Study of risk factors for healthcare-associated infections in acute cardiac patients using categorical principal component analysis (CATPCA).

Using categorical principal component analysis, we aimed to determine the relationship between health care-associated infections (HAIs) and diagnostic categories (DCs) in patients with acute heart disease using data collected in the Spanish prospective ENVIN-HELICS intensive care registry over a 10-year period (2005-2015). A total of 69,876 admissions were included, of which 5597 developed HAIs. Two 2-component CATPCA models were developed. In the first model, all cases were included; the first component was determined by the duration of the invasive devices, the ICU stay, the APACHE II score and the HAIs; the second component was determined by the type of admission (medical or surgical) and by the DCs. No clear association between DCs and HAIs was found. Cronbach's alpha was 0.899, and the variance accounted for (VAF) was 52.5%. The second model included only admissions that developed HAIs; the first component was determined by the duration of the invasive devices and the ICU stay; the second component was determined by the inflammatory response, the mortality in the ICU and the HAIs. Cronbach's alpha value was 0.855, and VAF was 46.9%. These findings highlight the role of exposure to invasive devices in the development of HAIS in patients with acute heart disease.

Eradication of Staphylococcus aureus Post-Sternotomy Mediastinitis Following the Implementation of Universal Preoperative Nasal Decontamination With Mupirocin: An Interrupted Time-Series Analysis.

BACKGROUND: Although presurgical nasal decontamination with mupirocin (NDM) has been advocated as a measure for preventing postsurgical mediastinitis (PSM) due to Staphylococcus aureus, this strategy is not universally recommended due to lack of robust supporting evidence. We aimed to evaluate the role of preoperative NDM in the annual incidence of S. aureus PSM at our institution. METHODS: An interrupted time-series analysis, with an autoregressive error model, was applied to our single-center cohort by comparing preintervention (1990-2003) and postintervention (2005-2018) periods. Logistic regression was performed to analyze risk factors for S. aureus PSM. RESULTS: 12 236 sternotomy procedures were analyzed (6370 [52.1%] and 5866 [47.9%] in the pre- and postintervention periods, respectively). The mean annual percentage adherence to NDM estimated over the postintervention period was 90.2%. Only 4 of 127 total cases of S. aureus PSM occurred during the 14-year postintervention period (0.68/1000 sternotomies vs 19.31/1000 in the preintervention period; P < .0001). Interrupted time-series analysis demonstrated a statistically significant annual reduction in S. aureus PSM of -9.85 cases per 1000 sternotomies (-13.17 to -6.5; P < .0001) in 2005, with a decreasing trend maintained over the following 5 years and an estimated relative reduction of 84.8% (95% confidence interval [CI], 89.25-74.09%). Chronic obstructive pulmonary disease was the single independent risk factor for S. aureus PSM (odds ratio, 3.7; 95% CI, 1.72-7.93) and was equally distributed in patients undergoing sternotomy during pre- or postintervention periods. CONCLUSIONS: Our experience suggests the implementation of preoperative NDM significantly reduces the incidence of S. aureus PSM.

Awake ECMO-VA en shock cardiogénico: una experiencia prometedora / Awake VA-ECMO in cardiogenic shock: an experience with future potential

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Incidence, Risk Factors and Outcomes of Early Acute Kidney Injury After Heart Transplantation: An 18-year Experience.

BACKGROUND: Little is known about the incidence of acute kidney injury (AKI), as defined using the Kidney Disease Improving Global Outcome classification, after heart transplantation (HT). Our objective was to evaluate the impact of AKI in a cohort of HT recipients. (Setting: University Hospital.) METHODS: We studied 310 consecutive HT recipients from 1999 to 2017, with AKI being defined according to the Kidney Disease Improving Global Outcome criteria. Risk factors were analyzed by multivariable analyses, and survival by Kaplan-Meier curves and a risk-adjusted Cox proportional hazards regression model. RESULTS: One hundred twenty-five (40.3%) patients developed AKI, with 73 (23.5%), 18 (5.8%), and 34 (11%) patients having AKI stages 1, 2, and 3, respectively. Cardiac tamponade (odds ratio [OR], 16.82; 95% confidence interval [CI], 1.06-138), acute right ventricular failure (OR, 3.54; 95% CI, 1.82-6.88), and major bleeding (OR, 2.46; 95% CI, 1.18-5.1) were the principal risk factors for AKI. Patients with AKI had a greater hospital mortality (3.8% vs 16%, P < 0.05), especially those requiring renal replacement therapy (46.9% vs 5.4%, P = 0.006). Acute kidney injury requiring renal replacement therapy was independently associated with hospital mortality (OR, 11.03; 95% CI, 4.08-29.8). With a median follow-up after hospital discharge of 6.7 years (interquartile range, 2.4-11.6), overall survival at 1, 5, and 10 years was 95.4%, 85.1%, and 75.4% versus 85.2%, 69.8% and 63.5% among patients without AKI and with AKI stages 2 to 3, respectively (P = 0.08). CONCLUSIONS: The onset of AKI after HT is mainly associated with postoperative complications. Only severe AKI stage predicts worse short-term outcome, with this impact appearing to be lost at long-term follow-up.

