Cardiac Surgical Patients Research Articles

Preoperative Non-Invasive Mapping for Targeted Concomitant Surgical Ablation of Non-Paroxysmal Atrial Fibrillation (PreMap Study)

Background/Objectives: The present study introduces our targeted approach for concomitant surgical ablation (CSA) using non-invasive phase mapping (NIPM) and describes its effectiveness regarding freedom from atrial fibrillation (AF). Methods: This retrospective study included cardiac surgical patients undergoing preoperative NIPM for CSA guidance. The primary outcome was freedom from AF six months after surgery. Key secondary outcomes were freedom from AF at hospital discharge and three months, frequency of biatrial ablation, feasibility and safety, the rate of CSA, complications, and levels of biomarkers. The control group consisted of patients undergoing CSA without NIPM. Results: Forty-four patients (Control: n = 31/NIPM: n = 13) were included. The NIPM group was younger (64 vs. 71 years [p = 0.044]), had a lower EuroSCORE II (2.6 vs. 3.4 [p = 0.041]), and a smaller left atrial size (46 mm vs. 54 mm [p = 0.025]). Surgery duration was longer in the NIPM group (285 vs. 230 min [p = 0.037]) with similar aortic cross-clamp times. Preoperative NIPM resulted in an effective frequency of CSA of 93%. CSA was more extensive in the NIPM group, with biatrial ablation performed in 54% vs. 26% of patients (p = 0.09). Conclusions: Routine preoperative NIPM in patients with non-paroxysmal atrial fibrillation might aid in increasing the number of patients receiving concomitant surgical ablation and developing a personalized CSA approach for every patient.

Quantitative electroencephalography predicts postoperative delirium in adult cardiac surgical patients from a prospective observational study

The diagnostic and prognostic value of quantitative electroencephalogram (qEEG) in the the onset of postoperative delirium (POD) remains an area of inquiry. We aim to determine whether qEEG could assist in the diagnosis of early POD in cardiac surgery patients. We prospectively studied a cohort of cardiac surgery patients undergoing qEEG for evaluation of altered mental status. Delirium was assessed with the Confusion Assessment Method for the intensive care unit (CAM-ICU). The qEEG were interpreted by clinician, and reports were reviewed to identify features such as amplitude-integrated EEG (aEEG), relative band energy in ɑ/β/θ/δ frequencies, α variability and spectral entropy. The raw EEG was also preprocessed offline for nonlinear analysis including Multi-scale Entropy analysis (MSE) and Detrended Fluctuation Analysis (DFA). Linear regression was performed to quantify associations among EEG findings, delirium, and clinical outcomes. Receiver operating characteristic (ROC) analysis was used to assess the accuracy of the qEEG as POD prediction index. Meanwhile, a comprehensive comparison of dynamic complexity across time scales and DFA exponent α was conducted between the non-delirium and delirium groups. Among those recruited initially (n = 64), 60 patients were evaluated and 29 patients (48.3%) met delirium criteria. When comparing delirious and non-delirious participants, significant differences were found in terms of age (p = 0.03), APACHE II scores (p = 0.004), lactate (p = 0.03), and hospital days (p = 0.048). Multivariate regression analysis revealed that the first quartile (Q1) and fourth quartile (Q4) of peak or valley value of F3-P3/F4-P4 derivation (for example, Q1 of peak value for F3-P3 derivation: OR 12.4, 95% CI 1.72–89.76, p = 0.012) showed a higher association with the incidence of POD. ROC analysis demonstrated qEEG could predict POD with high sensitivity and specificity, yielding an overall good accuracy. For instance, the peak value of F3-P3 derivation (the area under the curve of 0.81), as a predictor of POD showed a sensitivity of 90% and specificity pf 72% (p < 0.001). Furthermore, the MSE curves indicated that the non-delirium group exhibited higher complexity values at fine scales, while the delirium group had significantly higher complexity at coarse scales. The DFA comparison results revealed that long-term fractal exponent alpha2 values were higher in delirium patients than in non-delirium patients, with significant differences observed at the F4-P4 electrodes (p = 0.04). The qEEG can reliably predict delirium after heart cardiac surgery. It is helpful for clinicians to early diagnose and manage these patients.Trial registration: Clinical Trials.gov Identifier, NCT03351985. Registered 1 December 2017.

