Massive pulmonary embolism in a patient with nephrotic syndrome and single lung.

We present a novel case of a patient with nephrotic syndrome and previous left pneumonectomy who had a massive pulmonary embolism of his remnant right pulmonary artery. He underwent surgical embolectomy and veno-arterial extracorporeal membrane oxygenation (ECMO). Early embolectomy using retrograde pulmonary perfusion and post-operative ECMO helped the patient survive this catastrophic event.

An Asian Perspective on Gender Differences in Clinical Outcomes and Echocardiographic Profiles of Patients With Medically Managed Severe Aortic Stenosis.

BACKGROUND: Gender differences in valvular heart disease are increasingly recognised. A prior study has suggested better surgical outcomes in women with symptomatic aortic stenosis (AS). We investigate gender differences in medically managed severe AS. METHOD: We studied 347 patients with severe AS (aortic valve area index <0.6 cm2/m2) in terms of baseline clinical background, echocardiographic characteristics, and clinical outcomes. Appropriate univariate and multivariate models were employed, while Kaplan-Meier curves were constructed to compare mortality outcomes. RESULTS: In total, 205 (59%) patients were women. Despite higher incidences of hypertension (75.6% vs 47.3%) and diabetes mellitus (46.5% vs 29.5%) in women, women had improved survival (Kaplan-Meier log-rank = 6.24, p = 0.012). After adjusting for age (hazard ratio [HR], 1.034; 95% confidence interval [CI], 1.014-1.054), hypertension (HR, 1.469; 95% CI, 0.807-2.673), diabetes (HR, 1.219; 95% CI, 0.693-2.145), and indexed aortic valve area (HR 0.145, 95% CI 0.031-0.684) on multivariate analyses, female gender remained independently associated with lower mortality (HR, 0.561; 95%, CI 0.332-0.947). Women tended to have smaller body surface area (BSA), left ventricular (LV) internal diastolic diameter, and smaller LV outflow tract diameter but were similar to men in terms of LV ejection fraction, AS severity, and patterns of LV remodelling. CONCLUSIONS: Women appeared to have better outcomes compared to men in medically managed severe AS. These gender differences warrant further study and may affect prognosis, follow-up, and timing of valve surgery.

Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. METHODS: An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). RESULTS: Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. CONCLUSION: This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.

Is preoperative IABP insertion significantly reducing postoperative complication in augmented high-risk coronary artery bypass grafting patients?

BACKGROUND: The aim of this study was to determine whether pre-operative intra-aortic balloon pump (IABP) insertion improves surgical outcomes in high-risk coronary artery bypass grafting (CABG) patients. METHODS: Patients with a EuroSCORE II greater than 1.2% who underwent CABG from 2009 to 2016 were included in the study, while those who utilized intra-operative or post-operative IABP were excluded. The analysis included a total of 2907 patients, with 377 patients undergoing preoperative IABP insertion (EuroSCORE II > 5.018%) and 1198 patients in the non-IABP group before matching; after propensity score matching (PSM), both groups consisted of a matched cohort of 250 patients. RESULTS: 30-day mortality events occurred in 9 (3.6%) non-IABP group and in 12 (4.8%) IABP patients (OR: 1.33 95%CI: 0.52-3.58). Kaplan-Meier survival curve analysis showed no significant differences between the two groups in mortality up to one year after the operation (p = 0.72). On multivariate analysis, IABP usage among the PSM patients was associated with lower 30-day mortality (OR: 0.28, 95%CI: 0.07-0.92, P-value = 0.043), 90-day mortality (OR: 0.26, 95%CI: 0.08-0.78, P-value = 0.022) and reduced risk of developing severe respiratory disorders (OR: 0.10, 95%CI:0.01-0.50, P-value = 0.011). CONCLUSION: Pre-operative IABP use in high-risk patients reduces 30- and 90-day mortality rates, along with a notable decrease in rates of severe respiratory disorders.

Routine preoperative screening computed tomography of the thorax for cardiac surgery.

