Integrating continuous monitoring and evaluation of risk-adjusted outcomes in a cardiac surgical program.

BACKGROUND: The variable life-adjusted display (VLAD) method shows the difference between predicted and observed outcomes over time. Our study aims to implement routine in-house monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery. METHODS: The Society of Thoracic Surgeons (STS) risk score was calculated for 249 isolated and combined coronary and aortic or mitral valve cases performed during a 6-month period. The nine predicted STS variables were operative mortality, permanent stroke, renal failure (RF), prolonged ventilation, deep sternal wound (DSW) infection, reoperation for any reason, short and long length of stay (LOS), and major morbidity or operative mortality. EuroSCORE II was also calculated for the study population. VLAD plots were generated for each variable indicating whether performance is better or worse than expected on the basis of predicted risk of failure. RESULTS: The mortality plot was fluctuating close to baseline risk. The prolonged ventilation, RF, reoperation, morbidity/mortality, and LOS plots were consistently positive, indicating favorable results. The stroke chart showed an upward trend for most of the period until two incidents toward last month led to a steep descent. The DSW infections plot though, indicated a worse-than-expected performance. The VLAD charts were shared in multidisciplinary meetings and clinicians were able to confront the performance with the population-specific expectancies and respond to adverse trends with further actions. CONCLUSION: Graphical tool monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery is feasible and allows detection of underperformance and implementation of changes in clinical practice.

The impact of deep sternal wound infections treated by negative pressure on early, 1 year and late mortality: A longitudinal case-control study.

BACKGROUND/AIM: Deep sternal wound infection (DSWI) after cardiac surgery, is a rare complication that can be fatal. Due to a lack of available data, we compared early in-hospital, 1-year and long-term mortality in patients with DSWI. METHODS: Patients undergoing any type of cardiac surgery, in the Cardiothoracic Surgery Department of G. Papanikolaou Hospital, between May 2012 and December 2016, were investigated. All patients who developed DWSI postoperatively, treated with negative pressure wound therapy (NPWT), were included in the group of cases. A random population from the rest of the patients was selected in a 1:2 ratio, representing controls. RESULTS: From a total of 2104 patients, 80 patients (3.8%) developed DSWI (cases group), whereas 180 patients were randomly selected as controls. Early (within 30 days) mortality was significantly higher in the DSWI group compared with controls (15% vs 3.9%, respectively; P = .002). Similarly, more deaths occurred in the cases group compared with controls during the follow-up (ie, 19 vs 12, respectively; P < .001); the majority of deaths (84.2%) occurred within the first year. Long-term survival did not differ between the two study groups during follow-up (median duration = 1072 vs 1022 days for cases and controls, respectively). CONCLUSIONS: DSWI significantly increased early and 1-year mortality in poststernotomy patients treated with NPWT compared with those not developing this complication. However, long-term survival was similar between the two study groups, thus highlighting the beneficial effect of NPWT in terms of clinical outcomes in patients with DWSI.

Serum Creatinine and Chronic Kidney Disease-Epidemiology Estimated Glomerular Filtration Rate: Independent Predictors of Renal Replacement Therapy following Cardiac Surgery.

BACKGROUND: Most studies evaluating predictors of renal replacement therapy (RRT) following cardiac surgery use arbitrary defined limits of preoperative serum creatinine. The aim of this study was to evaluate the effect of preoperative renal function using either estimated-glomerular filtration rate (eGFR) derived using Chronic Kidney Disease-Epidemiology (CKD-EPI) or serum creatinine alone as a predictor for RRT after cardiac surgery. METHODS: In this prospective cohort study, baseline, intraoperative, and postoperative data of all patients who underwent an elective, urgent, or emergency cardiac surgery between 2012 and 2016 in a single center were analyzed in order to identify multivariate parameters determining the need for RRT after surgery. For preoperative renal function, we used serum creatinine levels and eGFR-derived CKD-EPI equation. We also divided our cohort into eGFR groups following the thresholds of the currently proposed CKD classification. RESULTS: From the 1,614 patients (mean age: 65.4 ± 10.6 years; male: 77.6%) that constituted the study population, 42 (2.6%) underwent RRT postoperatively. EUROSCORE II, cardiopulmonary bypass time, cross clamp time, red blood cell (RBC) units transfused, type and urgency of surgery, combined/non combined operation, peripheral vascular disease, heart failure, chronic obstructive pulmonary disease, dyslipidemia, and preoperative renal function were all univariately associated with RRT use. Multivariate regression with bootstrap utilization indicated that CKD-EPI eGFR (OR 0.979; 95% CI 0.956-0.998), heart failure with the New York Heart Association class ≥2 (OR 4.695; 95% CI 1.756-14.061) and RBC units transfused (OR 1.287; 95% CI 1.081-1.850) were independently associated with RRT need. When serum creatinine (OR 2.920, 95% CI1.056-8.074) was used in the model, the associations with RRT were also significant. CONCLUSION: Preoperative renal function, defined by serum creatinine or eGFR by CKD-EPI, NYHA class II-IV, and the number of blood units transfused were all independent predictors of RRT postoperatively.

