Predictors and outcomes of discharge to long-term acute care facilities after cardiac surgery.

OBJECTIVE: An increasing number of patients with significant comorbidities present for complex cardiac surgery, with a subgroup requiring discharge to long-term acute care facilities. We aim to examine predictors and mortality after discharge to a long-term acute care facility. METHODS: From January 1, 2015, to April 30, 2021, all adult cardiac surgeries were queried and patients discharged to long-term acute care facilities were identified. Baseline characteristics, procedures, and in-hospital complications were compared between long-term acute care facility and non-long-term acute care facility discharges. Random forest analysis was conducted to establish predictors of discharge to long-term acute care facilities. Kaplan-Meier survival analysis was used to determine probability of survival over 7 years. Multivariate regression modeling was used to establish predictors of death after long-term acute care facility discharge. RESULTS: Of 29,884 patients undergoing cardiac surgery, 324 (1.1%) were discharged to a long-term acute care facility. The long-term acute care facility group had higher rates of urgent/emergency operation (54% vs 23%; 10% vs 3%, P < .001) and longer mean cardiopulmonary bypass (167 vs 110 minutes, P < .001). By random forest analysis, emergency/urgent status, longer cardiopulmonary bypass duration, redo surgery, endocarditis, and history of dialysis were the most predictive of discharge to a long-term acute care facility. Although the non-long-term acute care facility group demonstrated greater than 95% survival at 6 months, Kaplan-Meier survival analysis showed 28% 6-month mortality in the long-term acute care facility cohort. Random forest analysis demonstrated that chronic lung disease and postoperative respiratory complications were significant predictors of death at 6 months after discharge to a long-term acute care facility. CONCLUSIONS: Patients with chronic lung and kidney disease undergoing prolonged procedures are at higher risk to be discharged to long-term acute care facilities after surgery with worse survival. Efforts to minimize postoperative respiratory complications may reduce mortality after discharge to long-term acute care facilities.

Coexisting Coronary and Carotid Artery Disease: What We Did, What Happened

ABSTRACT Introduction: There is no complete consensus on the three surgical methods and long-term consequences for coexisting coronary and carotid artery disease. We retrospectively evaluated the surgical results in this high-risk group in our clinic for a decade. Methods: Between 2005 and 2015, 196 patients were treated for combined carotid and coronary artery disease. A total of 50 patients were operated on with the staged method, 40 of which had carotid endarterectomy (CEA) priority, and 10 had coronary artery bypass grafting (CABG) priority. CABG and CEA were simultaneously performed in 82 patients; and in 64 asymptomatic patients with unilateral carotid artery lesions and stenosis over 70%, only CABG was done (64 patients). Results were evaluated by uni-/multivariate analyses for perioperative, early, and late postoperative data. Results: In the staged group, interval between the operations was 2.82±0.74 months. Perioperative and early postoperative (30 days) parameters did not differ between groups (P-value < 0.05). Postoperative follow-up time was averaged 94.9±38.3 months. Postoperative events were examined in three groups as (A) deaths (all cause), (B) cardiovascular events (non-fatal myocardial infarction, recurrent angina, congestive heart failure, palpitation), and (C) fatal neurological events (amaurosis fugax, transient ischemic attack, and stroke). When group C events were excluded, event-free actuarial survival rates were similar in all three methods (P=0.740). Actuarial survival rate was significantly different when all events were included (P=0.027). Neurological events increased markedly between months 34 and 66 (P=0.004). Conclusion: Perioperative and early postoperative event-free survival rates were similar in all three methods. By the beginning of the 34th month, the only CABG group has been negatively separated due to neurological events. In the choice of methodology, "most threatened organ priority'' was considered as clinical parameter.

Incremental Utility of 3D Printing to Guide the Surgical Management of Apical Aneurysm.

A 24-year-old man presented with a nonischemic cardiomyopathy of unknown etiology, apical aneurysm, and a secondary mitral regurgitation. Computer tomography-derived 3-dimensional model of the patient's heart was an essential step in guiding the surgical management for an optimal outcome. (Level of Difficulty: Advanced.).

Coexisting Coronary and Carotid Artery Disease: What We Did, What Happened.