Non-pharmacologic nephroprotective strategies combined with nitric oxide delivery in cardiac surgical patients with chronic kidney disease

Introduction: One of the promising areas of nephroprotection in cardiac surgery is perioperative nitric oxide donation. The combined using of Goal-Directed Perfusion (GDP), Kidney Disease Improving Global Outcomes (KDIGO) and nitric oxide delivery strategies can reduce the incidence of acute kidney injury by targeting different links in the pathogenesis of kidney injury. Objective: To assess the nephroprotective properties of nitric oxide delivery in combination with KDIGO and GDP strategies during cardiac surgery with cardiopulmonary bypass in patients with chronic kidney disease.Methods: The study included 136 cardiac surgery patients with chronic kidney disease. The patients were randomized into 2 groups of 68 individuals each. The complex of non-pharmacological nephroprotection methods KDIGO and GDP was used in the control group. In the main group, perioperative delivery of nitric oxide was performed along with a set of KDIGO and GDP measures.Results: In the main group, the incidence of acute kidney injury was significantly lower compared to the control: 23.5% versus 39.7% (p = 0.043), respectively. Both groups did not differ in the concentration of renal injury biomarkers. In the control group, the concentration of exhaled nitric oxide significantly decreased 2 hours after surgery (p &lt; 0.001), while in the main group no changes were recorded (p = 0.966). Conclusion: During cardiac surgery in patients with chronic kidney disease, delivery of nitric oxide in combination with the KDIGO and GDP measures reduced the incidence of acute kidney injury compared with the isolated using of non-pharmacological nephroprotective methods via leveling the perioperative deficiency of endogenous nitric oxide but did not affect the expression of kidney injury biomarkers. ClinicalTrials.gov ID NCT05757557 Received 31 October 2024. Revised 21 November 2024. Accepted 22 November 2024. FundingThe study was performed within the framework of the state assignment (topic No. 122123000017-3). Conflict of interestThe authors declare no conflict of interest. Contribution of the authorsConception and study design: M.A. Tyo, N.O. Kamenshchikov, Yu.K. Podoksenov, B.N. KozlovData collection and analysis: M.A. Tyo, I.V. Kravchenko, E.A. Churilina, Yu.S. SvirkoStatistical analysis: M.A. Tyo, I.V. KravchenkoDrafting the article: M.A. TyoCritical revision of the article: N.O. Kamenshchikov, Yu.K. Podoksenov, B.N. KozlovFinal approval of the version to be published: M.A. Tyo, Yu.K. Podoksenov, I.V. Kravchenko, E.A. Churilina, Yu.S. Svirko, B.N. Kozlov, N.O. Kamenshchikov

Prognostic models for prediction of perioperative allogeneic red blood cell transfusion in adult cardiac surgery: A systematic review and meta-analysis.

Identifying cardiac surgical patients at risk of requiring red blood cell (RBC) transfusion is crucial for optimizing their outcome. We critically appraised prognostic models preoperatively predicting perioperative exposure to RBC transfusion in adult cardiac surgery and summarized model performance. Design: Systematic review and meta-analysis. Studies developing and/or externally validating models preoperatively predicting perioperative RBC transfusion in adult cardiac surgery. Information sources MEDLINE, CENTRAL & CDSR, Embase, Transfusion Evidence Library, Web of Science, Scopus, ClinicalTrials.gov, and WHO ICTRP. Risk of bias and applicability: Quality of reporting was assessed with the Transparent Reporting of studies on prediction models for Individual Prognosis or Diagnosis adherence form, and risk of bias and applicability with the Prediction model Risk of Bias ASsessment Tool. Random-effects meta-analyses of concordance-statistics and total observed:expected ratios for models externally validated ≥5 times. Nine model development, and 27 external validation studies were included. The average TRIPOD adherence score was 66.4% (range 44.1%-85.2%). All studies but 1 were rated high risk of bias. For TRUST and TRACK, the only models externally validated ≥5 times, summary c-statistics were 0.74 (95% CI: 0.65-0.84; 6 contributing studies) and 0.72 (95% CI: 0.68-0.75; 5 contributing studies) respectively, and summary total observed:expected ratios were 0.86 (95% CI: 0.71-1.05; 5 contributing studies) and 0.94 (95% CI: 0.74-1.19; 5 contributing studies), respectively. Considerable heterogeneity was observed in all meta-analyses. Future high quality external validation and model updating studies which strictly adhere to reporting guidelines, are warranted.

