Haematic antegrade repriming to enhance recovery after cardiac surgery from the perfusionist side.

Background: New era of cardiac surgery aims to provide an enhanced postoperative recovery through the implementation of every step of the process. Thus, perfusion strategy should adopt evidence-based measures to reduce the impact of cardiopulmonary bypass (CPB). Hematic Antegrade Repriming (HAR) provides a standardized procedure combining several measures to reduce haemodilutional priming to 300 mL. Once the safety of the procedure in terms of embolic release has been proven, the evaluation of its beneficial effects in terms of transfusion and ICU stay should be assessed to determine if could be considered for inclusion in Enhanced Recovery After Cardiac Surgery (ERACS) programs. Methods: Two retrospective and non-randomized cohorts of high-risk patients, with similar characteristics, were assessed with a propensity score matching model. The treatment group (HG) (n = 225) received the HAR. A historical cohort, exposed to conventional priming with 1350 mL of crystalloid confirmed the control group (CG) (n = 210). Results: Exposure to any transfusion was lower in treated (66.75% vs. 6.88%, p < 0.01). Prolonged mechanical ventilation (>10 h) (26.51% vs. 12.62%; p < 0.01) and extended ICU stay (>2 d) (47.47% vs. 31.19%; p < 0.01) were fewer for treated. HAR did not increase early morbidity and mortality. Related savings varied from 581 to 2741.94 $/patient, depending on if direct or global expenses were considered. Discussion: By reducing the gaseous and crystalloid emboli during CPB initiation, HAR seems to have a beneficial impact on recovery and reduces the overall transfusion until discharge, leading to significant cost savings per process. Due to the preliminary and retrospective nature of the research and its limitations, our findings should be validated by future prospective and randomized studies.

Accessory left atrial cords: A case report and literature review.

INTRODUCTION: Accessory left atrial cords are fibroelastic structures found in the left atrium. Left atrial cords may be associated with mitral valve disease, atrial fibrillation, stroke, and other congenital left-side anomalies. METHODS: We presented the case of a man with severe Mitral Regurgitation and two accessories left atrial cords attached to P2 scallop by a single tendon and performed a literature review using PUBMED/MEDLINE, Web of Science, and EMBASE databases on December 4, 2021. RESULTS: According to our review, accessory left atrial cords were found more frequently in women (36 patients, 62%), more frequently attached to the mitral valve (66% of reports) and mitral regurgitation was the most frequently reported pattern of mitral valve disease (64.2%). No other cases of double left atrial cords attached to P2 segment were found. CONCLUSION: Accessory left atrial chords may be related to mitral valve disease and other left-side congenital abnormalities. These structures were found more frequently in females and A2 insertion was the most frequently observed pattern in the review.

Outcomes of rapid deployment aortic valve replacement with concomitant cardiac procedures.

Background: Rapid deployment aortic valve replacement (RD-AVR) has been recently introduced with encouraging results. Outcomes of isolated RD-AVR include good hemodynamic profile, facilitation of minimally invasive techniques, and reduction of surgical times. However, role of this prosthesis in concomitant surgery is not well known. Methods: In 2016, we formed a registry to monitor the introduction of this prosthesis, RApid Deployment Aortic Replacement (RADAR). We aim to report mid-term outcomes focusing on patients who had RD-AVR combined with other surgical procedures. Results: Between July 2012 and February 2021, 370 patients were included in this registry (mean age, 75.8±8.0 years; 64.32% male; mean EuroSCORE II, 3.5±2.8). Of these, 128 (34.59%) had concomitant procedures including myocardial revascularization surgery in 69 patients (53.91%), surgery on the ascending aorta in 34 (26.56%), and procedures on other valves in 10 patients (7.81%). There were no significant differences between the isolated AVR and concomitant AVR groups in postoperative complications, in-hospital mortality (4.72% vs. 3.32%, P=0.524), or hemodynamic behavior of these prostheses. Three-year survival was 83.73% and 89.89% in the isolated and concomitant AVR group respectively. There was no difference in survival between the two groups (log-rank test, P=0.4124). Conclusions: Our results support the safety and efficacy of the Edwards INTUITY valve system even in complex aortic valve disease with additional cardiac procedures. RD-AVR could become a useful tool for concomitant surgeries where surgical times are expected to be prolonged.

