Adenosine 2A Receptor Agonism Improves Survival in Extracorporeal Cardiopulmonary Resuscitation.

INTRODUCTION: Despite resuscitation advances including extracorporeal cardiopulmonary resuscitation (ECPR), freedom from neurologic and myocardial insult after cardiac arrest remains unlikely. We hypothesized that adenosine 2A receptor (A2AR) agonism, which attenuates reperfusion injury, would improve outcomes in a porcine model of ECPR. METHODS: Adult swine underwent 20 min of circulatory arrest followed by defibrillation and 6 h of ECPR. Animals were randomized to receive saline vehicle or A2AR agonist (ATL1223 or Regadenoson) infusion during extracorporeal membrane oxygenation. Animals were weaned off extracorporeal membrane oxygenation and monitored for 24 h. Clinical and biochemical end points were compared. RESULTS: The administration of A2AR agonists increased survival (P = 0.01) after cardiac arrest compared to vehicle. Markers of neurologic damage including S100 calcium binding protein B and glial fibrillary acidic protein were significantly lower with A2AR agonist treatment. CONCLUSIONS: In a model of cardiac arrest treated with ECPR, A2AR agonism increased survival at 24 h and reduced neurologic damage suggesting A2AR activation may be a promising therapeutic target after cardiac arrest.

Does Timing Matter? The Effect of Intensive Care Unit Arrival Timing on Elective Cardiac Surgery.

BACKGROUND: Due to staffing changes at scheduled intervals and decreases in essential staff in the evenings, late intensive care unit (ICU) arrivals may be at risk for suboptimal outcomes. Utilizing a regional collaborative, we sought to determine the effect of ICU arrival timing on outcomes in elective isolated coronary artery bypass. METHODS: Adults undergoing elective, isolated coronary artery bypass from 17 hospitals between 2013 and 2023 were identified. Patients with missing predicted risk of mortality or missing ICU arrival time were excluded. Late ICU arrival time was defined as between 6:00 pm and 6:00 am. Hierarchical logistic regression with appropriate predicted risk scores was utilized for outcome risk adjustment. RESULTS: We identified 11,638 patients, with 972 (8.4%) experiencing late ICU arrival. Late ICU arrival patients had higher predicted risk of morbidity or mortality (8.2%; [interquartile range {IQR}, 5.6%, 12.0%] vs 7.7% [IQR, 5.5%, 11.5%], P = .048) compared with early ICU arrival patients with longer median cardiopulmonary bypass times (96 minutes [IQR, 78, 119] vs 93 [IQR, 73, 116], P < .001). Late ICU arrival patients experienced more unadjusted complications including prolonged ventilation (7.7% vs 4.2%, P < .001) and operative mortality (2.0% vs 1.1%, P = .02), although no difference in failure-to-rescue (11.0% vs 10.4%, P = .84). Logistic regression with risk adjustment demonstrated late ICU arrival as a predictor of prolonged ventilation (odds ratio, 1.49 [95% CI, 1.12-1.99], P = .006). CONCLUSIONS: After adjustment, late ICU arrivals experienced higher rates of prolonged ventilation, although this did not translate to failure-to-rescue.

Mitral valve repair in a regional quality collaborative: Respect or resect?

