Zolpidem improves patients' sleep quality after surgical treatment for infective endocarditis: a prospective observational study.

PURPOSE: The objective of this study was to investigate the efficacy of zolpidem for improving post-operative sleep quality among patients with infective endocarditis (IE) and to identify the potential risk factors for impaired sleep quality at 6 months after surgery. METHODS: Patients with IE who underwent surgical treatment were divided into two groups according to zolpidem usage. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were used to evaluate patients' sleep quality and daytime sleepiness at baseline, which was the second day after transferal, and at 6 months after surgery. Logistic regression was used to identify potential risk factors. RESULTS: There were 32 patients in the zolpidem group and 42 in the control group. The PSQI and ESS scores at 6 months after surgery were significantly lower than those at baseline in both groups (P = 0.04). Additionally, 9 patients (28%) in the zolpidem group and 22 patients (52%) in the control group suffered poor sleep quality. Multivariate analysis identified age (odds ratio [OR] = 1.26, 95% confidence interval [CI]: 1.12-1.42), baseline PSQI score (OR = 2.66, 95%CI: 1.55-4.65), and no zolpidem usage (OR = 45.48, 95%CI: 3.01-691.23) as independent factors for poor sleep quality. CONCLUSIONS: Poor sleep quality after IE surgery was prevalent among patients even 6 months after IE surgery. Age, baseline PSQI score and no zolpidem usage were independently associated with poor sleep quality. Therefore, zolpidem has the potential to be an effective part of a treatment arsenal for poor sleep quality after surgical treatment for IE.

Timing, Threshold, and Duration of Intraoperative Hypotension in Cardiac Surgery: Their Associations With Postoperative Delirium.

OBJECTIVES: To study the timing, threshold, and duration of intraoperative hypotension (IOH) associated with the risk of postoperative delirium (POD). DESIGN: A single-center retrospective observational study. SETTING: University teaching hospital. PARTICIPANTS: A total of 503 adult patients who underwent cardiac valvular surgery that required cardiopulmonary bypass (CPB). MEASUREMENTS AND MAIN RESULTS: The authors predefined the following 4 periods: (1) during surgery, (2) pre-CPB, (3) during CPB, and (4) post-CPB, and 8 thresholds of mean arterial pressure for IOH according to every 5 mmHg between 50 mmHg and 85 mmHg. The authors calculated the cumulative duration below the 8 thresholds in each period. The primary outcome was delirium defined as a score of ≥4 for at least one Intensive Care Delirium Screening Checklist assessment during 48 h after the surgery. Among 503 patients, POD occurred in 95 patients (18.9%). There was no significant association of POD with all of the thresholds of IOH in the periods of pre-CPB, during CPB, and during surgery. However, in the post-CPB period, the patients with POD had a significantly longer cumulative duration of IOH according to all of the thresholds of mean arterial pressure. In multivariate analyses, 4 IOH thresholds in the post-CPB period were associated independently with POD: <60 mmHg (odds ratio [OR] =1.84 [95% CI 1.10-3.10]), <65 mmHg (OR = 1.72 [1.01-2.92]), <70 mmHg (OR = 1.83 [1.03-3.26]), and <75 mmHg (OR = 1.94 [1.02-3.69]). CONCLUSIONS: A longer cumulative duration of IOH with the threshold between <60 and <75 mmHg that occurred after CPB was independently associated with the risk of POD.

Intravenous Iron Versus Placebo in the Management of Postoperative Functional Iron Deficiency Anemia in Patients Undergoing Cardiac Valvular Surgery: A Prospective, Single-Blinded, Randomized Controlled Trial.

OBJECTIVE: To compare the efficacy of intravenous iron versus placebo to correct postoperative functional iron deficiency anemia in patients undergoing cardiac valvular surgery. DESIGN: A prospective, single-blinded, randomized controlled study. SETTING: National Center for Cardiovascular Diseases and a university hospital. PARTICIPANTS: The study comprised 150 patients with postoperative functional iron deficiency anemia after cardiac valvular surgery. INTERVENTIONS: The patients were randomly assigned (1:1) to either the treatment (intravenous iron) group or the control (placebo) group. MEASUREMENTS AND MAIN RESULTS: The hemoglobin and ferritin concentrations and postoperative adverse events were collected and compared between the 2 groups. The hemoglobin concentration and the proportion of patients who had their anemia corrected or achieved hemoglobin increments of >20 g/L in the intravenous iron group were significantly higher than that in the placebo group at postoperative day 14 (p = 0.023, p = 0.037, and p = 0.001), whereas there was no statistical difference at postoperative day 7. The ferritin concentration was substantially higher at postoperative day 7 and postoperative day 14 in the intravenous iron group compared with the placebo group (both p < 0.001). There were no significant differences in rates of death, blood tranfusion, antibiotic upgrade, ventilator time >24 hours, postoperative hospital stay >10 days, poor wound healing, and perivalvular leakage between the 2 groups. CONCLUSIONS: Intravenous iron could significantly increase the hemoglobin level in patients with postoperative functional iron deficiency anemia at postoperative day 14. However, there is no difference in blood transfusion requirements or postoperative adverse outcomes between the 2 groups.

