Interventions Triggered During Routine Use of NIRS Cerebral Oxygenation Monitoring in Cardiac Surgical Patients.

OBJECTIVE: The purpose of this study was to determine the incidence and types of interventions triggered during a drop of baseline near-infraredspectroscopy (NIRS) values in consecutive cardiac surgical patients. DESIGN: A single-center, retrospective observational study. SETTING: A university-affiliated tertiary care center. PARTICIPANTS: Three thousand three hundred two consecutive cardiac surgical patients from October 2016 to August 2017 Interventions: None. MEASUREMENTS AND MAIN RESULTS: Of the 1,972 patients who met the inclusion criteria, 576 (29.2%) patients showed NIRS deviation of -20% from baseline. Interventions performed during the drop of baseline NIRS values were documented in 285 (14.4%) patients, with a total of 391 interventions. Three hundred fifteen (80%) interventions were triggered by a deviation in NIRS and concomitant changes in standard monitoring parameters. Seventy-six (20%) interventions were triggered by NIRS deviation alone, with no concomitant pathologic deviation in standard monitoring. A total of 279 (71%) interventions were performed on patients who had no recommendation for NIRS monitoring by current national guidelines. Out of these, 30 (7.7%) interventions (1.3% of all patients) were performed based on NIRS monitoring alone. The higher risk deviation group had longer intensive care unit and hospital lengths of stays (one and 15 days) and postoperative delirium when compared with the no-deviation group (zero and 13 days) Conclusions: The authors' data suggested that most interventions triggered during the drop of baseline values during routine use of NIRS would have also been triggered by the concomitant changes in standard monitoring parameters. Routine use of NIRS for all cardiac surgical patients still is debatable and needs to be evaluated in a large prospective trial.

Mortality in patients with normal left ventricular function requiring emergency VA-ECMO for postcardiotomy cardiogenic shock due to coronary malperfusion.

OBJECTIVES: To analyze outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy due to postcardiotomy cardiogenic shock (PCCS) related to coronary malperfusion. METHODS: Retrospective single-center analysis in patients with normal preoperative LVEF treated with VA-ECMO for coronary malperfusion-related PCCS between May 1998 and May 2018. The primary outcome was 30-day mortality, which was compared using the Kaplan-Meier method and the log-rank test. Multivariable logistic regression was performed to identify predictors of mortality. RESULTS: During the study period, a total of 62,125 patients underwent cardiac surgery at our institution. Amongst them, 59 patients (0.1%) with normal preoperative LVEF required VA-ECMO support due to coronary malperfusion-related PCCS. The mean duration of VA-ECMO support was 6 days (interquartile range 4-7 days). The 30-day mortality was 50.8%. Under VA-ECMO therapy, a complication composite outcome of bleeding, re-exploration for bleeding, acute renal failure, acute liver failure, and sepsis occurred in 51 (86.4%) patients. Independent predictors of 30-day mortality were lactate levels > 9.9 mmol/l before VA-ECMO implantation (odds ratio [OR]: 3.3; 95% confidence interval [CI] 1.5-7.0; p = 0.002), delay until revascularization > 278 minutes (OR: 2.9; 95% CI 1.3-6.4; p = 0.008) and peripheral arterial artery disease (OR: 3.3; 95% 1.6-7.5; p = 0.001). CONCLUSIONS: Mortality rates are high in patients with normal preoperative LVEF who develop PCCS due to coronary malperfusion. The early implantation of VA-ECMO before the development of profound tissue hypoxia and early coronary revascularization increases the likelihood of survival. Lactate levels are useful to define optimal timing for the VA-ECMO initiation.

Postoperative Weight Gain within Enhanced Recovery after Cardiac Surgery.

Optimal fluid therapy during perioperative care as part of enhanced recovery after cardiac surgery (ERACS) should improve the outcome. Our objective was finding out the effects of fluid overload on outcome and mortality within a well-established ERACS program. All consecutive patients undergoing cardiac surgery between January 2020 and December 2021 were enrolled. According to ROC curve analysis, a cut-off of ≥7 kg (group M, n = 1198) and <7 kg (group L, n = 1015) was defined. A moderate correlation was shown between weight gain and fluid balance r = 0.4, and a simple linear regression was significant p < 0.0001, R2 = 0.16. Propensity score matching showed that increased weight gain was associated with a longer hospital length of stay (LOS) (L 8 [3] d vs. M 9 [6] d, p < 0.0001), an increased number of patients who received pRBCs (L 311 (36%) vs. M 429 (50%), p < 0.0001), and a higher incidence of postoperative acute kidney injury (AKI) (L 84 (9.8%) vs. M 165 (19.2%), p < 0.0001). Weight gain can easily represent fluid overload. Fluid overload after cardiac surgery is common and is associated with prolonged hospital LOS and increases the incidence of AKI.

Tricuspid valve repair with echocardiographic guiding.