Evaluation of right ventricular function after cardiac surgery: The importance of tricuspid annular plane systolic excursion and right ventricular ejection fraction.

OBJECTIVE: The evaluation of right ventricular systolic function is essential to the hemodynamic management of critically ill cardiac patients. Nevertheless, assessment of right ventricular function remains problematic. We sought to analyze the correlation between tricuspid annular plane systolic excursion (TAPSE) and right ventricular ejection fraction (RVEF) in the assessment of global and regional right ventricular function, respectively. METHODS: This was a prospective study of 61 cardiac surgical patients. TAPSE was measured with transthoracic echocardiography and RVEF was obtained by a thermodilution pulmonary artery catheter. Both measurements were estimated simultaneously during the early postoperative period. Patients with previously identified severe tricuspid insufficiency were excluded from the study to avoid confounding results. RESULTS: The etiologies for cardiac surgery were surgical pulmonary thromboendarterectomy in 19 patients, valve replacement in 17 patients, heart transplant in 13 patients, and coronary artery bypass graft in 9 patients. Mean RVEF and TAPSE were 26.2% ± 9.7% and 11.4 ± 4 mm, respectively. RVEF and TAPSE showed a significant correlation (r = 0.73, P < .001). Weak reverse relationships between TAPSE or RVEF with afterload hemodynamic parameters, mean pulmonary artery pressure, or pulmonary vascular resistance were elucidated. CONCLUSIONS: TAPSE is a robust measure of right ventricular function that correlates with RVEF assessed by pulmonary artery catheter. A noninvasive method such as echocardiography can guide and support invasive monitoring of right ventricular function in cardiac surgical patients.

Veno-arterial ECMO for rescue of severe airway hemorrhage with rigid bronchoscopy after pulmonary artery thromboendarterectomy.

Pulmonary endarterectomy (PEA) is the treatment of choice to relieve pulmonary artery obstruction in patients with chronic thromboembolic pulmonary hypertension (CTEPH). We present a patient with airway obstruction and acute respiratory failure due to large blood clots obstructing the trachea and main left bronchus. This condition was accompanied by right ventricle failure and cardiogenic shock. A venoarterial ECMO system was used for cardiopulmonary support before extracting the clots and clearing the airway by rigid bronchoscopy.

Insuficiencia ventricular derecha en el seno de la cirugía cardiaca / Right ventricular failure and cardiac surgery

La insuficiencia del ventrículo derecho tras la cirugía cardiaca sigue siendo un problema clínico significativo, especialmente en determinados contextos quirúrgicos: cardiopatías congénitas, enfermedad valvular mitral con hipertensión pulmonar, enfermedad coronaria de alto riesgo, trasplante cardiaco, tromboendarterectomía pulmonar e inserción de un dispositivo de asistencia ventricular izquierda. Durante los últimos años, varios estudios han demostrado el valor pronóstico de la función del ventrículo derecho en cirugía cardiaca y, por lo tanto, la utilidad de una adecuada estratificación del riesgo. La tasa de supervivencia a la insuficiencia del ventrículo derecho aguda y refractaria tras la cirugía cardiaca puede situarse en cifras tan bajas como un 20-25%. Grados menos graves se asocian también a un aumento de la morbimortalidad postoperatoria y tienen un notable impacto en la estancia hospitalaria. Esto destaca la relevancia de conocer su particular fisiopatología, espectro clínico, diagnóstico precoz y estrategias de prevención, aspectos todos ellos tratados en este artículo de revisión (AU)

Right ventricular failure after cardiac surgery remains an important clinical problem, especially in certain surgical settings: congenital heart disease, mitral valve disease with pulmonary hypertension, high-risk coronary artery disease, heart transplantation, pulmonary thromboendarterectomy and left ventricular assist device placement. In recent years, a number of studies have demonstrated the prognostic value of right ventricular function in cardiac surgery and, therefore, the usefulness of accurate risk stratification. The survival rate for acute, refractory, right ventricular failure after cardiac surgery may be as low as 20-25%. Less severe disease is also associated with increased postoperative morbidity and mortality and has a marked effect on the length of hospitalization. This highlights the importance of understanding the underlying pathophysiology of the condition, its clinical spectrum, early diagnosis and preventive strategies, all of which are discussed in this review article (AU)

Ductular cholestasis, an unusual form of intrahepatic cholestasis, associated with cardiogenic shock and ventricular assist device.