Predictive performance of surgical mortality risk scores in infective endocarditis.

OBJECTIVES: This observational study aimed to evaluate Association pour l'Etude et la Prévention de l'Endocardite Infectieuse (AEPEI) surgery score predictive performance in comparison to general (EuroSCORE I, II) and specific (De Feo, PALSUSE) surgical risk scores for infective endocarditis (IE). METHODS: The study included patients who underwent surgery for IE during the acute phase at Bichat University Hospital (Paris, France) between 1 January 2006 and 31 December 2016 and at Nancy University Hospital (Nancy, France) between 1 January 2009 and 31 December 2019. Patients with IE complicating percutaneous aortic valve implantations or implantable intra-cardiac devices were excluded. Discrimination and calibration were assessed using receiver operating characteristic curve analysis, calibration curves and the Hosmer-Lemeshow test. RESULTS: In-hospital mortality rates were 18% at Bichat and 16% at Nancy. Discrimination was high for all risk scores at Bichat (area under the receiver operating characteristic curve = 0.77 for EuroSCORE I, 0.78 for EuroSCORE II, 0.76 for De Feo score, 0.72 for PALSUSE and 0.73 for AEPEI with 95% confidence interval ranging from 0.67 to 0.83), but lower at Nancy (0.56 for EuroSCORE I, 0.65 for EuroSCORE II, 0.63 for De Feo score, 0.67 for PALSUSE and 0.66 for AEPEI score with 95% confidence interval ranging from 0.47 to 0.75). With Brier score, all scores were adequately calibrated in both populations between 0.129 (De Feo) and 0.135 (PALSUSE) for Bichat and between 0.128 (De Feo) and 0.135 (EuroSCORE I) for Nancy. With the Hosmer-Lemeshow test, the AEPEI score exhibited the best calibration (observed/predicted ratio 1.058 in Bichat, 1.087 in Nancy). CONCLUSIONS: This surgical score external validation in 2 large independent populations demonstrated that the AEPEI surgical score had the best predictive performance compared to other prognosis scores. It could be helpful in clinical practice to assist the endocarditis team in decision-making.

Efficacy of automated fasteners versus hand-tied knots in cardiac surgery: a systematic review and meta-analysis.

Valve surgery is common in cardiac procedures, with fasteners like COR-KNOT® and hand-tied knots used for knot securing. This study compares their efficacy in valve surgery patients. We searched PubMed, SCOPUS, and Cochrane Central until August 2023. Outcomes assessed included aortic cross-clamp time (AXT), cardiopulmonary bypass (CPB) time, valvular regurgitation, mortality, prolonged ventilatory support, atrial fibrillation, postoperative left ventricular ejection fraction (LVEF), and renal failure. Subgroup analysis was performed for minimally invasive and open cardiac surgery. We used a random effects model for analysis. We included eight observational studies and two randomized controlled trials (RCTs) with a total of 1.411 participants. COR-KNOT significantly reduced AXT [MD -15.14, 95 % CI (-18.57, -11.70), P<0.00001] and CPB time [MD -12.38, 95 % CI (-14.99, -9.77), P<0.00001]. Valvular regurgitation [RR 0.40, 95 % CI (0.26, 0.61), P<0.0001] and need for prolonged ventilatory support [RR 0.29, 95 % CI (0.13, 0.65), P=0.003] were significantly lower with COR-KNOT. There were no significant differences in mortality [RR 0.39, 95 % CI (0.09, 1.69), P=0.44], atrial fibrillation [RR 1.03, 95 % CI (0.83, 1.27), P=0.81], LVEF changes [MD 0.05, 95 % CI (-1.37, 1.47), P = 0.95], or renal failure [RR 0.87, 95 % CI (0.16, 4.80), P = 0.87]. COR-KNOT devices reduce operative time and valvular regurgitation without increasing mortality or adverse outcomes. This supports their use in enhancing surgical efficiency and patient outcomes. However, ongoing discussions about suturing techniques, especially in minimally invasive procedures, highlight the need for further research and consensus among practitioners. See also the graphical abstract(Fig. 1).

Identification of risk factors for infection after mitral valve surgery through machine learning approaches.