Objective: Mitral valve repair is the gold standard for treatment of mitral regurgitation, but the optimal technique remains debated. By using a regional collaborative, we sought to determine the change in repair technique over time. Methods: We identified all patients undergoing isolated mitral valve repair from 2012 to 2022 for degenerative mitral disease. Those with endocarditis, transcatheter repair, or tricuspid intervention were excluded. Continuous variables were analyzed via Wilcoxon rank sum, and categorical variables were analyzed via chi-square testing. Results: We identified 1653 patients who underwent mitral valve repair, with 875 (59.2%) undergoing a no resection repair. Over the last decade, there was no significant trend in the proportion of repair techniques across the region (P = .96). Those undergoing no resection repairs were more likely to have undergone prior cardiac surgery (5.0% vs 2.2%, P = .002) or minimally invasive approaches (61.4% vs 24.7%, P < .001) with similar predicted risk of mortality (median 0.6% vs 0.6%, P = .75). Intraoperatively, no resection repairs were associated with longer bypass times (140 [117-167] minutes vs 122 [91-159] minutes, P < .001). Operative mortality was similar between both groups (1.1% vs 1.0%, P = .82), as were other postoperative outcomes. Anterior leaflet prolapse (odds ratio, 11.16 [6.34-19.65], P < .001) and minimally invasive approach (odds ratio, 6.40 [5.06-8.10], P < .001) were most predictive of no resection repair. Conclusions: Despite minor differences in operative times, statewide over the past decade there remains a diverse mix of both classic "resect" and newer "respect" strategies with comparable short-term outcomes and no major timewise trends. These data may suggest that both approaches are equivocal.

Impact of Frailty in Patients Undergoing Minimally Invasive Mitral Valve Surgery.

OBJECTIVE: Psoas muscle size is a reliable marker of sarcopenia and frailty that correlates with adverse outcomes after cardiac surgery. However, its use in mitral and minimally invasive cardiac surgery is lacking. We sought to determine whether frailty, as measured by psoas muscle index, increases surgical risk for minimally invasive mitral valve surgery. METHODS: Patients undergoing isolated minimally invasive mitral surgery via right minithoracotomy were identified. Patients who underwent maze, tricuspid intervention, and those who were emergent were excluded. Total psoas muscle area was calculated using the average cross-sectional area at the L3 vertebra on computed tomography scan and indexed to body surface area. Sarcopenia was defined as <25th gender-specific percentile. Patients were stratified by sarcopenia status and outcomes compared. RESULTS: Of 287 total patients, 192 patients met inclusion criteria. Sarcopenic patients were 6 years older (66 vs 60 years, P = 0.01), had lower preoperative albumin levels (4.0 vs 4.3 g/dL, P < 0.001), and had higher Society of Thoracic Surgeons risk of morbidity/mortality (13.1% vs 9.0%, P = 0.003). Operative major morbidity or mortality was 6.4% versus 5.5% (P = 0.824), while the 1-year mortality rate was 2.1% versus 0% (P = 0.08). After risk adjustment, psoas index did not predict operative morbidity or mortality. However, sarcopenia was associated with higher odds of readmission (odds ratio = 0.74, P = 0.02). CONCLUSIONS: Contrary to other cardiac operations, for patients undergoing isolated minimally invasive mitral valve surgery, sarcopenia was not associated with increased perioperative risk except for higher readmission rates. Minimally invasive surgical approaches should be strongly considered as the approach of choice in frail patients.

Extracorporeal Life Support Organization Center of Excellence recognition is associated with improved failure to rescue after cardiac arrest.

OBJECTIVE: The influence of Extracorporeal Life Support Organization (ELSO) center of excellence (CoE) recognition on failure to rescue after cardiac surgery is unknown. We hypothesized that ELSO CoE would be associated with improved failure to rescue. METHODS: Patients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. Patients were stratified by whether or not their operation was performed at an ELSO CoE. Hierarchical logistic regression analyzed the association between ELSO CoE recognition and failure to rescue. RESULTS: A total of 43,641 patients were included across 17 centers. In total, 807 developed cardiac arrest with 444 (55%) experiencing failure to rescue after cardiac arrest. Three centers received ELSO CoE recognition, and accounted for 4238 patients (9.71%). Before adjustment, operative mortality was equivalent between ELSO CoE and non-ELSO CoE centers (2.08% vs 2.36%; P = .25), as was the rate of any complication (34.5% vs 33.8%; P = .35) and cardiac arrest (1.49% vs 1.89%; P = .07). After adjustment, patients undergoing surgery at an ELSO CoE facility were observed to have 44% decreased odds of failure to rescue after cardiac arrest, relative to patients at non-ELSO CoE facility (odds ratio, 0.56; 95% CI, 0.316-0.993; P = .047). CONCLUSIONS: ELSO CoE status is associated with improved failure to rescue following cardiac arrest for patients undergoing cardiac surgery. These findings highlight the important role that comprehensive quality programs serve in improving perioperative outcomes in cardiac surgery.

