Heart failure (HF) remains a public health concern affecting millions of individuals worldwide. Despite recent advances in device-related therapies, the prognosis for patients with chronic HF remains poor with significant long-term risk of morbidity and mortality. Left ventricular assist devices (LVADs) have transformed the landscape of advanced HF management, offering circulatory support as destination therapy or as a bridge for heart transplantation. Among the latest generation of LVADs, the HeartMate 3 (HM3) has gained popularity due to improved clinical outcomes and lower risk of serious adverse events when compared to previous similar devices. The ELEVATE (Evaluating the HeartMate 3 with Full MagLev Technology in a Post-Market Approval Setting) Registry and the MOMENTUM 3 (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3) trial represent landmark investigations into the performance and comparative effectiveness of the HeartMate 3 LVAD. This review provides a comprehensive synthesis of the safety and efficacy of the 2-year and 5-year HM3 LVAD outcomes, highlighting key findings, methodological considerations, implications for clinical practice and future directions.

ObjectivesThis study aimed to compare the sensitivity, specificity, receiver operating characteristic (ROC), and area under the curve (AUC) using modified frailty index (mFI), EuroSCORE II, and combined mFI-11 and EuroSCORE II to predict in-hospital mortality and composite morbidities. DesignRetrospective cohort study SettingSongklanagarind Hospital, a tertiary care center in the Southern of Thailand. ParticipantsElderly patients aged ≥ 60 years who underwent elective open-heart surgical procedures on a pump between January 2017 and December 2022 were included. InterventionsROC curves were constructed to evaluate the discriminatory power of EuroSCORE II and mFI-11 for predicting in-hospital mortality and postoperative complications. Measurements and Main ResultsThe actual in-hospital mortality was 2.5 % for all patients. The discriminative accuracy of mFI-11, EuroSCORE II, and combined mFI-11 with EuroSCORE II for predicting in-hospital mortality was good, with respective AUCs of 0.733 (95% CI 0.6157–0.8499), 0.793 (0.6826–0.9026), and 0.78 (0.6686–0.893). The AUC of mFI-11 for predicting postoperative cardiac, respiratory, neurological, and renal complications was 0.558 (95% CI 0.5101–0.6063), 0.606 (0.5542–0.6581), 0.543 (0.4533–0.6337), and 0.652 (0.5859–0.7179), respectively, and that of EuroSCORE II was 0.553 (0.5038–0.6013), 0.631 (0.578–0.6836), 0.619 (0.5306–0.7076) and 0.702 (0.6378–0.7657), respectively. ConclusionFrailty (mFI-11) and EuroSCORE II demonstrated good discrimination in ROC analysis, with EuroSCORE II showing superior predictive accuracy for in-hospital mortality in elderly elective cardiac surgery patients. However, neither score independently predicted mortality in multiple logistic regression, nor did combining them enhance predictive power significantly. Furthermore, both scores were less effective in predicting postoperative complications.

ObjectivesDescribe clinical characteristics and outcomes including transfusion requirements of pediatric patients with congenital heart disease undergoing aspiration thrombectomy DesignRetrospective chart review SettingQuaternary academic children's hospital ParticipantsPatients < 18yrs with congenital heart disease undergoing aspiration thrombectomy from November 2017-February 2022. Measurements and main results13 patients underwent mechanical thrombectomy with the Penumbra Indigo System®. Median age was 3.8 years and median weight was 15.2kg. Seven patients had palliated single ventricle and 6 had biventricular circulation. Nine patients were receiving ICU care pre-procedure and 12 required ICU care post-procedure. Indications for thrombectomy included systemic venous thrombus (n=7), pulmonary arterial thrombus (n=3), systemic arterial thrombus (n=2), and systemic to pulmonary shunt occlusion (n=1). Median estimated blood loss was 7.7ml/kg (interquartile range 1.4ml/kg-15.8ml/kg, range 0.5ml/kg-51.5ml/kg). Seven patients required intraoperative transfusion of pRBCs (n=4), FFP (n=2), platelets (n=3), and/or cryoprecipitate (n=1). In those requiring transfusion, median transfusion volume was 22ml/kg (interquartile range 15.5ml/kg-76.5ml/kg, range 9.3ml/kg-132.8ml/kg). Thrombectomy was successful in 8 of 13 patients, although 3 experienced recurrent thrombosis. ConclusionsMechanical aspiration thrombectomy is increasingly used to treat critically ill pediatric patients and presents unique anesthetic considerations particularly related to the need for volume and blood product resuscitation