Background: Selecting features related to postoperative infection following cardiac surgery was highly valuable for effective intervention. We used machine learning methods to identify critical perioperative infection-related variables after mitral valve surgery and construct a prediction model. Methods: Participants comprised 1223 patients who underwent cardiac valvular surgery at eight large centers in China. The ninety-one demographic and perioperative parameters were collected. Random forest (RF) and least absolute shrinkage and selection operator (LASSO) techniques were used to identify postoperative infection-related variables; the Venn diagram determined overlapping variables. The following ML methods: random forest (RF), extreme gradient boosting (XGBoost), Support Vector Machine (SVM), Gradient Boosting Decision Tree (GBDT), AdaBoost, Naive Bayesian (NB), Logistic Regression (LogicR), Neural Networks (nnet) and artificial neural network (ANN) were developed to construct the models. We constructed receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) was calculated to evaluate model performance. Results: We identified 47 and 35 variables with RF and LASSO, respectively. Twenty-one overlapping variables were finally selected for model construction: age, weight, hospital stay, total red blood cell (RBC) and total fresh frozen plasma (FFP) transfusions, New York Heart Association (NYHA) class, preoperative creatinine, left ventricular ejection fraction (LVEF), RBC count, platelet (PLT) count, prothrombin time, intraoperative autologous blood, total output, total input, aortic cross-clamp (ACC) time, postoperative white blood cell (WBC) count, aspartate aminotransferase (AST), alanine aminotransferase (ALT), PLT count, hemoglobin (Hb), and LVEF. The prediction models for infection after mitral valve surgery were established based on these variables, and they all showed excellent discrimination performance in the test set (AUC > 0.79). Conclusions: Key features selected by machine learning methods can accurately predict infection after mitral valve surgery, guiding physicians in taking appropriate preventive measures and diminishing the infection risk.

Assessing the Patient Outcomes and Performance of a Cardiothoracic and Vascular Surgery (CTVS) Unit During Its First Two Years in a Tier-2 City in India: A Comprehensive Audit and Analysis.

This detailed article presents a comprehensive overview of the initial two-year experience in establishing a new cardiothoracic vascular surgery (CTVS) facility in a tier-2 city in India. The article discusses various aspects of setting up and operating a specialized healthcare facility. The first two years of developing the CTVS facility were included in the study period. The manpower included one cardiothoracic vascular surgeon, one cardiac anesthesiologist, two perfusionists, and two physician assistants, along with four other ancillary staff to assist in the smooth functioning of the operation theater. The CTVS recovery staff included 15 nursing officers. There was only one modular operation theater reserved for cardiothoracic vascular surgeries, along with a five-bed recovery room (CTVS intensive care unit). One-hundred-seventy-two procedures were done, including 122 open heart surgeries, 36 vascular procedures, and 14 thoracic procedures. The majority of patients were discharged by the seventh day postoperatively. Overall complication and mortality rates were 8% and 4.6%, respectively. This article also discusses relevant hospital policy, challenges faced, and future recommendations for similar endeavors. The findings highlight the successful implementation of the facility and its impact on providing specialized cardiac care to the local population.

Staged Versus Concomitant Carotid Endarterectomy and Aortic Valve Replacement: A Case Report and Literature Review.

Stroke is a common complication of cardiac surgery, and carotid artery stenosis is an established risk factor for stroke. Therefore, patients with carotid artery stenosis who are undergoing cardiac surgery require proper management of the former either simultaneously or before cardiac surgery. We present a challenging case of a 67-year-old male patient who presented with generalized weakness, severe aortic stenosis, and significant bilateral carotid artery stenosis. The coexistence of these findings sparked a debate about whether to perform a carotid endarterectomy first or an aortic valve replacement. Moreover, a past history of percutaneous coronary intervention and coronary artery bypass grafts made the decision more challenging. Multiple approaches have been employed for the management of coexisting carotid artery stenosis with cardiac surgery; however, no definitive guidelines exist, especially for surgeries other than coronary artery bypass grafts or where the carotid stenosis is bilateral and severe.

Corrigendum: Machine Learning for the Prediction of Complications in Patients After Mitral Valve Surgery.

[This corrects the article DOI: 10.3389/fcvm.2021.771246.].

Corrigendum: Machine Learning for the Prediction of Complications in Patients After Mitral Valve Surgery.

[This corrects the article DOI: 10.3389/fcvm.2021.771246.].

Machine Learning for the Prediction of Complications in Patients After Mitral Valve Surgery.