Transient receptor potential vanilloid 4 channel inhibition attenuates lung ischemia-reperfusion injury in a porcine lung transplant model.

OBJECTIVE: Transient receptor potential vanilloid 4 (TRPV4) is a nonselective cation channel important in many physiological and pathophysiological processes, including pulmonary disease. Using a murine model, we previously demonstrated that TRPV4 mediates lung ischemia-reperfusion injury, the major cause of primary graft dysfunction after transplant. The current study tests the hypothesis that treatment with a TRPV4 inhibitor will attenuate lung ischemia-reperfusion injury in a clinically relevant porcine lung transplant model. METHODS: A porcine left-lung transplant model was used. Animals were randomized to 2 treatment groups (n = 5/group): vehicle or GSK2193874 (selective TRPV4 inhibitor). Donor lungs underwent 30 minutes of warm ischemia and 24 hours of cold preservation before left lung allotransplantation and 4 hours of reperfusion. Vehicle or GSK2193874 (1 mg/kg) was administered to the recipient as a systemic infusion after recipient lung explant. Lung function, injury, and inflammatory biomarkers were compared. RESULTS: After transplant, left lung oxygenation was significantly improved in the TRPV4 inhibitor group after 3 and 4 hours of reperfusion. Lung histology scores and edema were significantly improved, and neutrophil infiltration was significantly reduced in the TRPV4 inhibitor group. TRPV4 inhibitor-treated recipients had significantly reduced expression of interleukin-8, high mobility group box 1, P-selectin, and tight junction proteins (occludin, claudin-5, and zonula occludens-1) in bronchoalveolar lavage fluid as well as reduced angiopoietin-2 in plasma, all indicative of preservation of endothelial barrier function. CONCLUSIONS: Treatment of lung transplant recipients with TRPV4 inhibitor significantly improves lung function and attenuates ischemia-reperfusion injury. Thus, selective TRPV4 inhibition may be a promising therapeutic strategy to prevent primary graft dysfunction after transplant.

Prophylactic left atrial appendage ligation during coronary artery bypass grafting: A propensity score-matched analysis.

OBJECTIVE: The study objective was to evaluate short-term outcomes and statewide practice patterns of prophylactic left atrial appendage ligation in patients undergoing coronary artery bypass grafting without preoperative atrial fibrillation. METHODS: Adult patients who underwent on-pump coronary artery bypass grafting (2017-2023) within a regional collaborative were identified. Patients with a history of atrial fibrillation, previous cardiac surgery, or nondevice-based left atrial appendage ligation were excluded. Patients were stratified by left atrial appendage ligation status and were propensity score matched. Univariable analysis was used to compare short-term clinical outcomes. RESULTS: Of 16,547 patients examined, 442 underwent prophylactic left atrial appendage ligation. The propensity score-matched cohort (439 in the prophylactic left atrial appendage ligation group, 439 in the no prophylactic left atrial appendage ligation group) was compared and had no significant differences in preoperative Congestive heart failure, Hypertension, Age ≥ 75 (doubled), Diabetes mellitus, prior Stroke, Transient ischemic attack or Thromboembolism (doubled), Vascular disease, Age 65 to 74, Sex category (female)(CHA2DS2-VASc) scores or operative variables. The prophylactic left atrial appendage ligation group had longer crossclamp time (82 vs 76 minutes, P = .001), intensive care unit hours (72 vs 66, P = .001), and length of stay (6.0 vs 6.0 days, P = .010); increased postoperative atrial fibrillation (35% vs 24%, P < .001); and more discharges on anticoagulation (17% vs 8.2%, P < .001). There were no significant differences in postoperative stroke (1.1% vs 2.1%, P = .423), readmission (13% vs 9.6%, P = .118), operative mortality (2.5% vs 1.6%, P = .480), or readmission for thrombotic or bleeding complications (0.7% vs 1.1%, P = .724). Hospitalization costs were significantly higher for the prophylactic left atrial appendage ligation group ($43,478 vs $40,645, P < .001). The rate of prophylactic left atrial appendage ligation during coronary artery bypass grafting increased from 1.61% (2017) to 5.65% (2023) (P < .001). CONCLUSIONS: Despite higher rates of postoperative atrial fibrillation, discharge on anticoagulation, and hospitalization costs in patients undergoing prophylactic left atrial appendage ligation during coronary artery bypass grafting, there was no difference in short-term clinical end points including stroke and operative mortality.