BACKGROUND: In this study we discuss the conditions of four patients with severe tricuspid valve (TV) regurgitation, in which a differentiated intraoperative transesophageal echocardiographic (TEE) analysis - as performed in TV-clipping procedures - provided major guidance for refined TV repair. METHODS: Between January 2019 and March 2020, four patients with central tricuspid regurgitation and an intercommisural jet underwent annuloplasty with an echo-guided plication stitch on the affected leaflet basis, especially anteroseptal. RESULTS: All patients underwent complex multiple valve (aortic- and/or mitral valve) surgery with concomitant TV-repair. No or mild TV regurgitation after TV repair was confirmed in the predischarge echocardiography in all patients. CONCLUSIONS: We conclude, that differentiated intraoperative TEE is essential for the surgical TV repair strategy. Plication of the anteroseptal commissure additionally performed to TV annuloplasty, is an easy and effective add-on in selected patients.

Persistent and acute postoperative pain after cardiac surgery with anterolateral thoracotomy or median sternotomy: A prospective observational study.

OBJECTIVE: The primary objective of this study was to compare the association between cardiac surgical approach (thoracotomy vs. sternotomy) and incidence of persistent postoperative pain at 3 months. Secondary objectives were the incidence and intensity of persistent pain at 6 and 12 months, acute postoperative pain, analgesic requirement and its side effects. DESIGN: Single-center, prospective, observational study. Recruitment between December 2017 and August 2018. SETTING: Perioperative care at university-affiliated tertiary care centre. PATIENTS: 202 adults scheduled for cardiac surgery. Patients with chronic pain or behavioural disorder were excluded. INTERVENTIONS: Thoracotomy (n = 106) and sternotomy (n = 96). MEASUREMENTS: Pain scores and pain medication requirements from extubation until hospital discharge. Persistent postoperative pain was assessed using a telephone questionnaire. MAIN RESULTS: Incidence and intensity of pain was not significantly different between thoracotomy or sternotomy either in the short- or in the long-term follow-up. Incidence of persistent postoperative pain showed no differences between groups (30.2 vs 22.9% at 3 months (p = 0.297), 10.4 vs 7.3% at 6 months (p = 0.364) and 7.5 vs 7.3% at 12 months (p = 0.518) in thoracotomy and sternotomy group). A significant decrease of pain incidence was observed between 3 and 6 months (p < 0.001) but not between 6 and 12 months (p = 0.259) in both groups. ANOVA of repeated measures adjusted for confounding variable showed a decrease of acute pain intensity over time (p = 0.001) with no difference between groups (p = 0.145). Acute pain medication requirements were not different between the groups (p = 0.237 for piritramide and p = 0.743 for oxycodone) with no difference in their side effects. CONCLUSIONS: Our study showed no difference in short- or long-term pain in patients undergoing anterolateral thoracotomy or median sternotomy. Both groups showed a decrease in persistent postoperative pain incidence between 3 and 6 months without any significant changes at 12 months.

A Comparison of Patients Undergoing On- vs. Off-Pump Coronary Artery Bypass Surgery Managed with a Fast-Track Protocol.

The purpose of this study was to compare patients who underwent on- vs. off-pump coronary artery bypass surgery managed with a fast-track protocol. Between September 2012 and December 2018, n = 3505 coronary artery bypass surgeries were managed with a fast-track protocol in our specialized post-anesthesia care unit. Propensity score matching was applied and resulted in two equal groups of n = 926. There was no significant difference in ventilation time (on-pump 75 (55-120) min vs. off-pump 80 (55-120) min, p = 0.973). We found no statistically significant difference in primary fast-track failure in on-pump (8.2% (76)) vs. off-pump (6% (56)) groups (p = 0.702). The secondary fast-track failure rate was comparable (on-pump 12.9% (110) vs. off-pump 12.3% (107), p = 0.702). There were no significant differences between groups in regard to the post-anesthesia care unit, the intermediate care unit, and the hospital length of stay. Postoperative outcome and complications were also comparable, except for a statistically significant difference in PACU postoperative blood loss in on-pump (234 mL) vs. off-pump (323 mL, p < 0.0001) and red blood cell transfusion (11%) and (5%, p < 0.001), respectively. Our results suggest that on- and off-pump coronary artery bypass surgery in fast-track settings are comparable in terms of ventilation time, fast-track failure rate, and postoperative complications rate.

30-Day perioperative mortality following venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock in patients with normal preoperative ejection fraction.