Background: This study intended to use a machine learning model to identify critical preoperative and intraoperative variables and predict the risk of several severe complications (myocardial infarction, stroke, renal failure, and hospital mortality) after cardiac valvular surgery. Study Design and Methods: A total of 1,488 patients undergoing cardiac valvular surgery in eight large tertiary hospitals in China were examined. Fifty-four perioperative variables, such as essential demographic characteristics, concomitant disease, preoperative laboratory indicators, operation type, and intraoperative information, were collected. Machine learning models were developed and validated by 10-fold cross-validation. In each fold, Recursive Feature Elimination was used to select key variables. Ten machine learning models and logistic regression were developed. The area under the receiver operating characteristic (AUROC), accuracy (ACC), Youden index, sensitivity, specificity, F1-score, positive predictive value (PPV), and negative predictive value (NPV) were used to compare the prediction performance of different models. The SHapley Additive ex Planations package was applied to interpret the best machine learning model. Finally, a model was trained on the whole dataset with the merged key variables, and a web tool was created for clinicians to use. Results: In this study, 14 vital variables, namely, intraoperative total input, intraoperative blood loss, intraoperative colloid bolus, Classification of New York Heart Association (NYHA) heart function, preoperative hemoglobin (Hb), preoperative platelet (PLT), age, preoperative fibrinogen (FIB), intraoperative minimum red blood cell volume (Hct), body mass index (BMI), creatinine, preoperative Hct, intraoperative minimum Hb, and intraoperative autologous blood, were finally selected. The eXtreme Gradient Boosting algorithms (XGBOOST) algorithm model presented a significantly better predictive performance (AUROC: 0.90) than the other models (ACC: 81%, Youden index: 70%, sensitivity: 89%, specificity: 81%, F1-score:0.26, PPV: 15%, and NPV: 99%). Conclusion: A model for predicting several severe complications after cardiac valvular surgery was successfully developed using a machine learning algorithm based on 14 perioperative variables, which could guide clinical physicians to take appropriate preventive measures and diminish the complications for patients at high risk.

Falla del ventrículo derecho en el posoperatorio de cirugía cardíaca valvular: prevalencia, características clínicas y ecocardiográficas y pronóstico / Right ventricular failure in the postoperative period of heart valve surgery: prevalence, clinical and echocardiographic characteristics, and prognosis / Insuficiência ventricular direita no pós-operatório de cirurgia cardíaca valvar: prevalência, características clínicas e ecocardiográficas e prognóstico

Introducción: la falla aguda del ventrículo derecho (VD) en el posoperatorio de cirugía cardíaca (POCC) constituye un desafío clínico por su importante morbimortalidad. El reconocimiento de la importancia de la función del VD en el POCC es un hecho reciente, lo que puede evidenciarse por la ausencia de parámetros de función ventricular derecha en los scores de estratificación del riesgo quirúrgico. Su definición varía según diferentes autores; es difícil conocer su prevalencia y los factores asociados a su desarrollo. Objetivo: analizar la prevalencia, las características clínicas, ecocardiográficas y el pronóstico de los pacientes con falla del VD en el POCC valvular intervenidos en el Instituto Nacional de Cirugía Cardíaca (INCC) en el año 2021 y establecer una comparación con los pacientes intervenidos en el mismo período que no desarrollaron dicha complicación. Método: estudio observacional retrospectivo, analítico. Se incluyeron los pacientes sometidos a cirugía cardíaca valvular en el INCC durante el 2021 que no presentaban ciertos criterios de exclusión preestablecidos. Se consideró la falla aguda del VD en el POCC como la evidencia ecocardiográfica de disfunción ventricular derecha definida cualitativamente en el ecocardiograma posoperatorio. El análisis estadístico se realizó con el software SPSS versión 26.0. Resultados: se incluyeron en el estudio 45 pacientes, de los cuales 7 (15,6%) desarrollaron falla del VD en el POCC. No hubo diferencias entre las características basales. El grupo que desarrolló falla del VD en el POCC presentó una fracción de eyección del ventrículo izquierdo (FEVI) significativamente menor en el ecocardiograma preoperatorio (p = 0,010). No se objetivaron diferencias en las variables intraoperatorias. Respecto al pronóstico, falleció un paciente de cada grupo en el POCC inmediato. Conclusiones: la FEVI preoperatoria podría cumplir un rol predictor de falla aguda del VD en el POCC valvular, hallazgo para comprobar en estudios prospectivos. El impacto de la falla del VD en la mortalidad no pudo definirse, dado el limitado número de pacientes.

Introduction. acute right ventricle (RV) failure in the postoperative period of cardiac surgery (POCC) constitutes a clinical challenge due to its significant morbidity and mortality. Recognition of the RV function importance in POCC is a recent fact, which can be evidenced by the absence of right ventricular function parameters in surgical risk stratification scores. Its definition varies according to different authors, it is difficult to know its prevalence and the factors associated with its development. Objective: to analyze the prevalence, clinical and echocardiographic characteristics, and prognosis of patients with RV failure in valvular POCC operated at the National Institute of Cardiac Surgery (INCC) in 2021 and to establish a comparison with patients operated on in the same period who did not develop this complication. Method: retrospective analytical observational study. Patients undergoing heart valve surgery in the INCC during 2021 were included. Acute RV failure in the POCC was considered as echocardiographic evidence of qualitatively defined right ventricular dysfunction in the postoperative echocardiogram. Statistical analysis was performed using SPSS version 26.0 software. Results: forty-five patients were included in the study, of which 7 (15.6%) developed RV failure in the POCC. There were no differences between baseline characteristics. The group that developed RV failure in POCC had a significantly lower left ventricular ejection fraction (LVEF) on preoperative echocardiography (p = 0.010). No differences were observed in the intraoperative variables. Regarding the prognosis, one patient from each group died in the immediate POCC. Conclusions: preoperative LVEF could play a role in predicting acute RV failure in valvular POCC, a finding to be verified in prospective studies. The impact of RV failure on mortality could not be defined given the limited number of patients.