Cardiac Surgery Outcomes During the COVID-19 Pandemic Worsened Across All Socioeconomic Statuses.

BACKGROUND: Increasing socioeconomic distress has been associated with worse cardiac surgery outcomes. The extent to which the pandemic affected cardiac surgical access and outcomes remains unknown. We sought to examine the relationship between the COVID-19 pandemic and outcomes after cardiac surgery by socioeconomic status. METHODS: All patients undergoing a Society of Thoracic Surgeons (STS) index operation in a regional collaborative, the Virginia Cardiac Services Quality Initiative (2011-2022), were analyzed. Patients were stratified by timing of surgery before vs during the COVID-19 pandemic (March 13, 2020). Hierarchic logistic regression assessed the relationship between the pandemic and operative mortality, major morbidity, and cost, adjusting for the Distressed Communities Index (DCI), STS predicted risk of mortality, intraoperative characteristics, and hospital random effect. RESULTS: A total of 37,769 patients across 17 centers were included. Of these, 7269 patients (19.7%) underwent surgery during the pandemic. On average, patients during the pandemic were less socioeconomically distressed (DCI 37.4 vs DCI 41.9; P < .001) and had a lower STS predicted risk of mortality (2.16% vs 2.53%, P < .001). After risk adjustment, the pandemic was significantly associated with increased mortality (odds ratio 1.398; 95% CI, 1.179-1.657; P < .001), cost (+$4823, P < .001), and STS failure to rescue (odds ratio 1.37; 95% CI, 1.10-1.70; P = .005). The negative impact of the pandemic on mortality and cost was similar regardless of DCI. CONCLUSIONS: Across all socioeconomic statuses, the pandemic is associated with higher cost and greater risk-adjusted mortality, perhaps related to a resource-constrained health care system. More patients during the pandemic were from less distressed communities, raising concern for access to care in distressed communities.

The Society of Thoracic Surgeons Definition of Failure to Rescue Should Consider Including Cardiac Arrest.

BACKGROUND: Failure to rescue (FTR) is a new quality measure in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. The STS defines FTR as death after permanent stroke, renal failure, reoperation, or prolonged ventilation. Our objective was to assess whether cardiac arrest should be included in this definition. METHODS: Patients undergoing an STS index operation in a regional collaborative (2011-2021) were included. The performance of the STS definition of FTR was compared with a definition that included the STS complications plus cardiac arrest (STS+). Centers were grouped into FTR rate terciles using the STS and STS+ definitions of FTR, and changes in their relative performance rating were assessed. RESULTS: A total of 43,641 patients were included across 17 centers. Cardiac arrest was the most lethal complication: 55.0% of patients who experienced cardiac arrest died. FTR after any complication (13 total) occurred among 884 patients. The STS definition of FTR accounted for 83% (735 of 884) of all FTR. The addition of cardiac arrest to the STS definition significantly increased the proportion of overall FTR accounted for (92.2% [815 of 884]; P < .001). Choice of FTR definition led to substantial differences in center-level relative performance rating by FTR rate. CONCLUSIONS: Mortality after cardiac arrest is not completely captured by the STS definition of FTR and represents an important source of potentially preventable death after cardiac surgery. Future quality improvement efforts using the STS definition of FTR should account for this.