Evaluation of the impact of a quality improvement program and intensivist-directed ICU team on mortality after cardiac surgery.

OBJECTIVE: Quality improvement is an important pursuit for critical care teams. DESIGN: The authors performed an observational cohort study with historic control. SETTING: Eight-bed cardiac surgery ICU in a tertiary university hospital. PARTICIPANTS: A total of 4,866 patients undergoing cardiac surgery over a 6-year period between January 2005 and December 2010. INTERVENTIONS: In this study, the influence of the introduction of a quality improvement program under the supervision of a newly appointed intensivist on patient outcomes after cardiac surgery was evaluated. Patients were further divided into three 2-year periods: Period I, 2005-2006, before appointment of an intensivist; Period II, 2007-2008, after appointment of an intensivist and initial introduction of a quality improvement program; and Period III, 2009-2010, after implementation of the program and introduction of Critical Care Information Systems. MEASUREMENTS AND MAIN RESULTS: There were 1,633, 1,690, and 1,543 patients in each period, respectively. There was no significant difference in the severity of patient illness between the groups. Unadjusted in-hospital mortality decreased from 6.37% (104 patients) in Period I to 4.32% (73 patients) and 3.3% (51 patients) in Periods II and III, respectively (p< 0.01). CONCLUSIONS: Appointment of an intensivist-directed team model and introduction of quality improvement interventions were associated with decreased mortality after cardiac surgery.

Mitral valve repair: isolated posterior compared to anterior or bileaflet pathology.

OBJECTIVES: The results of mitral valve (MV) repair for anterior leaflet pathology (ALP) are considered less favorable than those for posterior leaflet pathology (PLP). We compared clinical and echocardiography outcomes of PLP repair with ALP and/or bileaflet pathology (BLP) repair. METHODS: Between 2004 and 2011, 407 patients underwent MV repair due to degenerative MV: 276 patients (68%) had PLP and 131 (32%) had ALP/BLP. Mean age was 59 ± 12 and 56 ± 15 years in PLP and ALP/BLP groups, respectively (p = 0.03). Patient characteristics and co-morbidities were similar between groups. Valve repair techniques included leaflet resection (61% and 24%), annuloplasty (99% and 97%), and artificial chordea (46% and 67%), in the PLP and ALP/BLP groups, respectively. RESULTS: There was one (0.4%) in-hospital death in the PLP group, and none in the ALP/BLP group. Early complication rate was similar between groups. Completed clinical and late echocardiography follow-up was 95% (29 ± 22 months, 1 to 87). Freedom from reoperation was 98% (270/276) and 98% (129/131), and there were three (1%) and three (2%) late deaths, in the PLP and ALP/BLP groups, respectively (NS). Late echocardiography revealed that 89% and 94% of patients (PLP and ALP/BLP groups, respectively) were free from moderate or severe mitral regurgitation (MR) (p = 0.13). All other late valve-related complications were similar between groups. CONCLUSIONS: Anterior and bileaflet MV disease can be repaired with early and mid-term results similar to those of posterior MV disease. All patients with severe MR due to anterior or posterior pathology should be considered equally for early valve repair.

Heparin-free management of intra-aortic balloon pump after cardiac surgery.

BACKGROUND: Anticoagulation with heparin is recommended in patients with an intra-aortic balloon pump (IABP) to prevent thrombosis and embolization. However, anticoagulation increases the risk of bleeding, particularly in the early postoperative period after cardiac surgery. We investigated the safety of heparin-free management after IABP insertion in patients who underwent cardiac surgery. METHODS: We studied 203 consecutive patients who received perioperative IABP support between August 2004 and December 2011. All patients were managed without heparin and were followed for thrombotic and/or hemorrhagic complications. RESULTS: Patients were divided into two groups, according to time of IABP treatment following surgery. Group I, 81 patients (39.9%) were treated less than 24 hours following surgery and Group II, 122 patients (60.1%) were treated more than 24 hours following surgery. Vascular complications developed in seven patients (3.4%), two in Group I and five in Group II. Three patients had major and four had minor limb ischemia. There were no major bleeding complications, but minor bleeding complications were observed in eight patients (4.2%). CONCLUSION: In patients undergoing cardiac surgery with IABP support, the rate of thromboembolic complications was relatively low compared to historical controls. Heparin-free management may reduce the risk of hemorrhagic complications, with a low risk of thrombotic complications. Heparin should not be routinely used in patients requiring IABP after cardiac surgery.