The complex care of patients on ECMO requires a high level of collaboration between multiple medical specialties and allied health professionals. Effective and timely communication between team members is imperative in ensuring patient safety. The COVID-19 pandemic posed unique challenges in the care of patients on ECMO. Communication between team members was complicated by social distancing recommendations, increased patient volume, and staff turnover. In this article, we describe a hybrid approach to rounds that allowed team members to attend virtually or in-person to improve team communication. Weekly hybrid ECMO rounds were held to discuss patient cases and work collectively to establish patient centered goals for the following week. Critical care and surgical consultants, RN ECMO specialists, RNs, perfusionists, respiratory therapists, physical and occupational therapists, pharmacists, ethics committee members, and patient family members were invited to attend hybrid ECMO rounds. After eight months of rounds, medical care team members were asked to provide feedback regarding the rounds format, strengths, and weaknesses. The most frequently identified strengths were improved multidisciplinary communication and continuity of care. This article demonstrates that hybrid virtual and in-person patient rounds are a feasible way for ECMO programs to improve team communication and overall patient care.

ObjectivesThe process of placing a patient on venoarterial extracorporeal membrane oxygenation (VA-ECMO) is complex and requires the activation and coordination of numerous personnel from a variety of disciplines to achieve procedural success, initiate flow, and subsequently monitor the patient's condition. Existing literature suggests that nighttime cannulation for extracorporeal cardiopulmonary resuscitation (eCPR) is associated with adverse outcomes compared to daytime cannulation. Given the strain on personnel that this process can create, it is plausible that patients who are initiated on VA-ECMO for non-eCPR indications during the nighttime and on weekends, which are generally periods with reduced staffing as compared to weekday daytime hours, may also experience worse outcomes including decreased survival. Our objective was to determine whether nighttime/weekend VA-ECMO cannulations were associated with worse outcomes including decreased survival. Designretrospective cohort study SettingLarge quaternary academic medical center Participantspatients InterventionsVA-ECMO cannulation during the day versus night/weekends MeasurementsWe performed a retrospective review of patients at a single center who underwent VA-ECMO cannulation between 2011-2021. There were 468 patients included: 158 (33.8%) patients in the daytime cannulation cohort and 310 (66.2%) in the nighttime/weekend cannulation cohort. Nighttime and weekend VA-ECMO cannulations were not associated with increased 1-year mortality (64.2% vs 60.1%, P=0.42) or renal replacement therapy (25.4% vs 22.2%, P=0.49). ConclusionsWe conclude nighttime and weekend VA-ECMO cannulations can be performed safely at a large academic medical center.

ObjectivesThis study retrospectively assessed the incidence and severity of perioperative protamine reactions in adult patients with documented history of fish allergy. DesignRetrospective, observational. SettingLarge, academic tertiary referral center. ParticipantsAdults with fish allergies undergoing surgeries involving protamine, from January 1, 2008, to March 1, 2018. InterventionsPerioperative protamine administration in patients with documented fish allergy. Measurements and Main ResultsWe reviewed perioperative protamine and anaphylactic reactions. A diagnosis of anaphylaxis or protamine reaction was based on clinical suspicion, perioperative events, and postoperative evaluations. Among 214 patients, two cases (<1%) of anaphylaxis or protamine reactions occurred. Cardiac procedures were most common (67%). Median intraoperative heparin dosage was 46,000 IU, and protamine dosage was 310 mg. Nearly all patients (99%) were admitted to the ICU postoperatively, with a median hospital stay of 6.5 days [5.2, 14.6]. There were three deaths (1%) within 30 days and 15 (7%) within a year. ConclusionsOur study suggests that in patients with history of fish allergy, cross-reactivity with protamine is unlikely, as anaphylaxis and/or protamine reactions were rare among this patient population in the perioperative environment. Based on the findings herein, this study does not recommend avoiding protamine solely based on a history of fish allergy when heparin reversal is required during surgery.

