Effect of Preincisional Liposomal Bupivacaine Sternal Blockade on Poststernotomy Opioid Use.

BACKGROUND: Prolonged and excessive opioid use in the postoperative setting is associated with multiple complications. The use of regional analgesia may reduce postoperative opioid use. METHODS: In a placebo-controlled, double-blinded trial patients undergoing sternotomy were randomly assigned in a 1:1 ratio to receive either a liposomal bupivacaine parasternal block or a normal saline parasternal injection. The primary endpoint was total morphine milligram equivalents (MMEs) used in the immediate 72-hour postoperative period. Secondary endpoints were intraoperative opioid use, pain scores, time to reach recovery milestones, and incidence of postoperative complications. RESULTS: Twenty-five patients received a normal saline injection, and 27 patients received an anesthetic sternal block. Randomization achieved excellent balance in demographics and comorbidities between the groups. Total postoperative opioid requirements at 72 hours were similar between the treatment and control groups (25.8 ± 10.4 vs 29.4 ± 16.3 MMEs, P = .60). Intraoperative opioid requirements were also similar between the 2 groups (124.8 ± 222.5 vs 114.9 ± 148.0 MMEs, P = .86). Length of stay in the intensive care unit (3.4 ± 2.5 vs 3.5 ± 2.6 days, P = .86) and hospital (8.7 ± 5.0 vs 7.5 ± 3.0 days, P = .45), time until return of bowel function (3.7 ± 1.4 vs 3.3 ± 1.4 days, P = .42), incidence of postoperative atrial fibrillation (24% vs 22.2%, P = .88), and incidence of nausea (24% vs 33.3%, P = .46) were similar. CONCLUSIONS: Preincisional sternal blockade with liposomal bupivacaine did not reduce the amount of opioid medication administered to patients in the first 72 hours after sternotomy.

Psychometric validity and reliability of the 10- and 2-item Connor-Davidson resilience scales among a national sample of Americans responding to the Covid-19 pandemic: an item response theory analysis.

PURPOSE: Psychometric validity/reliability of 10-item and 2-item abbreviations of the Connor-Davidson Resilience Scale (CD-RISC-10; CD-RISC-2) was investigated via item response theory and classic approaches. METHODS: We sampled 5023 adult American participants in a June/July 2020 survey on the COVID-19 pandemic's psychological effects. Our questionnaire incorporated the CD-RISC-10 with other validated measures. CD-RISC-10 items were ranked on item-to-scale correlations, loadings on a one-factor confirmatory factor analysis model, and item slope/threshold parameters plus information curves from a unidimensional graded response model. Concurrent validity of the highest ranked item pair was evaluated vis-à-vis the CD-RISC-10 and CD-RISC-2. Internal consistency, based on average variance extracted (AVE) and multiple reliability coefficients, was also compared. Convergent/divergent validity was tested by correlating anxiety, depression, fear of COVID-19, anxiety sensitivity, coping, and personality measures with both scales and the highest ranked item pair. Binary agreement/classification indexes assessed inter-rater reliability. RESULTS: Items 2 and 9 from CD-RISC-10 ranked the highest. Reliability coefficients were > 0.93, > 0.72, and > 0.82 for the CD-RISC-10, CD-RISC-2, vs summation of items 2 and 9. AVEs were 0.66, 0.67, and 0.77. CD-RISC abbreviations and the summation of items 2 and 9 correlated negatively with anxiety (> - 0.43), depression (> - 0.42), and fear of COVID-19 (> - 0.34); positively with emotional stability (> 0.53) and conscientiousness (> 0.40). Compared to the CD-RISC-2, summative scores of items 2 and 9 more efficiently classified/discriminated high resilience on the CD-RISC-10. CONCLUSION: We confirmed construct validity/reliability of copyrighted CD-RISC abbreviations. The CD-RISC-10's items 2 and 9 were psychometrically more salient than the CD-RISC-2.

Surgical debranching versus branched endografting in zone 2 thoracic endovascular aortic repair.