Introduction: This study aimed to evaluate the role of screening computed tomography (CT) of the thorax in cardiac surgery by analysing the presence of CT aortic calcifications in association with changes in operative strategy and postoperative stroke, and the CT features of emphysema with development of pneumonia. Methods: All patients who underwent cardiac surgery from January 2013 to October 2017 by a single surgeon were retrospectively studied. Patients who underwent screening CT thorax before cardiac surgery (CT group) were compared to those who did not (no CT group). Multivariate subgroup analyses were performed to determine significant association with postoperative outcomes. Results: A total of 392 patients were included, of which 156 patients underwent preoperative screening CT thorax. Patients in the CT group were older (63.9 vs. 59.0 years, P = 0.001), had fewer recent myocardial infarctions preoperatively (41% vs. 56.4%, P = 0.003) and had better ejection fraction (>30%; P = 0.02). Operative strategy was changed in 4.3% of patients, and 4.9% of patients suffered stroke postoperatively. The presence of CT aortic calcifications was significantly associated with change in operative strategy (P = 0.016) but not with postoperative stroke (P = 0.33). Age was an independent risk factor for change in operative strategy among patients with CT thorax (P = 0.02). Multivariate age-adjusted analysis showed only palpable plaque to be significantly associated with change in operative strategy (P < 0.001). None of the patients with CT emphysema features developed pneumonia. Conclusion: The results of this study do not support routine use of preoperative screening CT thorax. Contrasted CT may be advisable in older patients and for other operative planning purposes.

N-Acetylcysteine's Renoprotective Effect in Cardiac Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: To examine N-acetylcysteine's (NAC's) renoprotective effect in adult cardiac surgeryMethods: PubMed, Ovid Medline, and Embase were searched for randomized controlled trials published between January 1990 and May 2021 that investigated the effect of NAC in preventing acute kidney injury (AKI) in patients undergoing cardiac surgery. The inclusion criterion was studies that assessed the effect of NAC in comparison to placebo by measuring the incidence of AKI. RESULTS: Overall meta-analytic estimates of all 10 included trials showed that NAC did not have a significant effect (odds ratio [OR]: 0.84, 95% confidence interval [CI]: 0.64-1.10) on AKI. Further subgroup analysis did not show a significant benefit of NAC in preventing AKI. CONCLUSION: This meta-analysis suggests that NAC does not have a significant effect in reducing the incidence of AKI. However, there is notable heterogeneity among the included studies that could possibly account for the non-significant effect observed. It is worth noting that only one trial administered NAC high dosages perioperatively, and it is the only included trial to show a significant benefit in reducing the incidence of AKI (OR: 0.30, 95% CI: 0.11-0.81). Further studies on this dosage and duration of administration should be conducted to best elucidate the effect of administering NAC.

Minimally invasive tricuspid valve surgery and concomitant MAZE procedure with closure of LA appendage through an ASD.

Utilization of the ASD as a gateway to reach the left heart in tricuspid valve surgery may facilitate the use of a mini right thoracotomy and single atriotomy approach, avoiding the need for bi-atrial incisions and/or median sternotomy.

Optimal vortex formation time index in mitral valve stenosis.

Left ventricular vortex formation time (VFT) is a novel dimensionless index of flow propagation during left ventricular diastole, which has been demonstrated to be useful in heart failure and cardiomyopathy. In mitral stenosis (MS), flow propagation in the LV may be suboptimal. We studied VFT in varying degrees of MS. Echocardiography was performed on 20 healthy controls and 50 cases of rheumatic MS. Patients with atrial fibrillation, LV ejection fraction < 50% and other valvular heart diseases were excluded. VFT was obtained using the length-to-diameter ratio (L/D), where L is the continuous-wave Doppler velocity time integral stroke distance, divided by D, the mitral leaflet separation index. This was correlated against varying degrees of MS severity, left atrial (LA) volume and function. In controls, VFT was 3.92 ± 2.00 (optimal range) and was higher (suboptimal) with increasing severity of mitral stenosis (4.98 ± 2.43 in mild MS; 7.22 ± 2.98 in moderate MS; 11.55 ± 2.67 in severe MS, p < 0.001). VFT negatively correlated with mitral valve area (R2 = 0.463, p < 0.001) and total LA emptying fraction (R2 = 0.348, p < 0.001), and positively correlated with LA volume index (R2 = 0.440, p < 0.001) and mean transmitral pressure gradient (R2 = 0.336, p < 0.001). More severe MS correlated with suboptimal (higher) VFT. The restricted mitral valve opening may disrupt vortex formation and optimal fluid propagation in the LV. Despite the compensatory increase in LA size with increasingly severe MS, reduced LA function also contributed to the suboptimal LV vortex formation.