The impact of hyperlactatemia on postoperative outcome after adult cardiac surgery.

PURPOSE: To evaluate the value of blood lactate value in predicting postoperative mortality (primary outcome), duration of ventilation, and length of stay in an intensive care unit (ICU) and hospital (secondary outcomes). METHODS: We performed a prospective observation study on 1,820 consecutive patients undergoing open heart surgery in a tertiary university medical center. Blood lactate levels were obtained from patients on admission to the cardiac surgical ICU and measured serially. RESULTS: All patients were divided into three groups according to their maximum blood lactate levels: group I (normolactatemia, lactate ≤2.2 mmol/l), 332 patients; group II (mild hyperlactatemia, lactate 2.2-4.1 mmol/l), 1,054 patients; and group III (severe hyperlactatemia, lactate ≥4.4 mmol/l), 434 patients. Maximum blood lactate levels ≥4.4 mmol/l during the first 10 h post admission were associated with prolonged ventilation time, longer ICU stay, and increased mortality (P < 0.001). CONCLUSIONS: Hyperlactatemia is common after cardiac surgery. Maximal lactate threshold ≥4.4 mmol/l in the first 10 h after operation accurately predicts postoperative mortality.

[Bipolar radiofrequency and cryoablation for surgical treatment of atrial fibrillation].

BACKGROUND: The widespread use of new sources of energy for ablation of atrial fibrillation (AF) raised concerns regarding the safety and efficacy of the various devices. This article describes the results of our technique using a combination of bipolar radiofrequency (RF) and cryoablation. METHODS: From February 2004 till July 2006 this method was used on 94 patients. Fifty patients had persistent atrial fibrillation (53%), thirty-one suffered from permanent AF (33%) and thirteen patients had paroxysmal AF (14%). Lesions set similar to Maze III procedure were used with the addition of right atrial isthmus lesion in the area of coronary sinus and without right atrial appendage amputation and septal lesion. RESULTS: There were no procedure-related complications and no death or major morbidity in general. Average time for ablation procedure was 30 minutes (range 27-36 minutes) for biatrial and 16 minutes (range 15-19) for left atrial procedures. Seventy-one patients (75%) were discharged in sinus rhythm. At the end of the follow-up, seventy-five patients (80%) were in sinus rhythm. Mean follow-up was 21 months (1-32 months). Predictor for recurrent AF or atrial flutter after procedure was preoperative permanent AF for more than 10 years (p = 0.037) and cardiac surgery in the past (p = 0.012). CONCLUSION: The use of bipolar RF device with cryoprobe is an appealing combination. It enables the completion of a Maze III lesion set in an easy, safe and efficient way.

Mid-term results of the 'hybrid maze': a combination of bipolar radiofrequency and cryoablation for surgical treatment of atrial fibrillation.

BACKGROUND AND AIM OF THE STUDY: Although the use of new sources of energy for the ablation of atrial fibrillation (AF) has simplified the procedure, concerns have been expressed with regard to the safety and efficacy of the various devices. Herein are described the results of a technique using a combination of bipolar radiofrequency (RF) and cryoablation. METHODS: Between February 2004 and August 2005, the combined procedure was used on 60 patients, 32 of whom (54%) had persistent AF, and 28 (46%) permanent AF. Lesions set similar to the Maze III procedure were used, with the addition of a right atrial isthmus lesion in the area of the coronary sinus and without right atrial appendage amputation and septal lesion. RESULTS: There were no operative complications and no death or major morbidity. The mean duration of the ablation procedure was 30 min (range: 27-36 min) for biatrial procedures, and 16 min (range: 15-19 min) for left atrial procedures. Forty-two patients (70%) were discharged in sinus rhythm. On completion of follow up, 48 patients (80%) were in sinus rhythm. Among 45 patients treated with cryoablation rather than monopolar RF, 89% were in sinus rhythm at the mean follow up of nine months. The predictor for recurrent post-procedural AF was preoperative permanent AF for more than 10 years' duration (p = 0.039), while that for postoperative atypical flutter was use of the monopolar RF ablator rather than the cryoablator (p = 0.001). CONCLUSION: The use of a bipolar RF device with the cryoprobe is an appealing combination which enables the Maze III lesion set to be completed in a straightforward, safe, and efficient manner.