Introdução: a insuficiência aguda do ventrículo direito (VD) no pós-operatório de cirurgia cardíaca (CCPO) constitui um desafio clínico devido à sua significativa morbidade e mortalidade. O reconhecimento da importância da função do VD no CCPO é fato recente, o que pode ser evidenciado pela ausência de parâmetros de função ventricular direita nos escores de estratificação de risco cirúrgico. Sua definição varia de acordo com diferentes autores, é difícil conhecer sua prevalência e os fatores associados ao seu desenvolvimento. Meta: analisar a prevalência, as características clínicas e ecocardiográficas e o prognóstico dos pacientes com insuficiência de VD em POCC valvular operados no Instituto Nacional de Cirurgia Cardíaca (INCC) em 2021 e estabelecer uma comparação com pacientes operados no mesmo período que não desenvolveram essa complicação. Método: estudo observacional analítico retrospectivo. Foram incluídos pacientes submetidos à cirurgia valvar no INCC durante o ano de 2021. Insuficiência aguda do VD no POCC foi considerada como evidência ecocardiográfica de disfunção ventricular direita qualitativamente definida no ecocardiograma pós-operatório. A análise estatística foi realizada com o software SPSS versão 26.0. Resultados: quarenta e cinco pacientes foram incluídos no estudo, dos quais 7 (15,6%) desenvolveram falência do VD no POCC. Não houve diferenças entre as características basais. O grupo que evoluiu com falência do VD no POCC apresentou fração de ejeção do ventrículo esquerdo (FEVE) significativamente menor no ecocardiograma pré-operatório (p = 0,010). Não foram observadas diferenças nas variáveis intraoperatórias. Quanto ao prognóstico, um paciente de cada grupo faleceu no POCC imediato. Conclusões: a FEVE pré-operatória poderia desempenhar um papel na predição de insuficiência aguda do VD no CCPO valvular, achado para ser verificado em estudos prospectivos. O impacto da falência do VD na mortalidade não pôde ser definido devido ao número limitado de pacientes.

Results of late-onset type A aortic dissection after previous cardiac surgery: Does prior coronary artery bypass grafting affect survival?

BACKGROUND: This study aims to evaluate the results of late-onset type A aortic dissection following primary cardiac surgery and to compare the outcomes of patients with or without prior coronary artery bypass grafting. METHODS: Between January 2005 and December 2015, data of 32 patients (16 males, 16 females; mean age 58.1±10.9 years; range, 45 to 73 years) who were diagnosed with acute type A aortic dissection and underwent repair with a history of previous cardiac surgery at our institution were retrospectively analyzed. The patients were divided into two groups as those with a history of prior coronary artery bypass grafting (n=16) and the patients with a previous cardiac surgery without prior coronary artery bypass grafting (n=16). RESULTS: Dissection of the ascending aorta occurred in 32 patients (late acute in 22 and late chronic in 10) who underwent previous cardiac surgery (aortic valve replacement in 12, mitral valve replacement in two, aortic valve replacement + coronary artery bypass grafting in two, coronary artery bypass grafting in 10, mitral valve replacement + coronary artery bypass grafting in four, and dual valve replacement in two patients). The mean time between the first operation and dissection was 4.0±1.5 years. Dissections were treated with the Bentall procedures (n=8), ascending aorta replacement (n=14), ascending aorta replacement + hemiarch replacement (n=4), ascending aorta + aortic valve replacement (n=4) and Bentall + arch replacement (n=2). In-hospital mortality (30-day mortality) was seen in five patients, and oneyear mortality rate was 21.85% (n=7). The survival rates of the all patients for primary cardiac surgery vs primary cardiac surgery + coronary artery bypass grafting were 81.25% vs 75% at one year, 75% vs 68.75% at three years,75% vs 56.25% at five years, 68.75% vs 56.25% at seven years, and 68.75% vs 56.25% at 10 years, respectively (p=0.71, CI: 95%). CONCLUSION: Type-A aortic dissections may develop after cardiac operations with or without coronary artery bypass grafting at any time, and irrespective of associated histologies, they may result in high overall in-hospital mortality. With careful planning by prompt intervention, the outcomes in redo sternotomy operations with or without coronary artery bypass grafting for aortic dissections would be consistent the results of spontaneous aortic dissections.

Cardiac Surgery Compared With Antibiotics Only in Patients Developing Infective Endocarditis After Transcatheter Aortic Valve Replacement.