Mid-term outcomes of rapid deployment aortic prostheses in patients with small aortic annulus.

OBJECTIVES: The Edwards Intuity valve is a rapid deployment aortic prosthesis that favours less invasive approaches. However, evidence about the clinical behaviour of their smaller sizes is scarce. Herein, we studied haemodynamic behaviours and clinical outcomes of small Intuity prostheses (19-21 mm) in comparison to larger Intuity prostheses (>21 mm). METHODS: This is an observational study including patients implanted with an Edwards Intuity rapid deployment aortic prosthesis. Patients with prosthesis sizes 19-21 and >21 mm were included. Baseline and perioperative variables, as well as adverse events during the follow-up were recorded and compared between groups. RESULTS: A total of 122 patients (37% female, mean age 75 ± 4.5 years) were included, of whom 54 (45%) were implanted with a small prosthesis and 68 (55%) with a prosthesis >21 mm. There were no significant differences between patients with small Intuity prostheses and patients with larger prostheses regarding in-hospital mortality (2% vs 4%, P = 0.43) or mortality during the follow-up (3.41 vs 2.45 per 100 patients-years; P = 0.58). Survival in the small Intuity valve group was 95% at 1 year and 83% at 6 years, whereas in the larger Intuity valve group was 96% at 1 year and 78% at 6 years. The presence of a small prosthesis did not influence mid-term survival (log-rank P-value = 0.62). CONCLUSIONS: This study showed good clinical performance of Intuity aortic prostheses with appropriate mid-term survival in patients with the small aortic annulus. Thus, the Edwards Intuity rapid deployment aortic prosthesis may be considered as a potential option in patients with the small aortic annulus.

Rapid Deployment Aortic Replacement (RADAR) Registry in Spain: a protocol.

INTRODUCTION: Rapid deployment valves (RDV) represent a newly introduced approach to aortic valve replacement which facilitates surgical implantation and minimally invasive techniques, shortens surgical times and shows excellent haemodynamic performance. However, evidence on their safety, efficacy and potential complications is mostly fitted with small-volume and retrospective studies. Moreover, no current guidelines exist. To improve our knowledge on this technology, The Rapid Deployment Aortic Replacement (RADAR) Registry will be established across Spain with the aim of assessing RDV outcomes in the real-world setting. METHODS AND ANALYSIS: The RADAR Registry is designed as a product registry that would provide information on its use and outcomes in clinical practice. This multicentre, prospective, national effort will initially involve 4 centres in Spain. Any patient undergoing cardiac surgery for aortic valve replacement and receiving an RDV as an isolated operation or in combination with other cardiac procedures may be included. Participation is voluntary. Data collection is equal to information obtained during standard care and is prospectively entered by the participating physicians perioperatively and during subsequent follow-up visits. The primary outcome assessed is in-hospital and up to 5 years of follow-up, prosthetic valve functioning and clinical status. Secondary outcomes are to perform subgroup analysis, to compare outcomes with other existing approaches and to develop future clinical guidelines. The follow-up assessments are timed with routine clinical appointments. Dissociated data will be extracted and collectively analysed. Initial target sample size for the registry is 500 participants entered with complete follow-up information. Different substudies will be implemented within the registry to investigate specific populations undergoing aortic valve replacement. ETHICS AND DISSEMINATION: The protocol is approved by all local institutional ethics committees. Findings will be shared by the participant hospitals, policymakers and the academic community to promote quality monitoring and efficient use of this technology.

[Prognostic role of new biomarkers in off-pump coronary artery bypass surgery]. / Papel pronóstico de los nuevos biomarcadores en la cirugía coronaria sin circulación extracorpórea.

The value of biomarkers of myocardial damage or inflammation in off-pump coronary artery bypass (OPCAB) surgery has not yet been established. In a prospective study of 51 consecutive patients scheduled for elective OPCAB surgery, preoperative levels of troponin T, C-reactive protein, interleukin-6 and tumor necrosis factor-alpha were determined. The primary endpoint was the combination of cardiac death or acute myocardial infarction (AMI) within 30 days. Seven patients (14%) presented with an adverse event: three cardiac deaths and six AMIs. Univariate analysis identified the following adverse event predictors: renal failure (50% vs 11%, P=.028), left ventricular ejection fraction 0.10 ng/dL (43% vs 9%, P=.016), and EuroSCORE rating (7.6 [2.5] VS. 5.2 [2.6], P=.031). A preoperative troponin-T level > 0.10 ng/dL (P=.03) was the only independent adverse event predictor. No significant differences were found with biomarkers of inflammation (P.05). The presence of a preoperative troponin-T level > 0.10 ng/dL is associated with a higher risk of cardiac death or AMI in patients undergoing OPCAB surgery.