The changing characteristics and outcomes of patients undergoing surgical aortic valve replacement in the transcatheter aortic valve implantation era.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is thought to change the characteristics and outcome of patients with aortic stenosis undergoing surgical aortic valve replacement (SAVR). We investigated the difference in clinical characteristics and outcomes of SAVR patients in the TAVI era. METHODS: Two cohorts of consecutive patients undergoing isolated SAVR for severe tricuspid aortic stenosis, in 4 years before (period-1) and 4 years after (period-2) the introduction of TAVI were analysed. Primary endpoint of 1-year mortality by Cox proportional hazard models was analysed. Secondary endpoints included 1-year, 30-day mortality and adverse perioperative events. RESULTS: The study consisted of 207 patients in period-1 and 200 in period-2. Mean age was 74.9 ±â€Š9.6 and 73.5 ±â€Š9.4 years in periods 1 and 2, respectively. Mean EuroSCORE was 11.5 ±â€Š10.3 during period-1 vs. 8.4 ±â€Š7.2 during period-2 (P = 0.001). One-year mortality decreased from 15.5 to 7.5% (P = 0.013). Composite of major adverse perioperative complications dropped from 12.6 to 6% (P = 0.027). EuroSCORE was an independent predictor of 30-day and 1-year mortality in period-1 (P < 0.005 for both) and not in period-2. Chronic pulmonary disease and preoperative atrial fibrillation were also independent predictors of 1-year mortality in period-1 only, although lower haemoglobin predicted mortality in both periods. CONCLUSION: We show a dramatic decrease in 1-year mortality and adverse perioperative events in patients undergoing SAVR for severe aortic stenosis during recent years. This change is likely related to selection of lower-risk patients for AVR in the TAVI era.

Box lesion in the open left atrium for surgical ablation of atrial fibrillation.

OBJECTIVE: Cut-and-sew maze with a box lesion around the pulmonary veins is currently the criterion standard procedure for surgical ablation of atrial fibrillation. Recently, we changed our technique from standard bilateral epicardial pulmonary vein isolation with interconnecting lesions to a box lesion procedure with a bipolar radiofrequency ablation device. Our study describes this technique. METHODS: Between March 2009 and June 2012, we performed 90 ablations by the box technique with a bipolar radiofrequency device. Fifty-five patients (61%) had persistent atrial fibrillation, and 21 (23%) had long-standing persistent atrial fibrillation. The left atriotomy was performed along the interatrial septum and the left atrial appendage amputated. The box was made by connecting the left atriotomy to the base of the amputated appendage with lines along the transverse and oblique sinuses by epicardial and endocardial application of a bipolar radiofrequency ablation device. The left atrial isthmus was ablated by cryoprobe. RESULTS: There were no ablation-related complications. The box was easy to perform, with no dissection around the pulmonary veins. At 6-month, 1-year, and 2-year follow-ups, 80 (94%), 69 (93%), and 47 (91%) patients, respectively, were in sinus rhythm. Freedoms from antiarrhythmic medications in patients in sinus rhythm at 6 months, 1 year, and 2 years were 78%, 88%, and 85%, respectively. CONCLUSIONS: The box lesion provided excellent freedom from atrial fibrillation and may improve transmurality through ablation of 1 rather than 2 layers of atrial wall, as in epicardial pulmonary vein isolation. With the box lesion, dissection around the pulmonary veins is unnecessary.

Left atrial ablation for atrial fibrillation: creating the "box lesion" with a bipolar radiofrequency device.