RESULTS OF APPLICATION OF THE PROTOCOL FOR THE PREVENTION OF BLEEDING IN CARDIAC SURGICAL PATIENTS WITH PATHOLOGY OF THE AORTIC VALVE AND AORTIC ROOT

Purpose of the study: to evaluate the results of using a protocol for the prevention of bleeding in cardiac surgical patients with pathology of the aortic valve and aortic root to optimize tactics for preventing bleeding.Materials and methods: the first group included 185 cardiac surgical patients with pathology of the aortic valve and aortic root, who underwent surgery on the aortic valve, during the treatment of which a bleeding prevention protocol was applied. The second group consisted of 237 cardiac surgical patients with pathology of the aortic valve and aortic root who underwent surgery on the aortic valve, during whose treatment a bleeding prevention protocol was not used. Data were collected on the management tactics of the preoperative, intraoperative and postoperative periods, such as:– anamnestic data, results of echocardiographic examination, laboratory data: preoperative level of hemoglobin, fibrinogen;– intraoperative level of hemoglobin, fibrinogen, dose of transfused cryoprecipitate, thromboelastometry data, intraoperative blood loss;– drainage discharge during 1 day of the postoperative period, frequency of bleeding, resternotomy, and deaths.Study results: In the second group of patients, the number of cases of intraoperative hypofibrinogenemia was almost 5 times greater than in group 1; out of 237 patients, 62 (26.2%) had a critically low level of fibrinogen. Fibrinogen hemodilution coagulopathy (intraoperative hypofibrinogenemia) was associated with resternotomy: Х2 = 63.375, p = 0, df = 1, HR = 11.686, 95% CI: 5.61-24.33. Complications associated with bleeding were more common in the second group of patients – 44 (18,6%) cases out of 237 operated patients, Х2 = 10,6; р = 0,001, Х2Yates = 9,693; р = 0,002, RR = 2,453, 95% CI: 1,39-4,34. In the first group, there were only 14 (7,6%) cases of complications associated with bleeding out of 185 operated patients. Significant differences were also found in the frequency of resternotomies: in group 1 – 3 (1.6%) cases, in group 2 – 28 (11.8%) Х2 = 15,859; р = 0 (Х2Yates = 14,397, р = 0; р (F) = 0; RR = 7,286, 95% CI: 2,25-23,59). Of 185 operations in group 1, only 3 cases of resternotomy were observed, which corresponds to 1.6% of all patients in group 1. Upon repeated inspection of the surgical wound, surgical sources of bleeding were identified in all 3 cases. Of the 237 operations in group 2, there were 28 cases of repeated revision of the surgical wound. Of the 28 resternotomies, only in 15 cases a surgical source of bleeding was identified, therefore, the remaining 13 cases of bleeding occurred due to coagulopathy. In group 1, there were no cases of resternotomy performed due to hypocoagulable bleeding. A statistically significant association was found between preoperative anemia and resternotomy (x2, p = 0.039, RR = 2.03, 95% CI: 1-4).Conclusions:1) intraoperative hypofibrinogenemia increases the risk of resternotomy 11 times (x2 = 63.375, p = 0, df = 1, RR = 11.686, 95% CI: 5.61-24.33);2) preoperative anemia doubles the risk of resternotomy (p = 0,039, ОR = 2.03, 95% CI: 1-4);3) when using the bleeding prevention protocol, intraoperative hypofibrinogenemia occurs 5 times less often;4) when using the bleeding prevention protocol, complications associated with bleeding are 2.5 times less common: Х2 = 10,6; р = 0,001, Х2Yates = 9,693; р = 0,002, RR = 2,453, 95% CI: 1,39-4,34;5) when using a bleeding prevention protocol, the risk of resternotomy is reduced by 7 times: Х2 = 15,859; р = 0 (Х2Yates = 14,397, р = 0; р (F) = 0; RR = 7,286, 95% CI: 2,25-23,59).