Background Infective endocarditis ( IE ) after transcatheter aortic valve replacement is a devastating complication associated with a high mortality. Our objective was to determine the impact of cardiac surgery (CS) and antibiotics ( IE - CS ) compared with medical treatment with antibiotics only ( IE - AB x) on 1-year mortality in patients developing IE after transcatheter aortic valve replacement. Methods and Results Patients developing IE after transcatheter aortic valve replacement were included in this retrospective analysis. All-cause 1-year mortality was the primary end point. A total of 20 patients underwent IE - CS compared with 44 patients treated by IE - AB x. In this unmatched cohort, patients treated by IE - AB x were older ( P=0.006), had a higher Society of Thoracic Surgeons score ( P=0.029), and more often had severe chronic kidney disease ( P=0.037). One-year mortality was not different between groups ( IE -CS versus IE-ABx, 65% versus 68.2%; P=0.802). The rate of any complication during treatment was higher in the IE - CS group ( P=0.024). In a matched cohort, baseline characteristics were not significantly different. All-cause 1-year mortality was not different between groups ( IE -CS versus IE-ABx, 65% versus 75%; P=0.490). A Cox regression analysis revealed any indication for surgery (hazard ratio, 6.20; 95% confidence interval, 1.80-21.41; P=0.004), sepsis on admission (hazard ratio, 4.03; 95% confidence interval, 1.97-8.24; P<0.001), and mitral regurgitation ≥2 (hazard ratio, 2.91; 95% confidence interval, 1.33-6.37) as factors associated with 1-year mortality. Conclusions In patients developing IE after transcatheter aortic valve replacement, mortality was predicted by the severity of IE and concomitant mitral regurgitation. In this small, and therefore statistically limited, but high-risk patient cohort, CS provided no significant mortality benefit compared with medical therapy. Individual decision making by a "heart and endocarditis team" is necessary to offer those patients the most reasonable treatment option.

Simple Scoring System to Predict In-Hospital Mortality After Surgery for Infective Endocarditis.

BACKGROUND: Aspecific scoring systems are used to predict the risk of death postsurgery in patients with infective endocarditis (IE). The purpose of the present study was both to analyze the risk factors for in-hospital death, which complicates surgery for IE, and to create a mortality risk score based on the results of this analysis. METHODS AND RESULTS: Outcomes of 361 consecutive patients (mean age, 59.1±15.4 years) who had undergone surgery for IE in 8 European centers of cardiac surgery were recorded prospectively, and a risk factor analysis (multivariable logistic regression) for in-hospital death was performed. The discriminatory power of a new predictive scoring system was assessed with the receiver operating characteristic curve analysis. Score validation procedures were carried out. Fifty-six (15.5%) patients died postsurgery. BMI >27 kg/m2 (odds ratio [OR], 1.79; P=0.049), estimated glomerular filtration rate <50 mL/min (OR, 3.52; P<0.0001), New York Heart Association class IV (OR, 2.11; P=0.024), systolic pulmonary artery pressure >55 mm Hg (OR, 1.78; P=0.032), and critical state (OR, 2.37; P=0.017) were independent predictors of in-hospital death. A scoring system was devised to predict in-hospital death postsurgery for IE (area under the receiver operating characteristic curve, 0.780; 95% CI, 0.734-0.822). The score performed better than 5 of 6 scoring systems for in-hospital death after cardiac surgery that were considered. CONCLUSIONS: A simple scoring system based on risk factors for in-hospital death was specifically created to predict mortality risk postsurgery in patients with IE.

Neurological damage after transcatheter aortic valve implantation compared with surgical aortic valve replacement in intermediate risk patients.

BACKGROUND AND PURPOSE: The risk of neurological damage following transcatheter aortic valve implantation (TAVI) vs. surgical aortic valve replacement (SAVR) in severe aortic stenosis patients deemed to be at intermediate surgical risk is unknown. In this target population, the degree of neurological damage was compared using brain diffusion-weighted magnetic resonance imaging (DW-MRI) and cognitive testing. METHODS: Forty-six consecutive patients undergoing TAVI (78.0 ± 8.3 years; STS score 4.4 ± 1.7) and 37 patients undergoing SAVR (78.9 ± 6.2 years, STS score 4.7 ± 1.7) were compared. DW-MRI was performed in 67 patients (40 in TAVI vs. 27 in SAVR group) within the first 15 days post-procedure. A cognitive assessment was performed at baseline and at 3 months follow-up. The occurrence of potential cognitive impairment post-intervention was determined using the reliable change index (RCI). RESULTS: Baseline characteristics were comparable in TAVI and SAVR groups except for the presence of severe calcified aorta, which occurred more frequently in the TAVI group [17 (37 %) vs. 0 (0 %), p < 0.001]. Three patients presented a clinical stroke: 1 (2.2 %) in TAVI group vs. 2 (5.4 %) in SAVR group, (p = 0.58). No differences were observed in the rate of acute ischemic cerebral lesions detected by DWI in patients undergoing TAVI vs. SAVR [18 (45 %) in TAVI vs. 11 (40.7 %) in SAVR, adjusted OR 0.95; 95 % CI 0.25-3.65; p = 0.94]. TAVI was associated with a lower number of DWI lesions (adjusted OR 0.54; 95 % IC 0.37-0.79; p = 0.02). An older age was a predictor of the occurrence of acute lesions (OR 1.13; 95 % CI 1.03-1.23; p = 0.01), and the use of vitamin-K antagonist therapy had a protective effect (OR 0.25; 95 % CI 0.07-0.92; p = 0.037) regardless the type of intervention. Overall no significant changes were observed in global cognitive scores post-intervention (p = 0.23). The RCI showed mild cognitive decline in nine patients undergoing TAVI (26.4 %) and in six patients in the SAVR group (30.0 %) (p = 0.96). There was no association between the number and total volume of lesions and the occurrence of cognitive decline (CC Spearman 0.031, p = 0.85 and -0.011, p = 0.97, respectively). CONCLUSIONS: TAVI and SAVR were associated with a similar rate of acute silent ischemic cerebral lesions in intermediate risk patients. Although acute lesions occurred very frequently in both strategies, their cognitive impact was not clinically relevant.

