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.

Could Selective Re-look Angiography Improve the Outcome of Cardiogenic Shock in Patients Under Veno-arterial Extracorporeal Membrane Oxygenator?

It is not well studied whether a secondary look by angiography (Re-Ang) after fixing the culprit lesion would be beneficial or not in cardiogenic shock (CS) supported by veno-arterial extracorporeal membrane oxygenator (VA-ECMO). This study was a retrospective observational one that looked at 5-year data from a single tertiary center. Patients were grouped according to the need of Re-Ang during the VA-ECMO course into 2 groups. The indications to perform Re-Ang were loss of pulse pressure, drop in ejection fraction or velocity time integral, resistant arrhythmia, or new electrocardiographic changes suggestive of ischemia. Out of 150 patients with cardiogenic shock screened, 30 patients were enrolled in our study. Re-Ang was done in 10 patients only. In 80% of them, positive findings were found in terms of new significant stenosis (3 patients), stent restenosis (1 patient), stent thrombosis (3 patients), and patent stent(s) with intervention to the remaining lesions in other vessels (1 patient). Neither successful weaning from VA-ECMO nor mortality was statistically different between both groups. Our set indications for Re-Ang were effective in finding a possible new culprit for a conceivable coronary intervention.

Association of ruptured sinus of Valsalva aneurysm and congenital ventricular septal defect: a case series.

BACKGROUND: Ruptured sinus of Valsalva aneurysm (RSOVA) is rare, and it is more common in Asians. Typically, the patient presents with acute/subacute shortness of breath (SOB) and chest pain. Echocardiography is the gold standard for diagnosis in most of these cases. Surgery has remained the first line of management. CASE SUMMARY: We present two cases of RSOVA in which the patients presented to the emergency department with SOB. Their preoperative echocardiography results showed RSOVA into the right ventricle. During surgical repair, ventricular septal defect (VSD) was also found. DISCUSSION: RSOVA is frequently associated with other congenital anomalies, and most often with VSD. In our cases, we believe that VSDs were missed preoperatively because either the large aneurysmal sacs covered the VSD or there was overlap between the two shunts. Additionally, in the first case, right ventricular pressure was high approaching systemic pressure, which probably reduced the shunt across the VSD. Early intervention is recommended to prevent endocarditis or enlargement of the ruptured aneurysm; long-term results were excellent after surgical repair. Most patients undergo surgery between 20 and 40 years of age, and the reported survival rate is 95% at 20 years. If left untreated, patients typically die of heart failure or endocarditis within 1 year after onset of symptoms.

Intensive care outcome of left main stem disease surgery: A single center three years' experience.

BACKGROUND: Left main coronary artery (LMCA) supplies more than 80% of the left ventricle, and significant disease of this artery carries a high mortality unless intervened surgically. However, the influence of coronary artery bypass grafting (CABG) surgery on patients with LMCA disease on morbidity intensive care unit (ICU) outcomes needs to be explored. However, the impact of CABG surgery on the morbidity of the ICU population with LMCA disease is worth exploring. AIM: To determine whether LMCA disease is a definitive risk factor of prolonged ICU stay as a primary outcome and early morbidity within the ICU stay as secondary outcome. METHODS: Retrospective descriptive study with purposive sampling analyzing 399 patients who underwent isolated urgent or elective CABG. Patients were divided into 2 groups; those with LMCA disease as group 1 (75 patients) and those without LMCA disease as group 2 (324 patients). We correlated ICU outcome parameters including ICU length of stay, post-operative atrial fibrillation, acute kidney injury, re-exploration, perioperative myocardial infarction, post-operative bleeding in both groups. RESULTS: Patients with LMCA disease had a significantly higher prevalence of diabetes (43.3% vs 29%, P = 0.001). However, we did not find a statistically significant difference with regards to ICU stay, or other morbidity and mortality outcome measures. CONCLUSION: Post-operative performance of Patients with LMCA disease who underwent CABG were comparable to those without LMCA involvement. Diabetes was more prevalent in patients with LMCA disease. These findings may help in guiding decision making for future practice and stratifying the patients' care.

Ruptured Sinus Of Valsalva Into The Right Ventricle A New Management Strategy.

We present 2 cases presented to the emergency department with shortness of breath (SOB). Their preoperative echocardiographies showed ruptured right sinus of Valsalva (RSOV) into the right ventricle (RV). Ventricular septal defect (VSD) was diagnosed only intraoperatively.

Improving Incidence of Postoperative Atrial Fibrillation After Cardiac Surgery Using Simplified Clinical Practice Guidelines.