Comparison of Lung Ultrasound and Auscultation for confirmation of bilateral air entry after endotracheal intubation at two different tidal volumes in cardiac surgical patients - A Crossover Study

Comparison of Lung Ultrasound and Auscultation for confirmation of bilateral air entry after endotracheal intubation at two different tidal volumes in cardiac surgical patients - A Crossover Study

Trends in cardiac arrest outcomes & management in children with cardiac illness category compared to non-cardiac illness category: An analysis from the AHA get with the guidelines®-resuscitation registry

IntroductionContemporary rates of survival after pediatric in-hospital CPR events and trends in survival over the last 20 years have not been compared based on illness category. We hypothesized that survival to hospital discharge for surgical-cardiac category is higher than the non-cardiac category, and rates of survival after in-hospital CPR increased over time in all categories. MethodsThe AHA Get With The Guidelines®-Resuscitation registry was queried for index CPR events in children < 18 years of age from 2000 to 2021. Categories were surgical-cardiac (in-hospital CPR event following cardiac surgery); medical-cardiac (CPR event in non-surgical cardiac disease); and non-cardiac (CPR event in patients without cardiac disease). The primary outcome was survival to hospital discharge. We compared eras 2000–2004, 2005–2009, 2010–2014, and 2015–2021 with mixed logistic regression models, including event year as a continuous predictor and site as a random effect. ResultsOf 16,241 index events, in-hospital CPR event rates by illness category were: 19 % surgical-cardiac, 18 % medical-cardiac, and 63 % non-cardiac. Surgical-cardiac category had the highest rate of survival to hospital discharge compared to medical-cardiac and non-cardiac categories (56 % vs. 44 % vs. 46 %; p < 0.001). After controlling for age, location of event, and hospital size, the odds of survival were highest for surgical-cardiac category (aOR 1.28, 95 % CI 1.17–1.41) and lower for medical-cardiac category (aOR 0.90, 0.82–0.98), compared to the non-cardiac category. Odds of survival increased for all illness categories from the 2000–2004 era to the 2015–2021 era. Rates of improvement differed among illness categories with medical-cardiac having the lowest increased odds per era. Surgical-cardiac patients had the highest rates of extracorporeal resuscitation (ECPR) (20 % across the cohort), though the greatest increase in ECPR utilization was in the non-cardiac population (52 % increased odds per era). ConclusionsOver the last 20 years, both survival to hospital discharge and ECPR use has increased in all in-hospital CPR event illness categories. Children with surgical-cardiac CPR event have higher odds of survival to hospital discharge compared to non-cardiac CPR event categories, whereas odds of survival were lowest with medical-cardiac CPR events.

A multivariate and retrospective analysis of the impact of intra-aortic balloon counterpulsation in Open-Heart surgery

Background The use of intraaortic balloon pump (IABP) effectively reduces left ventricular afterload and significantly increases coronary perfusion pressure by raising aortic diastolic pressure. This study examined the short and medium-term outcomes of 22,540 adult cardiac surgical patients requiring an IABP. Methods From 2009 to 2018, 1114 patients (4.94%) undergoing open-heart surgery at a single tertiary cardiac hospital received IABP support and were included in this retrospective study. They were categorized into pre-operative (Group A, n = 577), intra-operative (Group B, n = 475), and post-operative (Group C, n = 62) IABP insertion groups. Results Cardiogenic shock occurred in 11.2% of cases, mainly in Group A. Hemodynamic instability (38.8%) drove IABP use in Groups A and C, while difficulty weaning from CPB was the primary reason in Group C. The overall operative mortality rate was 10.9%, highest at 25.8% postoperatively. Multivariate analysis identified significant predictors of mortality: age (OR: 1.067, 95% CI: 1.041–1.094, p < 0.001), higher BMI (OR: 1.071, 95% CI: 1.017–1.128, p = 0.009), pulmonary hypertension (OR: 2.085, 95% CI: 1.302–3.341, p = 0.002), renal disease (OR: 2.780, 95% CI: 1.556–4.967, p < 0.001), and cardiogenic shock (OR: 3.684, 95% CI: 2.066–6.569, p < 0.001). Complications were more common in Group C, especially with renal disease. Average preoperative and postoperative stays were 4.0 ± 4.8 days and 15.2 ± 20.4 days, respectively, with no significant differences between groups. Conclusion IABP might offer safety for open-heart surgery, with longer hospital stays potentially associated with high-risk patients. Pre-operative IABP prophylaxis could be crucial in high-risk open-heart cases to reduce mortality.Clinical registration number: NHG DSRB Ref No# 2016/01070 and 2019/00397.