Five-year epidemiological survey of valvular heart disease: changes in morbidity, etiological spectrum and management in a cardiovascular center of Southern China.

OBJECTIVE: The objective of the present study is to analyze the epidemiological profile of patients with abnormal valvular structure and function and highlight the etiological spectrum and management of valvular heart disease (VHD) in a single cardiovascular center of Southern China in five years. METHODS: The retrospective study included 19,428 consecutive patients (9,441 men and 9,987 women with a mean age of 52.03±20.50 years) with abnormal valvular structure and function who were screened by transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) at the in-patient department of Guangdong General Hospital from January 2009 to December 2013. Data on baseline characteristics, potential etiology, treatment strategies and discharge outcomes were collected from electronic medical records. RESULTS: There were 13,549 (69.7%) patients with relatively definite etiology for VHD. VHD was rheumatic in 7,197 (37.0%) patients, congenital in 2,697 (13.9%), degenerative in 2,241 (11.5%), ischemic in 2,460 (12.7%). The prevalence decreased significantly in rheumatic VHD from 2009 to 2013 (from 42.8% to 32.8%, P<0.001), but increased markedly in congenital VHD (from 9.0% to 12.3%, P<0.001), ischemic VHD (from 9.2% to 11.3%, P=0.003) and degenerative VHD (from 8.8% to 14.5%, P<0.001). Meantime, the prevalence of ischemic VHD increased after the age of 45, similar to that of degenerative VHD. From 2009 to 2013, the proportion of patients with VHD undergoing open cardiac valvular surgery decreased (from 49.5% to 44.3%, P<0.001) and that of patients treated with general medication increased (from 49.2% to 54.1%, P<0.001). However, there was markedly increment in video-assisted thoracoscopic surgery (VATS) from 2009 to 2013 (from 0.3% to 4.4%, P<0.001). Increasing tendencies were showed in aortic mechanical valve replacement (from 32.1% to 34.5%, P=0.001) and double mechanical valve replacement (from 20.9% to 22.3%, P=0.035), especially in mitral valvuloplasty (from 8.5% to 15.7%, P<0.001). However, the proportion of patients undergoing bioprosthetic valve replacement decreased from 2009 to 2013 (from 26.3% to 15.5%, P<0.001). CONCLUSIONS: Despite a significant shift from rheumatic towards degenerative etiology from 2009 to 2013, rheumatic VHD remains the leading etiology in Southern China, with a significant increase in the prevalence of ischemic, congenital and degenerative VHD. General medication and cardiac valvular surgery remain the main treatment options. The proportion of VATS increased markedly from 2009 to 2013, and mechanical valve replacement and mitral valvuloplasty showed an increasing tendency.

Preventive Effect of Tolvaptan on Pleural Effusion after Cardiac Valvular Surgery / 日本心臓血管外科学会雑誌

