Active clearance vs conventional management of chest tubes after cardiac surgery: a randomized controlled study.

BACKGROUND: Chest tubes are routinely used after cardiac surgery to evacuate shed mediastinal blood. Incomplete chest drainage due to chest tube clogging can lead to retained blood after cardiac surgery. This can include cardiac tamponade, hemothorax, bloody effusions and postoperative atrial fibrillation (POAF). Prior published non randomized studies have demonstrated that active tube clearance (ATC) of chest tubes can reduce retained blood complications prompting the ERAS Cardiac Society guidelines to recommend this modality. OBJECTIVE: A randomized prospective trial to evaluate whether an ATC protocol aimed at improving chest tube patency without breaking the sterile field could efficiently reduce complications related to retained blood after cardiac surgery. METHODS: This was a pragmatic, single-blinded, parallel randomized control trial held from November 2015 to June 2017 including a 30-day post index surgery follow-up. The setting was two academic centers affiliated with the Université de Montréal School of Medicine; the Montreal Heart Institute and the Hôpital du Sacré-Coeur de Montréal. Adult patients admitted for non-emergent coronary bypass grafting and/or valvular heart surgery through median sternotomy, in sinus rhythm for a minimum of 30 days prior to the surgical intervention were eligible for inclusion. In the active tube clearance group (ATC), a 28F PleuraFlow device was positioned within the mediastinum. In the standard drainage group, a conventional chest tube (Teleflex Inc.) was used. Other chest tubes were left at the discretion of the operating surgeon. RESULTS: A total of 520 adult patients undergoing cardiac surgery were randomized to receive either ATC (n = 257) or standard drainage (n = 263). ATC was associated with a 72% reduction in re-exploration for bleeding (5.7% vs 1.6%, p = .01) and an 89% reduction in complete chest tube occlusion (2% vs 19%, p = .01). There was an 18% reduction in POAF between the ATC and control group that was not statistically significant (31% vs 38%, p = .08). CONCLUSIONS AND RELEVANCE: In this RCT, the implementation of active clearance of chest tubes reduced re-exploration and chest tube clogging in patients after cardiac surgery further supporting recommendations to consider this modality postoperatively. TRIAL REGISTRATION: Clinical Trials NCT02808897 . Retrospectively registered 22 June 2016.

Evaluation of the real-world impact of rotational thromboelastometry-guided transfusion protocol in patients undergoing proximal aortic surgery.

BACKGROUND: Complex aortic procedures are potentially associated with important blood loss and coagulopathy. The aim of this study was to assess the impact of rotational thromboelastometry (ROTEM, Tem International GmBH, Munich, Germany) on transfusion requirements after proximal aortic operations in a real-world setting. METHODS: This single-center retrospective analysis based on 385 consecutive patients undergoing cardiac surgeries involving the aortic root, ascending aorta, or aortic arch compared 197 controls managed according to routine transfusion protocol before the introduction of the ROTEM in 2012 with 188 patients operated afterward. With the use of a 1:1 propensity score match, 224 patients were included in paired analysis (112 in each group). The primary end point was erythrocytes transfusion rate. The secondary end points comprised the transfusion of other allogeneic blood products, number of units transfused, postoperative blood loss, massive transfusion rate, and use of other hemostatic products. RESULTS: ROTEM implementation was associated with a trend toward reduction in the rate of erythrocytes transfusion (57% vs 46%, P = .08) and a decreased median number of units transfused for erythrocytes (1.0 [0.0-4.0] unit vs 0.0 [0.0-2.0] unit, P = .03) and plasma (0.0 [0.0-4.0] unit vs 0.0 [0.0-2.0] unit, P = .04). After sensitivity analysis, ROTEM displayed a comparable rate of erythrocytes transfusion (58% vs 47%, P = .15). CONCLUSIONS: In a real-world setting, ROTEM-based algorithm implementation could help reduce excess erythrocytes transfusion for complex aortic procedures. We advocate for a strict adherence and concerted team effort to maximize the benefits of such addition to patients' management.

Pericardial Blood as a Trigger for Postoperative Atrial Fibrillation After Cardiac Surgery.

BACKGROUND: Prevention strategies have long been sought to reduce the incidence and burden of postoperative atrial fibrillation (POAF) after heart surgery. However, none has emerged as a dominant and widely applicable prophylactic measure. The purpose of this review is to consider the biological mechanisms by which shed mediastinal blood leads to oxidation and inflammation within the postoperative pericardial environment and how this might trigger POAF in susceptible persons, as well as how it could represent a new target for prevention of POAF. METHODS: We conducted a structured research of literature using PubMed and MEDLINE databases to May 2016. Biomolecular and clinical articles focused on assessing the contribution of pericardial blood, or the resulting inflammation within the pericardial space and its potential role in triggering POAF, were included in this review. RESULTS: Evidence suggests that shed mediastinal blood through breakdown products, activation of coagulation cascade, and oxidative burst contributes to a highly pro-oxidant and proinflammatory milieu found within the pericardial space that can trigger postoperative atrial fibrillation in susceptible persons. The extent of this reaction could be blunted by reducing the exposition of pericardium to blood either through posterior pericardiotomy or improved chest drainage. CONCLUSIONS: Shed mediastinal blood undergoing transformation within the pericardium appears to be an important contributing factor to POAF. Strategies to prevent shed mediastinal blood from pooling around the heart might be considered in developing future paradigms for prevention of POAF.

Examining the impact of active clearance of chest drainage catheters on postoperative atrial fibrillation.

OBJECTIVE: Postoperative atrial fibrillation (POAF) is one of the most frequent complications encountered after heart surgery, and significantly increases complications and mortality. An obstructed chest tube, leaving unevacuated blood around the heart and lungs, can lead to atrial inflammation, which can trigger POAF. The aim of this study was to assess the effectiveness of chest drainage incorporating an active tube clearance (ATC) system in reducing the rate of POAF. METHODS: This retrospective analysis based on 300 consecutive patients undergoing heart surgery compared 142 patients allocated to an ATC drainage protocol with 158 controls managed with standard chest drainage. Using a 1:1 propensity score match, 214 patients were included in paired analysis (107 in each group). The primary endpoint was POAF. RESULTS: Unmatched patients managed with ATC chest drainage protocol had a reduction of 34% in their POAF rate compared with those managed with standard drains (23% vs 35%, P = .01). In the matched cohort, ATC was associated with a reduction of 31% in the rate of POAF (24% vs 35%, P = .09) and a trend toward shorter postoperative length of stay (5.0 [4.0; 7.0] vs 6.0 [5.0; 8.0], P = .08). In multivariable analysis, chest drainage with ATC showed a protective effect on POAF with odds ratio of 0.5 (95% confidence interval, 0.1-0.9; P = .02). CONCLUSIONS: The use of an ATC chest drainage protocol may be associated with reduced POAF. Our results suggest that efforts to maintain chest tube patency could be useful to reduce the incidence of POAF.

Surgical Treatment of an Anomalous Left Coronary Artery From the Pulmonary Artery in a Sexagenarian Woman.

Late presentation of an anomalous left coronary artery from the pulmonary artery (ALCAPA) is uncommon because patients rarely survive past infancy. We present a case of symptomatic ALCAPA associated with decreased myocardial contractility in a 68-year-old woman. The patient underwent reimplantation of the left coronary artery in the aortic root.