ObjectivePostoperative atrial fibrillation (POAF) is associated with increased morbidity, mortality, and length of stay. The objective of this study was to assess the utility of left atrial strain (LAS) to predict POAF in patients undergoing off pump coronary artery bypass grafting (OPCABG). DesignRetrospective Observational Study. SettingTertiary Care Level Hospital. Participants103 undergoing OPCABG. InterventionsNone. Measurements and ResultsIn addition to comprehensive TTE, LAS was measured for reservoir (R), conduction (CD), and contraction (CT) components. The POAF was defined as new electrocardiography evidence of AF requiring treatment. Logistic regression was done to assess the factors associated with POAF. The diagnostic accuracy of variables in predicting POAF was assessed by ROC analysis.POAF was documented in 24 (23.3%) patients. There was no difference in EF, average GLS and proportion of LVDD grades between patients with POAF and patients without POAF. All the three components of LAS: LAS R (19.2 ± 4.7 vs 23.5 ± 4.8; p<0.001), LAS CD (8.9 ± 3.7 vs 12.3 ± 4.8; p=0.1) and LAS CT (10.3 ± 3.9 vs 12.1 ± 4.1; p=0.04) were significantly lower among patients with POAF as compared to patients without POAF respectively. According to univariate analysis, all components of LAS were found to be statistically significant predictors of POAF. On multivariate analysis, only age (OR=1.08; p=0.025) and LAS R (OR=0.84; p=0.004) were independently associated with POAF. The LAS R was a better predictor of POAF with AUC of 0.758, than LAS CD (AUC=0.67) and LAS CT (AUC=0.62). The LAS R had optimal cut-off of 23% with sensitivity of 95.8% (C.I. 78.9%- 99.9%) and specificity of 49.4% (37.9%- 60.9%) to predict POAF. ConclusionsLAS R is significant predictor of POAF and its use can be recommended for screening of OPCABG patients at high risk of POAF.

ObjectivesGiven both the short- and long-term deleterious effects of opioids, there has been increased focused on reducing the use of postoperative opioid analgesia. As patients undergoing cardiac surgery often require high levels opioids postoperatively, understanding risk factors for increased postoperative opioid use may be helpful for the development of patient specific opioid sparing pain regimens for this patient population. DesignThis study was a retrospective analysis of data from our electronic medical records and the Society of Thoracic Surgeon's database. SettingThis was a single-institution study at an academic medical center. ParticipantsAll patients undergoing open adult cardiac surgery were included. Exclusion criteria were patients with continuous IV narcotic drips and operative mortality. InterventionsAs this was a retrospective study, no interventions were conducted on the participants. Measurements and Main ResultsData for patient's postoperative opioid requirements was extracted from the electronic medical record. Total opioid use on postoperative days 0-3 was converted to morphine milligram equivalent (MME) via standard conversion factors. A total of 1,604 patients were included in the study. 456 patients were female, and 1,066 underwent coronary artery bypass grafting. Patients undergoing CABG had 31.0% increased use of MME (P<.001), patients with liver disease had 76.3% increased use of MME (P=.005), and patients with patient-controlled analgesia had 48.8% increased use of MME (P<.001) during postoperative days 0-3. Younger age (P<.001) and increased BMI (P<.001) were also associated with increased MME prescription. ConclusionsPatients undergoing CABG, patients with liver disease, patients with patient-controlled analgesia, in addition to younger age and increased BMI, are associated with increased narcotic use after cardiac surgery. Implementation of more aggressive perioperative multimodal opioid sparing regimens should be considered for these patient groups.

ObjectiveTo assess whether bioimpedance spectroscopy analysis (BIA) can be used as a potential tool to guide postoperative fluid management in patients who undergo cardiac surgery. DesignAn observational study. SettingA single, tertiary hospital. ParticipantsPatients who underwent cardiac surgery with cardiopulmonary bypass between June to November 2023 who were able to undergo BIA measurements. InterventionsNone. Measurements and Main ResultsCorrelations between BIA measurements of extracellular fluid (ECF) and total body water (TBW) volumes and daily changes in weight and 24-hour net intake and output (I/O) of fluids were assessed. Correlations between pre-discharge ECF volume as a percentage of TBW volume (ECF%TBW) and pre-discharge Pro-BNP (Pro-BNP) levels and readmissions were analyzed. Changes in daily ECF volume significantly correlated with daily weight changes (p<0.01) and 24-hr I/O (p<0.01). TBW volume significantly correlated with daily weight changes (p<0.01) and with 24-hr I/O (p=0.04). Daily weight changes did not correlate with 24-hr I/O (p=0.06). The patients with pre-discharge ECF%TBW(%) greater than or equal to 51 had significantly higher pre-discharge Pro-BNP than those with ECF%TBW(%) less than 51 (p<0.01). Patients who had heart failure revisits or admissions after discharge had a higher pre-discharge ECF%TBW(%) on index admission compared to patients that did not have heart failure readmissions (p=0.01). ConclusionsUtilization of BIA measurements in postoperative cardiac surgery patients may be a valuable tool to quantitatively determine fluid status to help guide fluid management in this patient population. Further studies validating the use of BIA for postoperative care in this population are warranted.