BACKGROUND: Left subclavian artery (LSA) revascularization has been recommended for patients undergoing elective thoracic endovascular aortic repair (TEVAR) with a proximal zone 2 landing requiring coverage of the LSA. The clinical standard of care remains surgical LSA revascularization. However, recently, the feasibility of using branched endografts has been demonstrated. We compared the perioperative and mid-term outcomes of these approaches. METHODS: We performed a retrospective review of consecutive patients who underwent TEVAR with a proximal zone 2 landing at a single center from 2014 to 2020. The patients were divided into cohorts for comparison: those who underwent surgical revascularization (SR-TEVAR group) and those who underwent thoracic branched endografting with an investigational device (TBE group). Those patients who did not undergo LSA revascularization were excluded. Perioperative outcomes, including procedural success, death, stroke, limb ischemia, and length of stay, were compared. Kaplan-Meier survival curves were compared using the log-rank test. The cumulative incidence of device-related endoleak (types I and III) and device-related reintervention, accounting for death as a competing hazard, were compared using the Fine-Gray test. RESULTS: A total of 55 patients were included: 31 (56%) in the SR-TEVAR group and 24 (44%) in the TBE group. The preoperative demographics and comorbidities were similar between the two groups. Procedural success was 100% in both cohorts, with no periprocedural strokes or left upper extremity ischemic events. One operative or 30-day death (TBE, 4.2%; vs SR-TEVAR, 3.2%; P = .99) occurred in each cohort. The total operative time (TBE, 203 ± 79 minutes; vs SR-TEVAR, 250 ± 79 minutes; P = .03) and total length of stay (TBE, 5.2 ± 3.6 days; vs SR-TEVAR, 9.9 ± 7.2 minutes; P = .004) were both significantly shorter in the TBE group. No difference was found in mid-term survival (log-rank test, P = .50) nor the cumulative incidence of device-related endoleak (Fine-Gray test, P = .51) or reintervention (Fine-Gray test, P = .72). No occlusions of the TBE graft or surgical bypass or transpositions had occurred after a mean follow-up of 28 ± 16 and 34 ± 24 months, respectively. CONCLUSIONS: TBE can be performed with procedural success rate and safety profile comparable to those of TEVAR with surgical revascularization, with a decreased total length of stay, for patients requiring proximal zone 2 coverage. The mid-term outcomes for each approach were also similar. Prospective, randomized comparisons of these techniques are warranted.

Machine learning analysis of multispectral imaging and clinical risk factors to predict amputation wound healing.

OBJECTIVE: Prediction of amputation wound healing is challenging due to the multifactorial nature of critical limb ischemia and lack of objective assessment tools. Up to one-third of amputations require revision to a more proximal level within 1 year. We tested a novel wound imaging system to predict amputation wound healing at initial evaluation. METHODS: Patients planned to undergo amputation due to critical limb ischemia were prospectively enrolled. Clinicians evaluated the patients in traditional fashion, and all clinical decisions for amputation level were determined by the clinician's judgement. Multispectral images of the lower extremity were obtained preoperatively using a novel wound imaging system. Clinicians were blinded to the machine analysis. A standardized wound healing assessment was performed on postoperative day 30 by physical exam to determine whether the amputation site achieved complete healing. If operative revision or higher level of amputation was required, this was undertaken based solely upon the provider's clinical judgement. A machine learning algorithm combining the multispectral imaging data with patient clinical risk factors was trained and tested using cross-validation to measure the wound imaging system's accuracy of predicting amputation wound healing. RESULTS: A total of 22 patients undergoing 25 amputations (10 toe, five transmetatarsal, eight below-knee, and two above-knee amputations) were enrolled. Eleven amputations (44%) were non-healing after 30 days. The machine learning algorithm had 91% sensitivity and 86% specificity for prediction of non-healing amputation sites (area under curve, 0.89). CONCLUSIONS: This pilot study suggests that a machine learning algorithm combining multispectral wound imaging with patient clinical risk factors may improve prediction of amputation wound healing and therefore decrease the need for reoperation and incidence of delayed healing. We propose that this, in turn, may offer significant cost savings to the patient and health system in addition to decreasing length of stay for patients.

Liver stiffness and prediction of cardiac outcomes in patients with acute decompensated heart failure.