Meta-analysis of the benefit of beta-blockers for the reduction of isolated atrial fibrillation incidence after cardiac surgery.

Objectives: Postoperative atrial fibrillation (POAF) is a common problem of cardiac surgery. Beta-blockers are recognized as effective prophylactic agents available for POAF management. To better understand its effect on isolated atrial fibrillation after cardiac surgery, a meta-analysis was conducted. Methods: Randomized controlled trials (RCTs) were searched and filtered by comparing the efficacy of beta-blockers and control users in isolated POAF for cardiac surgery. Seventeen RCTs were identified and analyzed by typical meta-analysis methods. The search was performed from inception to May 31, 2020. Subgroup analyses were conducted for type of surgery and beta-blocker, starting time and route of administration of beta-blocker, and dosage of intravenous landiolol hydrochloride. Results: Beta-blockers were effective in reducing isolated POAF risk (risk ratio [RR], 0.52 [0.41, 0.66], P = .31, I2 = 12%). In subgroup analyses, beta-blocker administration during postoperative period (RR, 0.43 [0.29, 0.62], P = .84, I2 = 0%) and on-pump coronary artery bypass graft (RR, 0.34 [0.04, 3.15], P = .56, I2 = 0%) had lowest risk of isolated POAF incidence. Intravenous landiolol hydrochloride at 2 µg/kg/min also had low risk of isolated POAF occurrence. Conclusions: Beta-blocker treatment helps to reduce isolated atrial fibrillation incidence after cardiac surgery. Our subgroup analyses also reveal postoperative beta-blocker administration after on-pump coronary artery bypass graft surgery is most effective in reducing isolated POAF risk. Intravenous landiolol hydrochloride at a dosage of 2 µg/kg/min has also displayed favorable results. Further trials may be required to explore these factors.

Sleep apnoea and cardiovascular outcomes after coronary artery bypass grafting.

OBJECTIVE: Patients with advanced coronary artery disease are referred for coronary artery bypass grafting (CABG) and it remains unknown if sleep apnoea is a risk marker. We evaluated the association between sleep apnoea and major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing non-emergent CABG. METHODS: This was a prospective cohort study conducted between November 2013 and December 2018. Patients from four public hospitals referred to a tertiary cardiac centre for non-emergent CABG were recruited for an overnight sleep study using a wrist-worn Watch-PAT 200 device prior to CABG. RESULTS: Among the 1007 patients who completed the study, sleep apnoea (defined as apnoea-hypopnoea index ≥15 events per hour) was diagnosed in 513 patients (50.9%). Over a mean follow-up period of 2.1 years, 124 patients experienced the four-component MACCE (2-year cumulative incidence estimate, 11.3%). There was a total of 33 cardiac deaths (2.5%), 42 non-fatal myocardial infarctions (3.7%), 50 non-fatal strokes (4.9%) and 36 unplanned revascularisations (3.2%). The crude incidence of MACCE was higher in the sleep apnoea group than the non-sleep apnoea group (2-year estimate, 14.7% vs 7.8%; p=0.002). Sleep apnoea predicted the incidence of MACCE in unadjusted Cox regression analysis (HR 1.69; 95% CI 1.18 to 2.43), and remained statistically significant (adjusted HR 1.57; 95% CI 1.09 to 2.25), after adjustment for age, sex, body mass index, left ventricular ejection fraction, diabetes mellitus, hypertension, chronic kidney disease and excessive daytime sleepiness. CONCLUSION: Sleep apnoea is independently associated with increased MACCE in patients undergoing CABG. TRIAL REGISTRATION NUMBER: NCT02701504.