INTRODUCTION: There is no complete consensus on the three surgical methods and long-term consequences for coexisting coronary and carotid artery disease. We retrospectively evaluated the surgical results in this high-risk group in our clinic for a decade. METHODS: Between 2005 and 2015, 196 patients were treated for combined carotid and coronary artery disease. A total of 50 patients were operated on with the staged method, 40 of which had carotid endarterectomy (CEA) priority, and 10 had coronary artery bypass grafting (CABG) priority. CABG and CEA were simultaneously performed in 82 patients; and in 64 asymptomatic patients with unilateral carotid artery lesions and stenosis over 70%, only CABG was done (64 patients). Results were evaluated by uni-/multivariate analyses for perioperative, early, and late postoperative data. RESULTS: In the staged group, interval between the operations was 2.82±0.74 months. Perioperative and early postoperative (30 days) parameters did not differ between groups (P-value < 0.05). Postoperative follow-up time was averaged 94.9±38.3 months. Postoperative events were examined in three groups as (A) deaths (all cause), (B) cardiovascular events (non-fatal myocardial infarction, recurrent angina, congestive heart failure, palpitation), and (C) fatal neurological events (amaurosis fugax, transient ischemic attack, and stroke). When group C events were excluded, event-free actuarial survival rates were similar in all three methods (P=0.740). Actuarial survival rate was significantly different when all events were included (P=0.027). Neurological events increased markedly between months 34 and 66 (P=0.004). CONCLUSION: Perioperative and early postoperative event-free survival rates were similar in all three methods. By the beginning of the 34th month, the only CABG group has been negatively separated due to neurological events. In the choice of methodology, "most threatened organ priority'' was considered as clinical parameter.

The relationship between aortic calcification on chest radiograph and neurocognitive impairment after coronary artery bypass grafting.

BACKGROUND: In this study, we aimed to investigate the possible relationship between aortic calcification as detected by preoperative chest radiography and postoperative neurocognitive impairment in patients undergoing coronary artery bypass grafting. METHODS: A total of 124 patients (101 males, 23 females; mean age: 59.9±8.8 years; range, 34 to 84 years) who underwent coronary artery bypass grafting in our clinic between January 2019 and July 2019 were included. Of these patients, 35 whose preoperative chest radiography revealed aortic calcification in the aortic knuckle were included as the patient group. The control group consisted of 89 patients without aortic calcification. The patients with aortic calcification underwent additional imaging with thoracic computed tomography angiography and ascending aorta and aortic arch calcium scores were calculated. Neurocognitive dysfunction was assessed using the Standardized Mini-Mental State Examination. Postoperative delirium was evaluated by confusion assessment method in the intensive care unit. Both groups were compared for demographic, operative and postoperative data. RESULTS: Of all patients included in the study, the overall cerebrovascular event incidence was 3.2%. Although not statistically significant, the number of patients with neurocognitive decline was higher in the patient group than the control group (48.6% vs. 34.8%, respectively; p=0.157). Both Standardized Mini-Mental State Examination score decline and percentage decline were significantly higher in the patients with high aortic arch calcium scores (>2,250 AU). Carotid artery stenosis was 3.2 times higher in the patient group. In the patients with carotid artery stenosis, the aortic arch calcium scores were also higher (p=0.042). CONCLUSION: Aortic calcification detectable on chest radiography with high calcium scores may be associated with neurocognitive impairment and carotid artery stenosis in patients undergoing coronary artery bypass grafting.

Transposition of brachiobasilic arteriovenous fistulas: One-stage or two-stage technique and factors affecting the early maturation.

The brachiobasilic transposition (BBT) arteriovenous fistula (AVF) is a valuable option especially for dialysis patients with previously failed vascular access. We aim to report factors affecting the maturation of BBT-AVF created with either one-stage or two-stage technique. BBT-AVF procedures between January 2015 and May 2019 by a dedicated vascular access team were investigated retrospectively. A total of 122 patients (63 males, 59 females), with 6 to 12 weeks of follow-up after the BBT-AVF procedure were included in the study. Patients of one-stage and two-stage techniques were compared for maturation rates. Patients with successful and failed maturation were compared for baseline characteristics and anatomic factors. Of 122 BBT-AVF procedures, 54 were created with the one-stage and 68 were created with the two-stage technique. The mean age of the patients was 58.2 ± 13.8, the mean brachial artery and basilic vein diameters were 3.91 ± 1.02 mm, and 3.39 ± 1.16 mm. Of 122 included patients, 88 (72.1%) had mature AVFs at follow-up. The AVF maturation rates were similar between the one- and two-stage groups (70.4% vs 73.5%; P = .699). Lower age (62.8 ± 12.5 vs 56.5 ± 13.9; P = .023) and greater brachial artery diameter (3.09 ± 0.84 mm vs 4.23 ± 1.76 mm; P < .048) were the only factors affecting the AVF maturation in univariate analysis. Gender, extremity side, diabetes mellitus, hypertension, and targeted vein diameter were not found to affect the AVF maturation (P = .301, P = .084, P = .134, P = .858, P = .127). Target artery diameter (P = .049) was the only significant factor affecting BBT-AVF maturation in multivariate analysis. One-stage and two-stage BBT-AVFs are similar in terms of maturation rates. Targeted artery diameter was the only factor important in BBT-AVF maturation in our study group. The two-stage technique can be preferred considering smaller incision size and lower complication rate in patients with suitable anatomy.