BACKGROUND: In acute decompensated heart failure (ADHF), noninvasive markers that predict morbidity and mortality are limited. Liver stiffness measurement (LSM) increases with hepatic fibrosis; however, it may be falsely elevated in patients with ADHF in the absence of liver disease. We investigated whether elevated LSM predicts cardiac outcomes in ADHF. METHODS: In a prospective study, we examined 52 ADHF patients without liver disease between 2016 and 2017. Patients underwent liver 2D shear wave elastography (SWE) and were followed for 12 months to assess the outcomes of left ventricular assist device (LVAD), heart transplant (HT) or death. RESULTS: The median LSM was elevated in patients who received an LVAD or HT within 30-days compared to those who did not (median [IQR]: 55.6 [22.5 - 63.4] vs 13.8 [9.5 - 40.3] kPa, p = .049). Moreover, the risk of composite outcome was highest in the 3rd tertile (> 39.8 kPa compared to 1st and 2nd combined, HR 2.83, 95% CI 1.20- 6.67, p = .02). Each 1-kPa increase in LSM was associated with a 1%-increase in the incidence rate of readmissions (IRR 1.01, 95% CI 1.00-1.02, p = .01). CONCLUSIONS: LSM may serve as a novel noninvasive tool to determine LVAD, HT, or death in patients with ADHF.

Outcomes of Open Versus Percutaneous Access for Patients Enrolled in the GREAT Registry.

BACKGROUND: Arterial access and device delivery in endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) have evolved from open femoral or iliac artery exposure to selective percutaneous arterial access. Although regional application of percutaneous access for these 2 procedures varies widely, the use of this technique continues to increase. Currently, differences in the use of percutaneous access between EVAR and TEVAR have not been well explored. The Gore Global Registry for Endovascular Aortic Treatment (GREAT) registry collected relevant data for evaluation of these issues and the comparative results between open and percutaneous approaches in regard to complication rates and length of stay (LOS). METHODS: This study was performed via a retrospective review of patients from the GREAT registry (Clinicaltrials.gov no. NCT01658787). The primary variable of this study was access site complications including postoperative hematoma, vessel dissection, and pseudoaneurysm. Patients were categorized by abdominal (EVAR) and thoracic (TEVAR) aortic procedures using percutaneous-only, cutdown-only, and combined vascular access techniques for a total of 6 groups. Standard statistical methodology was used to perform single-variable and multivariable analysis of a variety of covariates including LOS, geographical location of procedure, procedural success rate, and access sheath size. RESULTS: Of 4,781 patients from the GREAT registry, 3,837 (80.3%) underwent EVAR and 944 (19.7%) underwent TEVAR with percutaneous-only access techniques being used in 2,017 (42.2%) and cutdown-only in 2,446 (51.2%). There was variable application of percutaneous access by geographic region with Australia and New Zealand using this technique more frequently and Brazil using percutaneous access the least. No significant difference in the rate of access site complications was detected between the 6 groups of patients in the study; however, significantly lower rates of access site complications were associated with percutaneous-only compared with both cutdown-only and combined techniques (P = 0.03). In addition, associated with significantly higher rates of access site complications was longer LOS (P < 0.01). Average LOS was 5.2 days and was higher in the TEVAR group (10.1 days) than that in EVAR (4.0 days, P < 0.05). Increased sheath size does not appear to increase the risk of access site complication. CONCLUSIONS: There was no significant difference found in the complication rate between percutaneous and cutdown access techniques. This analysis demonstrates that percutaneous-only access is safe, has low complication rates, and has lower LOS compared with open access or combined access techniques.

Comparison of the Bentall procedure versus valve-sparing aortic root replacement.

Bentall and valve-sparing root replacement (VSRR) procedures are established treatments for aortic root disease. We present a single-center retrospective analysis comparing outcomes of bioprosthetic Bentall (BB), mechanical Bentall (MB), and VSRR patients from November 2007 to October 2016. Survival analysis was performed to evaluate the composite endpoint of freedom from recurrent aortic insufficiency, reoperation, or death. Of the 170 patients, BB was performed in 36 patients, MB in 63 patients, and VSRR in 71 patients. For BB, MB, and VSRR, the mean age was 63.8, 45.5, and 49.2 years (P < 0.001), respectively. Additionally, significantly more patients in the MB group (n = 32, 50.8%, P < 0.001) than in the BB and VSRR groups had prior cardiac surgeries. Cardiopulmonary bypass time and cross-clamp time were significantly longer in the VSRR group (P = 0.04 and 0.0005, respectively). Despite the complexity of the procedure, VSRR patients had higher combined freedom from death and reoperation than patients in the BB or MB groups. Elective Bentall root replacement is an excellent option for patients with root disease. Patients undergoing Bentall tend to have more severe or emergent cases, making them unlikely candidates for VSRR. VSRR in experienced centers carries equivalent morbidity and mortality and improved survival.