'Early' post-cardiotomy chylopericardium and the imaging value of magnetic resonance thoracic-ductography.

Isolated chylopericardium is a rare postoperative complication after cardiac surgery. A delay in diagnosis or an inappropriate management can lead to serious consequences. The treatment, which may either be conservative or surgical, is controversial and it depends on the duration and volume of effusion. We report a case of chylopericardium after atrial septal defect repair in a young woman. The patient was treated initially with total parenteral nutrition for 10 days. After drainage diminished, low fat diet containing medium chain triglyceride was instituted. Postoperatively, the role of magnetic resonance thoracic ductography was important for the assessment of the treatment strategy.

Unligated left internal mammary artery side branch resulting in coronary artery steal syndrome.

Whether internal mammary artery side branches have the potential for hemodynamically significant flow steal in cases of postcoronary surgery ischemia remains a controversial issue. We present a case in which coil embolization of two unligated side branches resulted in symptomatic improvement and resolution of ischemia as evidenced by myoview imaging.

Abdominal compartment syndrome after surgical repair of Type A aortic dissection.

Abdominal compartment syndrome is associated with severe dysfunction of intra-abdominal and intrathoracic organs. Medical therapy, with the goal of reducing intra-abdominal pressure, leads to improvement in organ perfusion.

Sequestered hypoplastic pulmonary lobe supplied by the circumflex coronary artery in a patient with coronary artery disease: a case report.

Bronchopulmonary sequestrations are usually supplied by single or multiple branches from the descending aorta. We report on a rare form of sequestration of a hypoplastic mid-pulmonary lobe with arterial supply from the circumflex coronary artery coincidentally discovered during coronary angiography in a female patient with coronary artery disease and a history of recurrent hemoptysis. The patient underwent myocardial revascularization and resection of the sequestered lobe in a single-stage approach.

Prophylactic antibiotic administration for post cardiothoracic surgery sternal wounds: a retrospective study.

BACKGROUND: Cardiothoracic surgery sternal infections are difficult to treat situations. Until now there are no clear guidelines which or if an antibiotic could be used as prophylactic treatment. PATIENTS AND METHODS: We collected retrospectively data from 535 patients from our hospital which underwent cardiothoracic surgery and recorded several biological parameters and technical aspects of the surgery. RESULTS: It was observed that patients to whom vancomycin was administered had less post surgery infection than those to whom begalin was administered. Male who were treated with vancomycin it was observed that they had 1.67 chances to be treated properly than female. Patients which were hospitalized for more than 7 days before surgery had 62.6% higher chances for post surgery infection. CONCLUSIONS: It was observed that vancomycin can be used as a prophylactic treatment for cardiothoracic surgeries acting efficiently against sternal wounds.

Human immunodeficiency virus infection and pneumothorax.

Pneumothorax is a serious and relatively frequent complication of human immunodeficiency virus (HIV) infection that may associate with increased morbidity and mortality and may prove difficult to manage, especially in patients with acquired immunodeficiency syndrome (AIDS).

Pericardial fat is strongly associated with atrial fibrillation after coronary artery bypass graft surgery†.

OBJECTIVES: Recent evidence suggests that pericardial fat may represent an important risk factor for cardiovascular disease because of its unique properties and its proximity to cardiac structures. It has been reported that pericardial fat volume (PFV) is associated with atrial fibrillation (AF). The purpose of this study was to investigate the association between PFV and new-onset AF following coronary artery bypass graft surgery (CABG). METHODS: PFV was measured using computed tomography in 83 patients with coronary artery disease scheduled to undergo elective isolated on-pump CABG. Patient characteristics, medical history and perioperative variables were prospectively collected. Any documented episode of new-onset postoperative AF until discharge was defined as the study end point. RESULTS: Twenty-eight patients (33.7%) developed postoperatively AF during hospital stay. There was no significant difference in demographics and comorbidities among patients that maintained sinus rhythm (SR) and their AF counterparts. In univariate analysis, patients with postoperative AF had significantly more pericardial fat compared with SR patients (195 ± 80 ml vs 126 ± 47 ml, P = 0.0001). Larger left atrial diameter was also associated with postoperative AF (42.4 ± 6.9 mm vs 39.3 ± 4.8 mm, P = 0.017). Additionally, the prebypass use of calcium channel-blocking agents was independently associated with a lower incidence of postoperative AF, confirmed also by multivariate analysis (P = 0.035). In multivariate logistic regression analysis, PFV was the strongest independent variable associated with the development of postoperative AF (odds ratio: 1.018, 95% confidence interval: 1.009-1.027, P = 0.0001). The best discriminant value assessed by receiver operating characteristic analysis was 129.5 ml (sensitivity 86% and specificity 56%). CONCLUSIONS: PFV is strongly associated with AF following CABG, independently of many traditional risk factors. Our findings suggest that PFV may represent a novel risk factor for postoperative AF. However, the role of pericardial fat in AF mechanism needs to be further delineated.

