AHF may have end-organ damage, their prospect of recovery, once appropriate therapy is instituted, is better than for patients who had AHF for longer periods of time. We consider the multidisciplinary approaches used for the management of AHF and the novel cardiac support strategies (eg, MCS). Appropriate selection of patient, device, time, and end point is essential for better outcomes.