Effect of new and persistent left bundle branch block after transcatheter aortic valve replacement on long-term need for pacemaker implantation.

Cardiac conduction abnormalities, including left bundle branch block (LBBB), are common following transcatheter aortic valve replacement (TAVR). This study assessed the incidence and outcomes of new or widening persistent LBBB following TAVR. Data regarding 550 consecutive patients undergoing TAVR between 2012 and 2016 at our institution were retrospectively reviewed. Both 30-day and 1-year outcomes of patients with isolated new or worsening LBBB following TAVR were reviewed. Fifty-two patients (9.5%) developed new or worsening LBBB. Six of the 52 (11.5%) patients received a permanent pacemaker (PPM) for LBBB prior to discharge. For patients discharged home following TAVR without a PPM, the 1-year PPM requirement was 15.2% in patients with new or worsening LBBB compared to 4.5% in patients without new or worsening LBBB (P = 0.01). One-year mortality rates for patients who did not have a new PPM placed before discharge were 15.2% in patients with new or worsening LBBB, 13.9% in patients without new or worsening LBBB, and 11.9% in patients with preoperative PPMs (P = 0.81). Patients with new or worsening persistent LBBB discharged without a PPM experience a higher requirement for PPM implantation in the year following TAVR compared to patients without new or worsening persistent LBBB.

Digital Health Primer for Cardiothoracic Surgeons.

The burgeoning demands for quality, safety, and value in cardiothoracic surgery, in combination with the advancement and acceleration of digital health solutions and information technology, provide a unique opportunity to improve efficiency and effectiveness simultaneously in cardiothoracic surgery. This primer on digital health explores and reviews data integration, data processing, complex modeling, telehealth with remote monitoring, and cybersecurity as they shape the future of cardiothoracic surgery.

Extracorporeal Membrane Oxygenation Support for Vaping-Induced Acute Lung Injury.

Cases of vaporizer-induced acute lung injury are increasing in frequency as the use of these recreational products have become more popular. Such pathology can result in life-threatening conditions for otherwise healthy patients, with diagnostic difficulties and complex treatment plans. Presented is a case of severe acute lung injury caused by vaporizing substances in a young man requiring extracorporeal membranous oxygenation (ECMO) as a bridge to recovery. Recovery was successful despite rapid-onset of adult respiratory distress syndrome with prompt use of ECMO and appropriate lung-protective strategies.

A Newly Discovered Genetic Disorder Associated With Life-Threatening Aortic Disease in a 6-Year-Old Boy.

Aortic aneurysms in children are rare and when present are usually caused by a connective tissue disorder. In this article, we present a case of multiple aortic aneurysms in an adolescent with a novel finding of a gene variation that is associated with aortic disease.

Enhanced Recovery After Surgery: A Narrative Review of its Application in Cardiac Surgery.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a perioperative patient management strategy that is being adopted rapidly across surgical specialties worldwide. Components of ERAS work collaboratively throughout the perioperative course to achieve significant benefits for both the patient and the entire health care system. The use of ERAS in cardiac surgery (ERAS-C) could lead to similar improvements, but currently, use of ERAS-C programs is lacking and not well defined. METHODS: A literature search was performed of the Medline database to capture relevant studies discussing ERAS-C. Key concepts were extracted from these articles and grouped according to appropriate perioperative stages. Supporting literature was also included, briefly discussing the historical progression of cardiac surgery to enhanced recovery pathways, potential limitations to these pathways in cardiac surgery, and the first studies evaluating the use of an ERAS program with cardiac surgery patients. RESULTS: Initial results of ERAS-C studies have shown similar benefits to those of other surgical fields, including decreased hospital and intensive care unit lengths of stay (1-4 days and 4-20 hours, respectively), improved perioperative pain control (25%-60% decreased opioid usage), and improvements in early postoperative mobility and oral diets. Results especially beneficial to cardiac surgery have also been reported, such as an 8% to 14% decreased incidence of postoperative atrial fibrillation. CONCLUSIONS: This review presents pertinent current research related to the implementation of ERAS programs in the field of cardiac surgery and provides a call to action for further investigation and adaption of ERAS in cardiac surgery.