Atypical pattern of lung involvement in pacemaker endocarditis.

Pacemaker endocarditis has a high rate of morbidity and mortality and is associated with substantial health-care cost. To maximize the effectiveness of treatment, diagnosis of pacemaker endocarditis should be made as early as possible. Medical treatment alone is not successful, and the removal of the entire artificial pacing system is often required. We present a case of a female patient with a permanent transvenous pacemaker, recurring episodes of fever and chills, general malaise, and a computed tomography image of a solitary tumor-like lesion indicating pneumonia. The symptoms subsided with empirical antibiotics but without improvement in the radiologic images. A wedge resection of the lesion by thoracotomy was performed, revealing a necrotic lung lesion compatible with pulmonary infarct. Transesophageal echocardiography showed a mass that was adherent to the pacemaker lead. The therapeutic approach consisted of surgical removal of the complete pacing system along with long-term antibiotic therapy and implantation of a new device with an epicardial lead. Serial follow-up echocardiograms for a 1-y period did not show any recurrence, and the subsequent course was uneventful.

Review of mitral valve insufficiency: repair or replacement.

Mitral valve (MV) dysfunction is the second-most common clinically significant form of valvular defect in adults. MV regurgitation occurs with the increasing frequency of degenerative changes of the aging process. Moreover, other causes of clinically significant MV regurgitation include cardiac ischemia, infective endocarditis and rhematic disease more frequently in less developed countries. Recent evidence suggests that the best outcomes after repair of severe degenerative mitral regurgitation (MR) are achieved in asymptomatic or minimally symptomatic patients, who are selected for surgery soon after diagnosis on the basis of echocardiography. This review will focus on the surgical management of mitral insufficiency according to its aetiology today and will give insight to some of the perspectives that lay in the future.

The role for medical thoracoscopy in pneumothorax.

Pneumothorax is a life threatening situation that requires fast treatment. There are two major classifications: Primary and Secondary. Staging of pneumothorax is also very important for treatment. Treatment of pneumont can be performed either from thoracic surgeons, or pulmonary physicians. In our current work we provide up-to-date information regarding pneumothorax classification, staging and treatment from the point of view of expert pulmonary physicians.

Acute respiratory distress syndrome and pneumothorax.

Acute respiratory distress syndrome (ARDS) can occur during the treatment of several diseases and in several interventional procedures as a complication. It is a difficult situation to handle and special care should be applied to the patients. Mechanical ventilation is used for these patients and several parameters are changed constantly until compliance is achieved. However, a complication that is observed during the application of positive airway pressure is pneumothorax. In our current work we will present definition and causes of pneumothorax in the setting of intensive care unit (ICU). We will identify differences and similarities of this situation and present treatment options.

Unusual causes of pneumothorax.

Pneumothorax is divided to primary and secondary. It is a situation that requires immediate treatment, otherwise it could have severe health consequences. Pneumothorax can be treated either by thoracic surgeons, or pulmonary physicians. In our current work, we will focus on unusual cases of pneumothorax. We will provide the etiology and treatment for each case, also a discussion will be made for each situation.

Bronchoscopic interventions for severe COPD.

Chronic obstructive pulmonary disease (COPD) causes severe handicap among smokers. Most patients have to remain under continuous oxygen therapy at home. Moreover, respiratory infections are very common among these patients and vaccination is obligatory against influenza. Emphysema and bronchiectasis are observed with computed tomography (CT) and in several situations these parenchymal damages are responsible for pneumothorax in one case and pseudomonas aeroginosa infection. Novel mini-invasive techniques are used currently for emphysema treatments which are described extensively throughout our current work.

Approach of the treatment for pneumothorax.

Pneumothorax can occur in several situations such as; chronic obstructive pulmonary disease (COPD) where emphysema is observed or due to a biopsy for malignancy suspicion. In any case it is a dangerous situation that requires immediate attention and treatment. Pneumothorax can be divided in primary and secondary. Staging of pneumothorax is also very important. In our current editorial we summarize etiology and treatment of pneumothorax from a panel of pulmonary physicians, oncologists and thoracic surgeons.

Pneumothorax: observation.

Pneumothorax based on the cause, it can be divided into two large categories; primary and secondary. The staging of pneumothorax plays a crucial role for treatment. Currently both thoracic surgeons and pulmonary physicians can handle efficiently treatment. Pulmonary physicians with the minimally medical thoracoscopy while thoracic surgeons with a more extensive intervention. Experience defines the outcome in most situations and not the method. In our current work we will present data regarding the observation of pneumothorax from a panel of experts.