Acute Effects of Aminophylline Effects on Hemodynamic Parameters and Fluid Balance in Pediatric Cardiac Intensive Care Patients: Machine Learning Insights Using High Fidelity Data.

Fluid overload is associated with increased morbidity and mortality after pediatric cardiac surgery. Management of fluid overload can be difficult and conventional tools may increase the risk of acute kidney injury. This study aimed to study the effects of aminophylline on fluid balance, urine output, blood urea nitrogen, and serum creatinine. Pediatric cardiac surgical patients who received aminophylline between September 2022 and December 2023 were identified. Data for various clinical parameters before and after an aminophylline dose were collected. Paired univariable analyses and a random forest classifier were conducted to help characterize the effects of aminophylline. A total of 169 aminophylline administrations in 72 unique patients were included in the final analyses. Fluid balance decreased by 115% in the 24h after aminophylline administration compared to the 24h preceding. Urine output peaked at 2h after administration and increased 100% from baseline. Heart rate increased by 5% after administration and peaked between 2 and 4h after. In pediatric patients after cardiac surgery, a 5mg/kg dose of aminophylline is safe and is associated with a reduction in fluid balance and increase in urine output without significantly changing blood urea nitrogen or serum creatinine levels.

The influence of rhythm disturbances on the results of combined operations of pulmonary endarterectomy and coronary artery bypass grafting in patients with chronic thromboembolic pulmonary hypertension and coronary heart disease

Aim. To study the features of the early postoperative period in patients with chronic thromboembolic pulmonary hypertension (CTEPH) with surgically significant stenosis of the coronary arteries and to evaluate the impact of cardiac arrhythmias on the hospital period after pulmonary endarterectomy (PEA) in combination with coronary artery bypass grafting (CABG).Material and methods. The study cohort included 45 patients with CTEPH with surgically significant coronary artery stenosis at the age of 61.4 (55.3-69.5) years. All patients underwent PEA (1st stage) and CABG (2nd stage). The relationship between concomitant rhythm disturbances and various complications in the early postoperative period was assessed using logistic regression analysis.Results. Initially, in the study cohort, rhythm disturbances were recorded in 33.3% of cases, where atrial fibrillation accounted for a large proportion. Among the early postoperative complications, the leading ones were neurological disorders (28.9%). Hospital mortality was 6.7%. Concomitant rhythm disturbances in the studied patients were associated with the postoperative development of neurological disorders (OR 4.7 (2.5-7.3; p=0.02)), heart failure (OR 2.2 (1.5-6.8); p=0.03)) and acute renal failure (OR 2.4 (1.4-7.9; p=0.01)).Conclusion. In high-risk cardiac surgical patients with CTEPH and surgically significant coronary artery stenosis, various rhythm disturbances are recorded in 33.3% of cases. In the hospital period after PEA and CABG in the studied patients, neurological disorders accounted for a large proportion of complications among the complications. Hospital mortality was 6.7%. Concomitant rhythm disturbances in patients with CTEPH with surgically significant coronary artery stenosis are associated with a more severe course of the early postoperative period and increase the chances of developing neurological disorders, acute renal failure and acute heart failure.

Abstract 4136509: Children in Foster Care with Heart Disease Have Greater Resource Utilization and Mortality