Predictors and impact of right heart failure severity following left ventricular assist device implantation.

BACKGROUND: Right heart failure (RHF) is a well-known consequence of left ventricular assist device (LVAD) placement, and has been linked to negative surgical outcomes. However, little is known regarding risk factors associated with RHF. This article delineates pre- and intra-operative risk factors for RHF following LVAD implantation and demonstrates the effect of RHF severity on key surgical outcomes. METHODS: We performed a retrospective analysis of consecutive LVAD patients treated at our center between 2008 and 2016. RHF was categorized using the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) definition of none/mild, moderate, severe, and acute-severe. We constructed a predictive model using multivariable logistic regression and performed a competing risks analysis for survival stratified by RHF severity. RESULTS: Of 202 subjects, 52 (25.7%) developed moderate or worse RHF. Cardiopulmonary bypass (CPB) time and nadir hematocrit contributed jointly to the model of RHF severity (moderate or worse vs. none/mild; area under the curve =0.77). Postoperative length of stay (LOS) was shortest in the non/mild group and longest in the acute-severe group (median 13 vs. 29.5 days; P<0.001). Stage 2/3 acute kidney injury (range, 26-57%, P=0.002), respiratory failure (13-94%, P<0.001), stroke (0-32%, P=0.02), and 1-year mortality (19-64%, P=0.002) differed by severity. Those with acute-severe RHF had 5.4 [95% confidence interval (CI), 2.5-11.8] times the risk of 1-year mortality compared to those who did not have RHF. CONCLUSIONS: RHF remains a postoperative threat and is associated with worsened surgical outcomes. Ongoing research will reveal further opportunities to mitigate RHF post-LVAD.

Papillary Fibroelastoma of the Ascending Aorta.

Papillary fibroelastomas are rare benign primary cardiac tumors. They are typically found on valvular surfaces, most commonly, the aortic valve. In this article, we report a case of papillary fibroelastoma arising from the sinotubular junction of the ascending aorta, a rare and unusual site causing an embolic stroke.

Outcomes of Moderate-to-Severe Acute Kidney Injury following Left Ventricular Assist Device Implantation.

BACKGROUND: Although acute kidney injury (AKI) is a common complication following cardiac surgery, less is known about the occurrence and consequences of moderate/severe AKI following left ventricular assist device (LVAD) implantation. METHODS: All patients who had an LVAD implanted at our center from 2008 to 2016 were reviewed to determine the incidence of, and risk factors for, moderate/severe (stage 2/3) AKI and to compare postoperative complications and mortality rates between those with and those without moderate/severe AKI. RESULTS: Of 246 patients, 68 (28%) developed moderate/severe AKI. A multivariable logistic regression comprising body mass index and prior sternotomy had fair predictive ability (area under the curve = 0.71). A 1-unit increase in body mass index increased the risk of moderate/severe AKI by 7% (odds ratio = 1.07; 95% confidence interval: 1.03-1.11); a prior sternotomy increased the risk more than 3-fold (odds ratio = 3.4; 95% confidence interval: 1.84-6.43). The group of patients with moderate/severe AKI had higher rates of respiratory failure and death than the group of patients with mild/no AKI. Patients with moderate/severe AKI were at 3.2 (95% confidence interval: 1.2-8.2) times the risk of 30-day mortality compared to those without. Even after adjusting for age and Interagency Registry for Mechanically Assisted Circulatory Support profile, those with moderate/severe AKI had 1.75 (95% confidence interval: 1.03-3.0) times the risk of 1-year mortality compared to those without. DISCUSSION: Risk-stratifying patients prior to LVAD placement in regard to AKI development may be a step toward improving surgical outcomes.

Durable left ventricular assist device implantation in extremely obese heart failure patients.