QRS duration and early hemodynamic instability after coronary revascularization surgery.

INTRODUCTION AND OBJECTIVES: The duration of the QRS interval measured by ECG is a marker of ventricular dysfunction and indicates a poor prognosis. Its value in patients undergoing coronary revascularization surgery has not been established. METHODS: The study involved 203 consecutive patients (age 64+/-9 years, 74% male) scheduled for elective coronary surgery. The maximum QRS duration measured on a preoperative 12-lead ECG was recorded. Hemodynamic instability was defined as the occurrence of cardiac death, heart failure, or a need for intravenous inotropic drugs or intra-aortic balloon counterpulsation during the postoperative period. RESULTS: The occurrence of hemodynamic instability (n=94, 46%) was associated with a longer preoperative QRS duration (97.5+/-21.14 ms vs 88.5+/-16.9 ms; P=.001). The QRS duration was also longer in patients who developed heart failure (n=23; 104.3+/-22.9 ms vs. 91.1+/-18.5 ms; P=.002), needed inotropic drugs (n=77; 96.5+/-20.5 ms vs. 90.1+/-18.2 ms; P=.007) or developed postoperative atrial fibrillation (n=58; 98.2+/-23.8 ms vs. 90.4+/-17.0 ms; P=.018). Bundle branch block was associated with a greater need for intra-aortic balloon counterpulsation (29% vs 12%; P=.012) or inotropic drugs (58% vs 35%; P=.014) and a higher incidence of hemodynamic instability (69% vs 42%; P=.006). Multivariate analysis identified the following independent predictors of hemodynamic instability: QRS duration (adjusted odds ratio [OR] per 10 ms=1.49; 95% confidence interval [CI], 1.11-2; P=.007), the lack of an arterial graft (OR=3.6; 95% CI, 1.14-11.6; P=.029) and extracorporeal circulation time (OR per min=1.013; 95% CI, 1.003-1.023; P=.013). CONCLUSIONS: The intraventricular conduction delay, or QRS duration, was associated with a higher risk of postoperative hemodynamic instability following coronary surgery.

[Epidemiology and new predictors of atrial fibrillation after coronary surgery]. / Epidemiología y nuevos predictores de la fibrilación auricular tras cirugía coronaria.

INTRODUCTION AND OBJECTIVES: Postoperative atrial fibrillation (PAF) is a frequent complication of coronary artery bypass grafting (CABG). Our aims were to study its epidemiology and to identify predictors in everyday clinical practice, while taking into account statin use, extracorporeal circulation, and new biomarkers of inflammation and ventricular stress. METHODS: The study included 102 consecutive patients (65 [9] years, 72% male) who were undergoing CABG. Blood samples were taken the day before surgery to determine baseline levels of C-reactive protein (CRP) and N-terminal probrain natriuretic peptide (NT-proBNP). Details of baseline clinical characteristics, preoperative treatment and surgery were recorded. The end-point was PAF at 30 days. RESULTS: The incidence of PAF was 23% (n=23; 3.2 [2.9] days, range 1-15 days). Its appearance was associated with a longer stay in the intensive care unit (+ 1 day; P=.019), but not with an increased total hospital stay (P=.213). Among patients with PAF, 4.3% had an embolism and 8.6% remained in atrial fibrillation at discharge. Moreover, PAF was associated with a longer duration of ischemia (28.5 [22.3] vs 18.0 [27.9]; P=.045) and a lower statin pretreatment rate (39% vs 66%; P=.022). Multivariate analysis showed that the only factor associated with a higher risk of PAF was the absence of statin pretreatment (odds ratio = 4.31, 95% confidence interval 1.33-13.88; P=.015). There was no association between either extracorporeal circulation or the baseline CRP or NT-proBNP level and an increased risk of PAF. CONCLUSION: In everyday clinical practice, PAF is a frequent complication. Statin pretreatment could have a protective effect against its appearance.