Background: While children and youth in foster care (CYFC) have greater healthcare needs generally, data are lacking in heart disease. We characterize CYFC with heart disease, assess the impacts of being in foster care on outcomes, and examine validity of ICD-10 code Z62.21 for identification of CYFC in administrative data. Methods: In this single-center, retrospective cohort study of all cardiac surgical patients (&lt;18yo) admitted 2017-2022, CYFC were identified using institutional Electronic Medical Records via natural language processing or ICD codes, with confirmation by chart review. Demographics, medical characteristics and outcomes of CYFC were compared to children not in foster care. Generalized linear models assessed associations with primary outcomes of mortality at current follow-up (logit link) and total hospital days (log link), controlling for clinical factors and length of follow-up. We separately added Child Opportunity Index (COI) and payer to models. This cohort was then studied in the administrative pediatric health information system (PHIS) dataset to calculate ICD code sensitivity and specificity. Results: Of 4,431 cardiac surgical patients, 67 (1.5%) were in foster care. CYFC did not have significantly higher mortality (9% vs 5.8%), 30-day readmission or cardiac reoperation, number of complex chronic conditions (CCC), RACHS-2, or distance from center compared to non-CYFC. CYFC had lower COI (median 61 vs 72, p=0.016) and more Medicaid coverage (87% vs 40%, p&lt;0.001). Length of stay after index surgery was similar; however, cumulative hospital days during the study were significantly higher for CYFC (median 22 [IQR 10,45] vs 12 [6,27], p&lt;0.001). Adjusting for RACHS-2, CCC, age, readmission, reoperation, and follow-up duration, CYFC had higher odds of mortality (2.7 [95%CI 1.0,6.9] p=0.046) and more total hospital days (p=0.008). With COI or payer in the model, CYFC was not associated with mortality but remained an independent risk factor for more total hospital days. Only 16/67 (23.9%) of CYFC were coded with the Z62.21 in PHIS, yielding sensitivity of 21.9% (95%CI 13.1,33.1), and specificity of 100% (99.9,100). Conclusion: CYFC with heart disease have a relative social disadvantage, greater hospital resource utilization, and long-term mortality despite similar illness severity. Improved capture of foster care status in administrative data is needed to guide future studies and reduce health disparities for the vulnerable population of CYFC.

Intraoperative Methadone in Adult Cardiac Surgical Patients and Risks for Postoperative QTc Prolongation

To evaluate the effect of intraoperative intravenous methadone within a standardized enhanced recovery after cardiac surgery pathway on the perioperative corrected QT interval (QTc). Retrospective cohort study. Cardiac surgical patients from a tertiary academic medical institution. Eligible 1,040 adult patients undergoing elective cardiac surgery from July 2020 through July 2023 using validated institutional electronic medical record data INTERVENTIONS: Patients were administered intravenous methadone (0.1 mg/kg) or received analgesics other than intravenous methadone as part of an enhanced recovery after cardiac surgery pathway. The primary outcomes were change in QTc and the percent QTc change between preoperative QTc and postoperative QTc upon intensive care unit admission. Secondary outcomes include postoperative ventricular arrhythmias, postoperative atrial fibrillation, intensive care unit length of stay, 30-day mortality, 1-year mortality, and mortality days from surgery. Out of a total of 1,040 patients, 423 received intraoperative methadone and 617 did not receive methadone. Methadone QTc mixed models demonstrated that QTc is prolonged immediately postoperatively and normalized 24 hours after surgery in both methadone and nonmethadone groups. There were no significant differences in baseline QTc, immediate postoperative QTc, changes in QTc, or percent change in QTc between the methadone and nonmethadone groups. There were no significant differences in ventricular or atrial arrhythmias, 30-day mortality, 1-year mortality, or days to death. A single intraoperative intravenous methadone dose did not prolong the QTc significantly or increase the incidence of arrhythmias and may be safe in adult cardiac surgical patients.

Patient perspectives on health care models in cardiac surgery: a qualitative evaluation

BackgroundThe implementation of ERAS represents a promising solution to improve treatment efficiency and facilitate patient involvement. This innovative care model aims to optimize recovery processes following surgeries by adopting a holistic, interprofessional approach. At our hospital, ERAS was implemented in minimally invasive heart valve surgery, offering two distinct ERAS models. Additionally, there is also the standard of care without ERAS. The objective of the study is to gain insight into patient satisfaction and perceived differences across these various care models.MethodsPatients were interviewed using semi-structured interviews approximately two to three months after undergoing surgery. The data were analysed using qualitative content analysis in accordance with the methodology proposed by Kuckartz. Four main categories were established: Preoperative care, postoperative care and communication, patient participation and involvement, and rehabilitation and post-clinical course.ResultsComprehensive preoperative education and seamless communication throughout the perioperative care journey were identified as fundamental to patient satisfaction and optimal care processes. Patients in the ERAS + model reported higher overall satisfaction with their care compared to patients in the standard of care and ERAS groups.ConclusionPreoperative education establishes the foundation for patients’ subsequent behaviours and expectations regarding their treatment. Physical activity, nutrition, and mental health are significant aspects. The active involvement and participation of patients and their families in the treatment process facilitated superior postoperative care, intensive physiotherapy, mental support, and faster recovery. A functional flow of information throughout the entire care process is vital. Moreover, having a dedicated point of contact had a beneficial impact on patients´ well-being. The integration of innovative ERAS concepts, which encompass interprofessional preoperative patient education and psychosomatic support, represents a promising approach from a patient perspective, offering benefits to a broad spectrum of cardiac surgical patients.