Left ventricular assist devices (LVADs) have improved clinical outcomes and quality of life for those with end-stage heart failure. However, the costs and risks associated with these devices necessitate appropriate patient selection. LVAD candidates are becoming increasingly more obese and there are conflicting reports regarding obesity's effect on outcomes. Hence, we sought to evaluate the impact of extreme obesity on clinical outcomes after LVAD placement. Consecutive LVAD implantation patients at our center from June 2008 to May 2016 were studied retrospectively. We compared patients with a body mass index (BMI) ≥40 kg/m2 (extremely obese) to those with BMI < 40 kg/m2 with respect to patient characteristics and surgical outcomes, including survival. 252 patients were included in this analysis, 30 (11.9%) of whom met the definition of extreme obesity. We found that patients with extreme obesity were significantly younger (47[33, 57] vs. 60[52, 67] years, P < 0.001) with fewer prior sternotomies (16.7% vs. 36.0%, P = 0.04). They had higher rates of pump thrombosis (30% vs. 9.0%, P = 0.003) and stage 2/3 acute kidney injury (46.7% vs. 27.0%, P = 0.003), but there were no differences in 30-day or 1-year survival, even after adjusting for age and clinical factors. Extreme obesity does not appear to place LVAD implantation patients at a higher risk for mortality compared to those who are not extremely obese; however, extreme obesity was associated with an increased risk of pump thrombosis, suggesting that these patients may require additional care to reduce the need for urgent device exchange.

Determinants and Outcomes of Vasoplegia Following Left Ventricular Assist Device Implantation.

BACKGROUND: Vasoplegia is associated with adverse outcomes following cardiac surgery; however, its impact following left ventricular assist device implantation is largely unexplored. METHODS AND RESULTS: In 252 consecutive patients receiving a left ventricular assist device, vasoplegia was defined as the occurrence of normal cardiac function and index but with the need for intravenous vasopressors within 48 hours following surgery for >24 hours to maintain a mean arterial pressure >70 mm Hg. We further categorized vasoplegia as none; mild, requiring 1 vasopressor (vasopressin, norepinephrine, or high-dose epinephrine [>5 µg/min]); or moderate to severe, requiring ≥2 vasopressors. Predictors of vasoplegia severity were determined using a cumulative logit (ordinal logistic regression) model, and 1-year mortality was evaluated using competing-risks survival analysis. In total, 67 (26.6%) patients developed mild vasoplegia and 57 (22.6%) developed moderate to severe vasoplegia. The multivariable model for vasoplegia severity utilized preoperative Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile, central venous pressure, systolic blood pressure, and intraoperative cardiopulmonary bypass time, which yielded an area under the curve of 0.76. Although no significant differences were noted in stroke or pump thrombosis rates (P=0.87 and P=0.66, respectively), respiratory failure and major bleeding increased with vasoplegia severity (P<0.01). Those with moderate to severe vasoplegia had a significantly higher risk of mortality than those without vasoplegia (adjusted hazard ratio: 2.12; 95% confidence interval, 1.08-4.18; P=0.03). CONCLUSIONS: Vasoplegia is predictive of unfavorable outcomes, including mortality. Risk factors for future research include preoperative INTERMACS profile, central venous pressure, systolic blood pressure, and intraoperative cardiopulmonary bypass time.

MicroRNA-34a dependent regulation of AXL controls the activation of dendritic cells in inflammatory arthritis.

Current treatments for rheumatoid arthritis (RA) do not reverse underlying aberrant immune function. A genetic predisposition to RA, such as HLA-DR4 positivity, indicates that dendritic cells (DC) are of crucial importance to pathogenesis by activating auto-reactive lymphocytes. Here we show that microRNA-34a provides homoeostatic control of CD1c+ DC activation via regulation of tyrosine kinase receptor AXL, an important inhibitory DC auto-regulator. This pathway is aberrant in CD1c+ DCs from patients with RA, with upregulation of miR-34a and lower levels of AXL compared to DC from healthy donors. Production of pro-inflammatory cytokines is reduced by ex vivo gene-silencing of miR-34a. miR-34a-deficient mice are resistant to collagen-induced arthritis and interaction of DCs and T cells from these mice are reduced and do not support the development of Th17 cells in vivo. Our findings therefore show that miR-34a is an epigenetic regulator of DC function that may contribute to RA.