OBJECTIVES: Postoperative atrial fibrillation (POAF) remains a major risk after cardiac surgery. Twelve percent patients admitted to this unit postcardiac surgery experienced POAF, which led to hemodynamic instability, increased risk of stroke, and increased length of postoperative intensive care unit stay. Our aim was to decrease the incidence of POAF in the cardiothoracic intensive care unit by the end of April 2014. METHODS: Design-Retrospective data analysis. Settings-Postcardiac surgery intensive care in a tertiary hospital. PARTICIPANTS: Postcardiac surgery patients. Intervention-A clinical practice guideline (CPG) was developed to promote early prevention and to improve adherence to POAF prophylaxis recommendations. Patient's charts were our key performance indicator. Primary outcome measure-Percentage of patients who developed episodes of POAF within the first 24 hours of cardiac surgery. Process measures-compliance with the newly developed CPG and early postoperative patient assessment. Balance measure-early administration of ß-blocker. RESULTS: We were able to decrease POAF to 8% after intervention. Compliance with early assessment improved from 25% to 87%. Compliance with adherence to the CPG was 80%. Adherence to the newly developed paper form was the major challenge that could be overcome by an electronic form. We hope to decrease the incidence of POAF to 6% and develop an electronic form by the end of December 2014. CONCLUSION: This quality improvement project changed the strategy and succeeded in decreasing the incidence of POAF after cardiac surgery. It also improved early assessment of risk factors.

Acute kidney injury induces high-sensitivity troponin measurement changes after cardiac surgery.

BACKGROUND: The value of cardiac troponin as a risk assessment tool for cardiac disease in the setting of end-stage renal diseases (ESRD) is not equivalent to its value in those with normal renal function. This consideration had not been studied in settings of acute kidney injury (AKI). We aim to explore the diagnostic value of high sensitive troponin T (hsTnT) in the settings of cardiac surgery-induced AKI. METHODS: Single center observational retrospective study. Based on the AKI Network, patients divided into 2 groups, group I without AKI (259 patients) and group II with AKI (100 patients) where serial testing of hsTnT and creatine kinase (CK)-MB were followed in both groups. Patients with (ESRD) were excluded. RESULTS: The mean age in our study was 55.1 ± 10.2 years. High association of AKI (27.8%) was found in our patients. Both groups were matched regarding the age, gender, body mass index, the association of diabetes or hypertension, and Euro score. AKI group had significantly higher mortality 5% vs group I 1.1% (p = 0.03). The hsTnt showed a significant sustained rise in the AKI group as compared to the non-AKI group, however CK-MB changes were significant initially but not sustained. The AKI group was more associated with heart failure 17.9% vs 4.9% (p = 0.001); and post-operative atrial fibrillation, 12.4% vs 2.9% (p = 0.005). Lengths of ventilation, stays in ICU and in hospital were significantly higher in the AKI group. CONCLUSIONS: Unlike the CK-MB profile, the hsTnT showed significant changes between both groups all over the course denoting possible delayed clearance in patients with AKI.

Kinetics of Highly Sensitive Troponin T after Cardiac Surgery.

Perioperative myocardial infarction (PMI) confers a considerable risk in cardiac surgery settings; finding the ideal biomarker seems to be an ideal goal. Our aim was to assess the diagnostic accuracy of highly sensitive troponin T (hsTnT) in cardiac surgery settings and to define a diagnostic level for PMI diagnosis. This was a single-center prospective observational study analyzing data from all patients who underwent cardiac surgeries. The primary outcome was the diagnosis of PMI through a specific level. The secondary outcome measures were the lengths of mechanical ventilation (LOV), stay in the intensive care unit (LOSICU), and hospitalization. Based on the third universal definition of PMI, patients were divided into two groups: no PMI (Group I) and PMI (Group II). Data from 413 patients were analyzed. Nine patients fulfilled the diagnostic criteria of PMI, while 41 patients were identified with a 5-fold increase in their CK-MB (≥ 120 U/L). Using ROC analysis, a hsTnT level of 3,466 ng/L or above showed 90% sensitivity and 90% specificity for the diagnosis of PMI. Secondary outcome measures in patients with PMI were significantly prolonged. In conclusion, the hsTnT levels detected here paralleled those of CK-MB and a cut-off level of 3466 ng/L could be diagnostic of PMI.

Impact of fast-track discharge from cardiothoracic intensive care on family satisfaction.

BACKGROUND: Dissatisfaction with the intensive care unit may threaten medical care. Clarifying treatment preferences can be useful in these settings, where physician direction may influence decision making and therefore medical treatment. This study aimed to evaluate whether fast-track discharge from intensive care units affects the satisfaction of family members. METHODS: We used a single-center non-randomized trial, with all eligible family members involved. To evaluate family satisfaction, we used the Society of Critical Care Family Needs Assessment questionnaire (SCCMFNAQ). We hypothesized that those discharged within 24 h of intensive care unit admission and their families would have higher levels of satisfaction. Patients were scored using the therapeutic interventions scoring system (TISS) and additive EuroSCORE. RESULTS: Two-hundred fifty-five family members were enrolled. The mean patient age was 53 years, and 92 % were male. The median satisfaction level among family members was 17.9 (range 14-31). Patients were divided into two groups, one receiving fast-track discharge (116 patients), and one whose members stayed longer (139 patients). The overall satisfaction was affected significantly by quality of the delivered care and dissatisfaction increased by lack of comfort in hospital settings, including the waiting room. No significant differences were seen between the two groups for overall satisfaction (p = 0.546) and individual components of the questionnaire. Higher satisfaction was linked to higher levels of education among family members (p = 0.045) and information being relayed by a senior physician p = 0.03 (two-tailed test). CONCLUSIONS: Fast-track discharge from intensive care did not influence family satisfaction as hypothesized. Satisfaction relied on family members' level of education and the level of seniority of the physician relaying information.