Background : Post-operative fluid management after cardiac valvular surgery is very important. In our institute, carperitide 0.0125 γ was started during surgery and oral furosemide 20-40 mg/day and spironolactone 25 mg/day were started at post-operative day (POD) 1 as the standard therapy. Tolvaptan, vasopressin V2 receptor antagonist, was started when fluid retention such as pleural effusion occurred. With this strategy, the frequency of pleural drainage was more than 40%. Therefore we changed our standard therapy in February 2018. In this new standard therapy, carperitide (0.0125 γ) was started and maintained until oral intake became possible and tolvaptan 7.5 mg was started with furosemide 20 mg and spironolactone 25 mg as oral medicine usually at POD 1. In this study, whether tolvaptan prevents pleural effusion or not after cardiac surgery was examined. Subjects and Methods : Sixty-four patients were operated during February 2017 and December 2018 were included in this study. Thirty-two patients operated in the period until January 2018 served as control group and were compared with 32 patients for whom tolvaptan was started on POD 1 (tolvaptan group). Results : There was no significant difference between two groups for background, operative procedure, operation time, cardiopulmonary bypass time, aortic cross clamp time and fluid balance during procedure. Tolvaptan was given to all patients in the tolvaptan group and in 22% of patients in the control group. Oral furosemide dose (tolvaptan group 21±5 mg/day, control group 31±20 mg/day, p＝0.0112), and the frequency of patients with intravenous furosemide administration (tolvaptan group 9%, control group 44%, p＝0.0038) were significantly less in tolvaptan group. In the tolvaptan group, intravenous furosemide administrated only once in all patients, whereas the frequency of intravenous furosemide administration was 1-32 times, average 6.6 times in control group. Tolvaptan was stopped within 1 week because of too much urination in two patients and the elevation of liver enzyme in two patients without any adverse effects. Post-operative urination volume until POD 5 did not differ. In both groups, body weight increased at POD 1 and 2 and returned to pre-operative weight at POD 3. Pleural effusion was significantly less in the tolvaptan group at POD 3 (tolvaptan group : none 66%, small amount 22%, moderate amount 3%, drain tube inserted 9%, control group : none 16%, small amount 34%, moderate amount 13%, drain tube inserted 38%, p＝0.0003), at POD 7 (tolvaptan group : none 72%, small amount 28%, vs., control group : none 47%, small amount 19%, moderate amount 22%, drain tube inserted 13%, p＝0.0041) and at discharge (tolvaptan group : none 94%, small amount 6%, vs., control group : none 69%, small amount 22%, moderate amount 9%, p＝0.0301). The frequency of pleural drainage was also less in the tolvaptan group (tolvaptan group 9.4%, control group 44%, p＝0.0038). Conclusion : After cardiac valvular surgery, tolvaptan started at POD 1 is very effective to reduce the frequency of pleural effusion and pleural drainage, and careful checking for too much urination and the elevation of liver enzymes is mandatory.

The current status and influential factors of uncertainty in illness in cardiac valvular surgery patients with cardiopulmonary bypass / 中华行为医学与脑科学杂志

Objective To investigate the current status of uncertainty in illness in cardiac valvular surgery patients with cardiopulmonary bypass and analyze its influential factor,and provide reference for effective intervention.Methods A total of 208 cardiac valvular surgery patients with cardiopulmonary bypass were recruited from 4 cardiovascular surgery in Guangdong and were investigated with the self-designed questionnaire,Mishel Uncertainty in Illness Scale (MUIS),Connor-Davidson Resilience Scale (CD-RISC),Medical Coping Modes Questionnaire (MCMQ),in the preoperative day and the day before discharge.The data were analyzed by single-factor and multiple-factor analysis.Results The average score of uncertainty in illness in cardiac valvular surgery patients with cardiopulmonary bypass was 99.09±11.41,and 92.3％ of patients got a moderate uncertainty in illness level in the preoperative day.The average score of uncertainty in illness in the patients was 90.33± 10.32,and 91.8％ of patients got a moderate uncertainty in illness level in the day before discharge.Multiple linear regression indicated that,age,cardiac valvular disease types,number of cardiac valvular surgery,optimism and yield were the protective factors of uncertainty in illness level.Average monthly household income,self-improvement,scores of resilience and confront coping were the risk factors of uncertainty in illness level.Conclusion The level of uncertainty in illness in cardiac valvular surgery patients with cardiopulmonary bypass is moderate.Age,average monthly household income,cardiac valvular disease types,number of cardiac valvular surgery,resilience and coping style are factors influencing uncertainty in illness level of patients.

The Risk Factors of Surgical Site Infection after Valvular Heart Surgery / 日本心臓血管外科学会雑誌

Surgical Site Infection (SSI) is one of the most serious post-operative complications and therefore its prevention is extremely important. SSI risk factors were evaluated in 337 cardiac valvular surgical cases without concomitant CABG or the thoracic great vessels interventions which had been performed in our center between January 2008 and December 2010. The Center for Disease Control and Prevention definition of SSI was used for case determination. The SSI incidence was 4.7% (16 cases). Univariate analysis found statistical significance in history of cardiac surgery, LVEF, surgical procedures, operative time and morning glucose level on post-operative days (POD) 1 and 2. POD 1 morning glucose level higher than 150 mg/dl (odds ratio 4.2 ; 95% confidence interval 1.3-13.7) and operative time (odds ratio 2.0 ; 95% CI 1.2-3.5) were identified as independent factors by multiple logistic regression. According to SSI rate comparison by glucose-level, the incidence was higher when POD 2 morning glucose level exceeded 150 mg/dl as in the case of POD 1 (<i>p</i><0.02). Longer operative time represented higher SSI rates in interquartile range-based comparison. This study suggested values of reducing surgical time and controlling POD 1 morning glucose level within 150 mg/dl.