An Alternative Technique for Ascending and Arcus Aorta Repair in Case of Vascular Diameter Mismatch.

Complicated Type A intramural hematoma involving the arcus aorta requires emergency correction of the aortic arch. Surgical options include reimplantation of the brachiocephalic vessels as an island to a vascular graft, debranching aortic arch surgery, and Kazui technique. This report describes a modified technique for aortic arch repair in a patient with vascular diameter mismatch between the ascending and descending aorta, as well as an intimal tear between the brachiocephalic vessels.

Ultrasonography-guided foam sclerotherapy in patients with small saphenous vein insufficiency.

PURPOSE: Chronic venous insufficiency is an important health problem; small saphenous vein (SSV) insufficiency is one of the leading causes and may affect up to 20% of adults. In addition to conventional treatment methods, endovenous treatment techniques have become popular in treatment of varicose veins. Herein, we report the outcomes of ultrasound-guided foam sclerotherapy (UGFS) in patients with symptomatic SSV insufficiency. METHODS: From January 2014 to June 2018, patients with primary SSV insufficiency treated with UGFS were followed to assess the effectiveness and safety of the procedure. A total of 31 lower limbs of 30 patients (18 females and 12 males), who attended control visits at 1 week, 1, 3, and 6 months, and yearly, after undergoing UGFS, were included in the study. The clinical results, occlusion rates, and the patients' preprocedure and postprocedure Venous Clinical Severity Scores were recorded. RESULTS: The records show that, during the procedure, severe pain occurred at the time of injection in one patient (3%), vasovagal syncope in one patient (3%), hyperpigmentation in five patients (16%), and phlebitis in three patients (9%). It was also recorded that during follow-up 24 legs (78%) showed complete thrombosis and 7 legs (22%) had partial thrombosis. The mean Venous Clinical Severity Score for the patients before UGFS was 8.58 ± 3.78, and 7.25 ± 3.17 after the procedure. No major complications, including sural nerve injury and deep venous thrombosis, were seen during the follow-up period. CONCLUSIONS: The results of this study show that UGFS is a simple, safe, and effective procedure for treatment in patients with symptomatic SSV insufficiency with acceptable side effects.

The effects of Ramadan fasting on patients with prosthetic heart valve taking warfarin for anticoagulation.

INTRODUCTION: Oral anticoagulation with warfarin is indicated for patients with prosthetic heart valves. The effects of religious fasting during Ramadan month (in the Islamic calendar) on anticoagulation aren't clear. OBJECTIVES: To study the impact of Ramadan fasting on international normalized ratio (INR), quality of anticoagulation, dose of warfarin used and blood osmolarity. METHODS: 18 patients were followed-up prospectively for 3 months (pre- Ramadan, Ramadan and post-Ramadan months). Patients presented for weekly visits in which blood samples were obtained. RESULTS: No significant difference in INR and warfarin dose was found between Ramadan month, and months before and after it. The post-Ramadan INR was significantly larger than pre-Ramadan (p = 0.004). Blood osmolarity was significantly lower during Ramadan compared to pre- and post-Ramadan months. A significantly better quality of anticoagulation was noticed during Ramadan (p < 0.001). A significantly larger ratio of supratherapeutic INR values occurred in the post-Ramadan month (p < 0.05). A significantly larger ratio of infra-therapeutic INR values was noticed in the pre-Ramadan month (p < 0.05). CONCLUSION: No significant difference in mean INR or warfarin dose was found and a better quality of anticoagulation was achieved during Ramadan. A tendency toward supra-therapeutic anticoagulation occurred after Ramadan, thus a closer follow up during this period may be reasonable.