Paradigm shift: Beyond the COVID-19 era, is YouTube the future of education for CABG patients?

INTRODUCTION: Patients commonly use YouTube for education, and this may have increased due to COVID-19 related restrictions on access to healthcare professionals. However, YouTube videos lack peer review and regulation. To assess patient education in the COVID-19 era, we analyzed the quality of YouTube videos on coronary artery bypass graft (CABG) surgery. METHODS: We searched YouTube using the phrase "coronary artery bypass graft." Two authors individually used the Journal of the American Medical Association (JAMA), DISCERN, and Health on the Net (HON) systems, to rate the first 50 videos retrieved. Data collected for each video included; number of views, duration since upload, percentage positivity (proportion of likes relative to total likes plus dislikes), number of comments, and video author. Interobserver reliability was assessed using an intraclass correlation coefficient (ICC). Associations between video characteristics and quality were tested using linear regression or t-tests. RESULTS: The average number of views was 575,571. Average quality was poor, with mean scores of 1.93/4 (ICC 0.54) for JAMA criteria, 2.52/5 (ICC 0.78) for DISCERN criteria, and 4.04/8 (ICC 0.66) for HON criteria. Videos uploaded by surgeons scored highest overall (p < .05). No other factors demonstrated significant association with video quality. CONCLUSION: YouTube videos on CABG surgery are of poor quality and may be inadequate for patient education. Given the complexity of the procedure and that beyond the COVID-19 era, patients are more likely to seek education from digital sources, treating surgeons should advise of YouTube's limitations and direct patients to reliable sources of information.

Starting and finishing a cardiac case: Sternotomy, hemostasis, and closure.

The cardiac multimedia literature is abundant, but a significant gap exists in educational videos demonstrating routine essential steps such as the sternotomy or the closure. These components are common and carry significant mortality and morbidity should a sternal complication occur, highlighting the importance for the cardiothoracic surgeon to master these steps.

The radial artery: Open harvesting technique.

The radial artery is an important conduit in coronary artery surgical revascularization due to its robust long-term clinical outcomes. The use of the radial artery has become popularized in recent times. Therefore it is essential for junior surgeons to master harvest techniques that are safe, reliable, and easy to replicate.

Surgeon's Focussed Ultrasound Examination of the Long Saphenous Vein Reduces Surgical Time and Wound Complications.

BACKGROUND: Despite increased use of arterial grafts, the long saphenous vein (LSV) is often utilised as conduit for coronary artery bypass graft (CABG). Preoperative ultrasound (U/S) vein assessment is limited to patients with varicosities, clinical signs suggestive of poor vein conduits and a history of cardiac or vascular surgery. The aim of this study was to evaluate the usefulness and logistics of the surgeon incorporating intraoperative U/S assessment of the LSV into their regular practice. METHODS: All patients undergoing coronary artery revascularisation and open vein harvest in our institution were recruited from July 2016 to February 2017. Demographics, including known risk factors for wound complications were documented, in addition to surgical details such as harvest time, vein length and surgical repairs of the conduit. Focussed U/S assessment was performed intraoperatively by the surgical registrar before beginning the procedure. The diameter of the leg pre and postoperatively, as well as the incidence, type and severity of wound complications were documented for further statistical analysis. RESULTS: A total of 103 patients were included in this study. Two patients died perioperatively and were excluded from the study. The remaining 101 patients were separated in two cohorts-U/S group (n=32) and blind technique group (n=69). Demographics were similar between the groups, whilst other risk factors for harvest complications, such as presence of superficial varicosities on clinical examination and renal failure were significantly more frequent in the U/S group. The median harvest time was significantly lower within the U/S group (25 mins versus 40 mins; p=0.001), as was the rate of overall wound complications (6.2% vs 23.2%; p=0.04). CONCLUSIONS: Ultrasound assessment of the LSV by the surgical team intraoperatively is feasible, easy to learn and does not demand extra costs or delays. It significantly reduces surgical harvest time and it is associated with a reduced incidence of wound complications, swelling and postoperative mobility impairment.

Hypoxic potentiation of nitrite effects in human vessels and platelets.