OBJECTIVES: Assessment of early outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) in whom venoarterial extracorporeal membrane oxygenation (VA-ECMO) was implanted for postcardiotomy cardiogenic shock (PCCS) during the first postoperative 48 h. METHODS: Retrospective single-centre analysis in adult patients with normal LVEF, who received VA-ECMO support for PCCS from May 1998 to May 2018. The primary outcome was 30-day perioperative mortality during the index hospitalization. RESULTS: A total of 62 125 adult patients underwent cardiac surgery at our institution during the study period. Among them, 173 patients (0.3%) with normal preoperative LVEF required VA-ECMO for PCCS. Among them, 71 (41.1%) patients presented PCCS due to coronary malperfusion and in 102 (58.9%) patients, no evident cause was found for PCCS. Median duration of VA-ECMO support was 5 days (interquartile range 2-8 days). A total of 135 (78.0%) patients presented VA-ECMO-related complications and the overall 30-day perioperative mortality was 57.8%. Independent predictors of mortality were: lactate level just before VA-ECMO implantation [odds ratio (OR) 1.27; P < 0.001], major bleeding during VA-ECMO (OR 3.76; P = 0.001), prolonged cardiopulmonary bypass time (OR 1.01; P < 0.001) and female gender (OR 4.87; P < 0.001). CONCLUSIONS: Mortality rates of VA-ECMO in PCCS patients are high, even in those with preoperative normal LVEF. Coronary problems are an important cause of PCCS; however, the aetiology remains unknown in the vast majority of the cases. The implantation of VA-ECMO before development of tissue hypoperfusion and the control of VA-ECMO-associated complications are the most important prognostic factors in PCCS patients. Lactate levels may help guide timing of VA-ECMO implantation and define the extent of therapeutic effort.

Echocardiographic Guidance of Intentional Leaflet Laceration prior to Transcatheter Aortic Valve Replacement: A Structured Approach to the Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction Procedure.

Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) is a recently developed technique to reduce the risk of ostial coronary obstruction during transcatheter aortic valve replacement. Intraprocedural fluoroscopy and transesophageal echocardiography imaging are used complimentarily to guide the procedure. So far, no structured echocardiographic imaging protocol has been described for this intervention. Based on an experience of more than 50 BASILICA procedures at two different institutions, we present a step-by-step approach for transesophageal echocardiography guidance during BASILICA and highlight anatomical and procedural characteristics from an echocardiographic perspective.

Transcatheter edge-to-edge mitral valve repair with the PASCAL system: early results from a real-world series.

AIMS: This study sought to characterise the real-world performance and clinical outcomes of the PASCAL system, a leaflet approximation device for transcatheter mitral valve repair. METHODS AND RESULTS: Fifty patients in NYHA Class II-IV despite optimal medical therapy (median age 78.0 years [IQR 74.5-81.0], 52% female, log EuroSCORE 21.6 [IQR 13.2-30.2]) were treated for severe mitral regurgitation (MR) and followed up for one month. Primary and secondary MR was present in 24% and 68% of patients, respectively, with a mixed aetiology observed in 8%. A 1-device strategy was employed in 26/50 patients (52%), a 2-device strategy in 23/50 (46%) patients, and a 3-device strategy in 1/50 (2%) patients. Technical and procedural success was achieved in 100% and 98% of patients, respectively. MR grade ≤1 was observed in 39/50 (78%) patients at discharge, and in 36/46 (78%) patients at one month, with transvalvular gradients remaining ≤5 mmHg in all patients. One device embolisation and one single leaflet device attachment were observed during follow-up. After one month, 73% of patients reported an improvement in NYHA class, and six-minute walk test distance increased by 73±12 m in patients without relevant tricuspid regurgitation. CONCLUSIONS: In a real-world population, the PASCAL device effectively reduces MR and leads to functional improvements on short-term follow-up.

Agreement of tricuspid annular systolic excursion measurement between transthoracic and transesophageal echocardiography in the perioperative setting.

OBJECTIVE: The aim of our study was to evaluate the level of agreement between tricuspid annular plane systolic excursion (TAPSE) measured by transthoracic echocardiography (TTE) and TAPSE measured using transesophageal echocardiography (TEE) in anesthetized patients. MATERIALS AND METHODS: Thirty patients scheduled for elective cardiac surgery were prospectively studied. Shortly after induction of anesthesia before the operation, TAPSE was measured by TTE using M-mode in apical 4chamber view (4CH) and by TEE in six different views: using 2D echocardiography in midesophageal (ME) 4CH view, using M-mode in deep transgastric right ventricle (dTG RV) view at 0° and dTG RV longaxis view (LAX) as well as using anatomical M-mode (AM-mode) in ME 4CH, dTG RV at 0° and dTG RV LAX views. RESULTS: Bland-Altman analysis showed a good agreement for TAPSE measured using M-mode in TTE and using AM-mode in TEE in the ME 4CH and dTG RV at 0° views (-2.5 ± 18 and -2.2 ± 14% respectively). The agreement between TAPSE measured in TTE and TEE using 2D in ME 4CH, using M-mode in dT GRV 0° and using M-mode and AM-mode in dTG RV LAX view showed a significant systematic underestimation of the measurements (-8.8 ± 21, -8.8 ± 24, -17.8 ± 28 and -6.4 ± 20%). CONCLUSION: Our study showed that the right ventricular function can be accurately and precisely estimated using TAPSE measurement by TEE in the midesophageal four chamber and deep transgastric right ventricle view at 0° using anatomical M-mode.