Ventricular assist devices have been shown to be effective in advanced heart failure selected patients. They often have borderline end-organ function, what facilitates organ dysfunction. Liver failure is difficult to manage and leads to increased morbidity and mortality. We report a case of ductular cholestasis, an unusual cholestatic hepatic failure with untractable coagulopathy, developed during the use of a magnetic levitation centrifugal pump, implanted as a bridge to heart transplantation, in a patient with cardiogenic shock (as an end-stage disease of idiopathic dilated cardiomyopathy). We discussed the pathophysiology of this entity and the possible related factors, including the assist device. Preemptive interventions have been advocated as the primary way of treatment. Preoperative optimization of heart function and avoidance of visceral hypoperfusion and sepsis may play a major role.

[Levosimendan for postoperative ventricular dysfunction following heart transplantation]. / Utilidad de levosimendán en la disfunción ventricular postoperatoria del injerto en el trasplante cardiaco.

The development of postoperative ventricular dysfunction immediately after heart transplantation is a serious complication that leads to low-output syndrome and which necessitates circulatory support. It is one of the most common causes of early morbidity and mortality. We present our experience with 6 heart transplant patients who were treated with intravenous levosimendan, a calcium sensitizer with inodilator properties, after regular hemodynamic therapy with sympathomimetic amines failed to result in a satisfactory hemodynamic status. Use of this drug was well tolerated and brought about hemodynamic improvements that were sufficient to enable patients to be weaned from inotropic support with amines and which led to clinical recovery, with 5 of the 6 patients being discharged from the intensive care unit.

Utilidad de levosimendán en la disfunción ventricular postoperatoria del injerto en el trasplante cardiaco / Levosimendan for postoperative ventricular dysfunction following heart transplantation

La disfunción ventricular del injerto en el postoperatorio inmediato del paciente trasplantado cardiaco es una complicación grave, que cursa con un síndrome de bajo gasto cardiaco y necesidad de soporte circulatorio, y es una de las causas más frecuentes de morbimortalidad inicial. Presentamos la experiencia clínica con 6 pacientes trasplantados en los que, tras un manejo hemodinámico habitual con aminas simpaticomiméticas, no se consiguió una adecuada situación hemodinámica y se utilizó levosimendán intravenoso, un fármaco sensibilizador al calcio con propiedades inodilatadoras. El uso de este fármaco fue bien tolerado y favoreció una mejoría hemodinámica que facilitó la retirada del soporte inotrópico con aminas y la recuperación clínica (con alta de UCI de 5 de los 6 pacientes) (AU)

The development of postoperative ventricular dysfunction immediately after heart transplantation is a serious complication that leads to low-output syndrome and which necessitates circulatory support. It is one of the most common causes of early morbidity and mortality. We present our experience with 6 heart transplant patients who were treated with intravenous levosimendan, a calcium sensitizer with inodilator properties, after regular hemodynamic therapy with sympathomimetic amines failed to result in a satisfactory hemodynamic status. Use of this drug was well tolerated and brought about hemodynamic improvements that were sufficient to enable patients to be weaned from inotropic support with amines and which led to clinical recovery, with 5 of the 6 patients being discharged from the intensive care unit (AU)

[Neurologic complications in the immediate postoperative period after cardiac surgery. Role of brain magnetic resonance imaging]. / Complicaciones neurológicas en el postoperatorio inmediato de la cirugía cardíaca. Aportación de la resonancia magnética cerebral.