Previous studies in non-human blood vessels and in platelets have demonstrated that under hypoxic conditions release of NO from nitrite (NO2(-)) is potentiated by deoxyhaemoglobin. In the current study, we characterized hypoxic potentiation of NO2(-) effects in human vasculature and platelets in vitro, addressing underlying mechanisms. The vasodilator efficacy of NO2(-), in comparison with glyceryl trinitrate (GTN), was evaluated in vitro, using segments of human saphenous vein. Under hypoxic conditions, there was a leftward shift of the NO2(-) concentration-response curve (EC50: 22 µM in hyperoxia vs 3.5 µM in hypoxia; p<0.01), but no significant potentiation of GTN effect. In the presence of red blood cells, hypoxic potentiation of NO2(-) vasodilator effect was accentuated. In whole blood samples and platelet-rich plasma (PRP) we assessed inhibition of platelet aggregation by NO2(-) (1mM), in comparison with that of sodium nitroprusside (SNP, 10 µM). In individual subjects (n=37), there was a strong correlation (r=0.75, p<0.0001) between anti-aggregatory effects of NO2(-) and SNP in whole blood, signifying that resultant sGC activation underlies biological effect and responses to NO2(-) are diminished in the presence of NO resistance. In PRP, the effects of NO2(-) were less pronounced than in whole blood (p=0.0001), suggesting an important role of Hb (within RBCs) in the bioconversion of NO2(-) to NO. Inhibition of platelet aggregation by NO2(-) was almost 3-fold greater in venous than in arterial blood (p<0.0001), and deoxyHb concentration directly correlated (r=0.69, p=0.013) with anti-aggregatory response. Incremental hypoxia applied to venous blood samples (in hypoxic chamber) caused a progressive increase in both deoxyHb level and anti-aggregatory effect of NO2(-). When subjects inhaled a 12% O2 mixture for 20 min, there was a 3-fold rise in blood deoxyHb fraction (p<0.01). In PRP, response to NO2(-) also increased under hypoxia, and was further enhanced (p<0.01) by deoxyHb. Furthermore, deoxyHb exerted significant anti-aggregatory effects even in the absence of added NO2(-), suggesting a role for endogenous NO2(-). The results of this work provide further mechanistic insights into hypoxic potentiation of vasodilator and anti-aggregatory actions of NO2(-). In human saphenous veins and blood, the balance of evidence suggests differential rates of NO release from NO2(-) (largely modulated by deoxyHb) as the fundamental mechanism.

Choice of valve prosthesis in a rare clinical condition: aortic stenosis due to alkaptonuria.

Alkaptonuria is a rare inherited disorder of tyrosine metabolism, which results in deposition of homogentisic acid in the connective tissues. The accumulation of homogentisic acid in connective tissue causes the syndrome known as ochronosis, which is typically manifested by skin pigmentation, degenerative arthropathy and discolouration of urine. Cardiovascular involvement is a much less common complication of alkaptonuria but poses a greater risk to the patient's health. We present the case of a 65 year-old man with aortic stenosis and a previous diagnosis of alkaptonuria who underwent successful aortic valve replacement with a mechanical prosthesis.

Preoperative and intraoperative factors associated with long-term survival in octogenarian cardiac surgery patients.

BACKGROUND: The proportion of octogenarians undergoing cardiac surgery is increasing though few studies have examined the simultaneous impact of preoperative and intraoperative factors on long-term survival in this age group. This study aimed to describe the preoperative clinical and demographic characteristics associated with long-term mortality risk and determine whether intraoperative factors related to surgical and cardiopulmonary bypass techniques impacted upon these. METHODS: Octogenarians undergoing coronary artery bypass grafting (CABG) +/- concomitant valvular procedure between 1992 and 2005 from three institutions were included in this study. The survival data of 606 octogenarians (414 isolated CABG, 192 concomitant valve procedures) were analyzed with multivariable proportional hazard models. RESULTS: There were 271 deaths and 2,675 person years of survival for analysis, and median follow-up was 7.15 years (95% confidence interval 6.47 to 7.82 years). Five-year survival for isolated CABG and concomitant valve procedures was 66.5% and 61.5%, respectively. An increase in mortality risk was attributable to older age, hypercholesterolemia, severely impaired left ventricular function, tobacco smoking history and high creatinine (> or = 0.15 mmol/L). Time spent on cardiopulmonary bypass was the only intraoperative risk factor associated with an increase in mortality risk (hazard ratio 1.01, 95% confidence interval: 1.00 to 1.02; p < 0.001). CONCLUSIONS: This study showed that from the intraoperative parameters examined only time spent on cardiopulmonary bypass was associated with long-term survival. Surgeons may be assisted in patient selection by identifying the factors that influence long-term survival among octogenarians and development of a preoperative risk model specific for this age group.