The maze procedure is the gold standard for the ablation of atrial fibrillation, and the "box lesion" around the pulmonary veins is the most important part of this procedure. We have created this lesion with a bipolar radiofrequency ablator, abandoning the usual use of this device (to achieve bilateral epicardial isolation of the pulmonary veins).From March 2004 through the end of May 2010, we performed surgical ablation of atrial fibrillation in 240 patients. Of this number, 205 underwent operation by a hybrid maze technique and the remaining 35 (our study cohort) underwent the creation of a box lesion around the pulmonary veins by means of a bipolar radiofrequency device. Ablation lines were created by connecting the left atriotomy to the amputated left atrial appendage, with 2 ablation lines made with a bipolar radiofrequency device above and below the pulmonary veins. Lesions were made along the transverse and oblique sinuses by epicardial and endocardial application of a bipolar device. The left atrial isthmus was ablated by bipolar radiofrequency and cryoprobe. No complications were associated with the box lesion: 90% and 89% of patients were in sinus rhythm at 3 and 6 months of follow-up, respectively.By creating a box lesion around the pulmonary veins, we expect to improve transmurality by means of epicardial and endocardial ablation of 1 rather than 2 layers of atrial wall, as in epicardial pulmonary vein isolation. Isolation of the entire posterior wall of the left atrium is better electrophysiologically and renders dissection around the pulmonary veins unnecessary.

Efficacy of surgical ablation of atrial fibrillation in patients with rheumatic heart disease.

BACKGROUND: Although atrial fibrillation (AF) ablation is efficient in many patient cohorts, its effect on rheumatic heart disease remains controversial. We describe a retrospective comparison of surgical ablation using the same technique in rheumatic versus nonrheumatic patients. METHODS: Between 2004 and 2009, we performed AF ablation as a part of another cardiac surgery in 192 patients with bipolar radiofrequency ablator and a cryoprobe. Patients were retrospectively allocated to a rheumatic heart disease group (76 patients, 40%) and a nonrheumatic heart disease group (116 patients, 60%). All demographic characteristics were similar in both groups, as well as in a number of patients with permanent and persistent AF and long-standing AF. Permanent AF was present in 37 patients (49%) and 51 patients (44%) in the rheumatic and nonrheumatic groups, respectively. Heart function and functional class were also similar, whereas more rheumatic patients had a severely enlarged left atrium (200 to 300 cc [p = 0.02]). RESULTS: There were 2 perioperative deaths. Postoperative complications were similar in both groups, with 51 rheumatic patients (67%) and 81 nonrheumatic patients (70%) in sinus rhythm at discharge. Total, mean follow-up was 16 months, after which 63 patients (83%) and 96 patients (84%) were in sinus in the rheumatic group and nonrheumatic group, respectively, of whom 72% were without antiarrhythmic medications. Ablation failure risk factors included AF duration of 10 years or longer before ablation (p < 0.05), and preoperative permanent AF (p = 0.03). CONCLUSIONS: The efficacy of AF ablation proved similar in rheumatic and nonrheumatic patients, providing preoperative AF type and duration were similar. Larger left atria in rheumatic patients did not influence ablation results.

Midterm results of mitral valve repair: closed versus open annuloplasty ring.

BACKGROUND: Closed and open annuloplasty rings are both used for mitral valve repair. This study compared the clinical and echocardiographic results in patients with degenerative mitral disease undergoing MV repair with closed semirigid rings vs open bands. METHODS: Between 2004 and 2008, 377 patients (mean age, 59 + or - 12 years) underwent mitral valve repair. Valve pathology was degenerative in 273 (72%). Closed rings were used in 163 (60%) and open rings in 110 (40%). Patients had similar characteristics and comorbidities. In addition to annuloplasty, repair techniques included leaflet resection (48% and 77%, p < 0.01), artificial chordal (55% and 36%, p < 0.01), and edge-to-edge repair (4% and 4%, p = 0.79), in closed and open groups, respectively. RESULTS: One patient in each group died (0.7%). Mean follow-up was 19 + or - 14 (closed group) and 34 + or - 15 months (open group; p < 0.01). Freedom from reoperation was 97.5% (closed group) vs 96.5% (open group). At follow-up, New York Heart Association functional class was similar between groups, and 91% in the closed group and 84% in the open group were free from moderate or severe mitral regurgitation (p = 0.05). Closed group patients had a longer line of leaflet coaptation (9.1 + or - 2.7 mm) vs the open group (7.1 + or - 1.9 mm; p < 0.01). CONCLUSIONS: Patients with closed semirigid annuloplasty rings demonstrated significantly longer lines of leaflet coaptation and tendency toward better echocardiographic midterm results than patients with open bands and may, therefore, benefit from improved repair durability.