INTRODUCTION AND OBJECTIVES: Neurologic complications still cause significant morbidity and mortality in the immediate postoperative period following cardiac surgery. Our understanding of the pathogenesis, prevention, and management of these lesions is constantly developing. MATERIAL AND METHOD: We describe neurologic complications and their course in a cardiac surgery cohort and analyze the value of brain magnetic resonance imaging (MRI), using T1-weighted, T2-weighted, and FLAIR sequences, in patients with postoperative stroke or encephalopathy in whom CT scanning revealed no abnormalities explaining their clinical condition. RESULTS: In 688 patients studied postoperatively, we observed 57 neurologic complications (8.3%): 25 strokes, 24 encephalopathies, 5 seizure disorders, 2 brain deaths, and 1 intracranial hemorrhage. Initial CT scanning failed to show significant findings in 70%. 18 patients underwent brain MRI. In all but 1 of the 11 with stroke, MRI showed areas of acute or subacute infarction (i.e., hyperintensity in FLAIR or T2-weighted sequences) in different locations, mainly in a watershed distribution. In 3 of the 4 patients with mild-to-moderate encephalopathy, MRI showed lesions similar to those previously described for stroke. In the remaining 3 patients, who had severe encephalopathy, MRI showed diffuse cortical necrosis. CONCLUSIONS: The incidence of neurologic complications in the postoperative period following cardiac surgery is significant. In a high percentage of patients, brain CT scanning may not show pathologic findings. In selected patients, MRI could help identify areas of infarction not detected by CT. These images could improve clinicians' understanding of the pathogenic, pathophysiologic, clinical, and prognostic characteristics of such neurologic complications.

Complicaciones neurológicas en el postoperatorio inmediato de la cirugía cardíaca. Aportación de la resonancia magnética cerebral / Neurologic complications in the immediate postoperative period after cardiac surgery. Role of brain magnetic resonance imaging

Introducción y objetivos. Las complicaciones neurológicas (CN) causan una importante morbimortalidad en el postoperatorio inmediato de la cirugía cardíaca. La comprensión de la etiopatogenia, la prevención y el tratamiento de éstas están en constante evolución. Material y método. Se describen las CN y su evolución en una serie quirúrgica, y se analizan las aportaciones de la resonancia magnética cerebral (RMC) con secuencias T1, T2 y la supresión de líquido cefalorraquídeo, en los pacientes que presentan ictus o encefalopatía poscirugía y tomografía computarizada (TC) craneal sin hallazgos que justifiquen la situación clínica. Resultados. Se estudió a 688 postoperados; se observaron 57 CN (8,3%): 25 ictus, 24 encefalopatías, 5 pacientes con crisis convulsivas, 2 muertes cerebrales y una hemorragia intracerebral. La TC craneal inicial no mostró hallazgos relevantes en el 70% de las ocasiones. Se realizó RMC en 18 pacientes, 11 de ellos con ictus: excepto en un estudio, en la RMC encontramos áreas de infarto agudo o subagudo (hiperintensas en la secuencia T2 y FLAIR) en diferentes localizaciones. También se realizó en 4 pacientes con encefalopatía leve-moderada y mostró en 3 de ellos lesiones similares a las descritas en los ictus. En los restantes 3 casos con encefalopatía severa, la RMC mostró áreas con múltiples infartos corticales. Conclusiones. Las CN tras cirugía cardíaca se presentan con una incidencia no despreciable. La TC craneal puede no presentar hallazgos patológicos en un alto porcentaje. En pacientes seleccionados, la RMC puede presentar lesiones, y demostrar áreas isquémicas no detectadas en la TC que ayudan a comprender a los clínicos la etiopatogenia, la fisiopatología, la clínica y la evolución de estas complicaciones (AU)

Introduction and objectives. Neurologic complications still cause significant morbidity and mortality in the immediate postoperative period following cardiac surgery. Our understanding of the pathogenesis, prevention, and management of these lesions is constantly developing. Matherial and method. We describe neurologic complications and their course in a cardiac surgery cohort and analyze the value of brain magnetic resonance imaging (MRI), using T1-weighted, T2-weighted, and FLAIR sequences, in patients with postoperative stroke or encephalopathy in whom CT scanning revealed no abnormalities explaining their clinical condition. Results. In 688 patients studied postoperatively, we observed 57 neurologic complications (8.3%): 25 strokes, 24 encephalopathies, 5 seizure disorders, 2 brain deaths, and 1 intracranial hemorrhage. Initial CT scanning failed to show significant findings in 70%. 18 patients underwent brain MRI. In all but 1 of the 11 with stroke, MRI showed areas of acute or subacute infarction (i.e., hyperintensity in FLAIR or T2-weighted sequences) in different locations, mainly in a watershed distribution. In 3 of the 4 patients with mild-to-moderate encephalopathy, MRI showed lesions similar to those previously described for stroke. In the remaining 3 patients, who had severe encephalopathy, MRI showed diffuse cortical necrosis. Conclusions. The incidence of neurologic complications in the postoperative period following cardiac surgery is significant. In a high percentage of patients, brain CT scanning may not show pathologic findings. In selected patients, MRI could help identify areas of infarction not detected by CT. These images could improve clinicians' understanding of the pathogenic, pathophysiologic, clinical, and prognostic characteristics of such neurologic complications (AU)