Characteristics and correlated factors of preoperative sleep disorders in cardiac surgical patients

Objective: To investigate the clinical characteristics and correlated factors of preoperative sleep disorders in patients undergoing various types of cardiac surgery. Methods: The data of patients at the Structural Heart Surgery Center of Beijing Anzhen Hospital, Capital Medical University, from April 2023 to February 2024 were retrospectively collected. Patients were categorized into five groups based on cardiac surgical diagnosis: coronary heart disease, valvular disease, large vessel disease, congenital heart disease, and others. Each group was further subdivided into normal sleep (NS) and sleep disorder (SD) groups based on the Pittsburgh Sleep Quality Index (PSQI) scores. Demographic information, cognitive function, psychiatric symptoms, and other relevant data were collected. Clinical characteristics were compared between groups, and factors associated with preoperative sleep disorders were analyzed using multivariate logistic regression. Results: A total of 1 016 patients aged (58.6±12.7) years were included in the study, including 701 males and 315 females. The incidence of SD was 45.6% (463/1 016). Multivariate logistic regression analysis showed that aging was a risk factor for sleep disorders in patients with coronary heart disease (OR=1.050, 95%CI: 1.026-1.077) and valvular disease (OR=1.033, 95%CI: 1.013-1.053). High Self-rating Depression Scale (SDS) score was a risk factor for sleep disorders in patients with valvular disease (OR=1.050, 95%CI: 1.013-1.091). High score on the Montreal Cognitive Assessment (MoCA) subitem-abstraction ability was a protective factor for sleep disorders in patients with coronary heart disease (OR=0.695, 95%CI: 0.490-0.981). Conclusions: The risk factors of preoperative sleep disorders in cardiac surgery patients vary based on the type of cardiac disease. Aging, depression and abstraction ability correlate with sleep disorders in cardiac surgical patients.

Generalizability of SELECT to a contemporary cohort of cardiac surgical patients: analysis of the TRICS III Randomized Trial

Abstract Background The SELECT trial reported a significant reduction in cardiovascular (CV) outcomes with semaglutide amongst patients without diabetes who had pre-existing CV disease and a body-mass index (BMI) of 27 or greater. Patients undergoing cardiac surgery represent a high-risk subset of those with established CV disease, and may benefit from treatment with semaglutide. Purpose This study evaluated the generalizability of SELECT to a contemporary international cohort of cardiac surgical patients, and assessed whether differences between SELECT-eligible and non-eligible patients translated to altered risks of CV outcomes. Methods Present data was gathered from the TRICS III trial, a multicentre, randomized trial of restrictive versus liberal red-cell transfusion thresholds amongst 5243 cardiac surgical patients with a EuroSCORE I of ≥6. The proportion of cardiac surgical patients eligible for SELECT was determined by applying its selection criteria to the TRICS III cohort. Finally, baseline characteristics and outcomes stratified by SELECT eligibility were compared. Results A total of 4887 patients from the TRICS III cohort had available data for analysis, of which 452 (9.2%) were deemed to have been eligible for the SELECT trial. A comparison of baseline characteristics between SELECT-eligible and non-eligible patients are presented in Table 1; while SELECT-eligible patients were more likely to have preserved left ventricular function (71.7% vs. 61.0%), EuroSCORE I values were comparable between the two groups (7.8±2.1 vs. 7.9±1.9). The rate of a 3-point MACCE of Death, MI or stroke in the present cohort of SELECT-eligible patients undergoing cardiac surgery (16.6%) was numerically higher than those enrolled in SELECT receiving semaglutide (8.1%) or placebo (10.0%), despite the shorter follow-up (6 months vs. 39.8 months). Six month outcomes following cardiac surgery were similar regardless of SELECT eligibility (Figure 1); no difference in risk of outcomes was documented for the 3-point MACCE [SELECT Eligible vs. Non-eligible – 16.6% vs. 14.5%; OR 1.17 (0.9-1.53); P=0.24] and the TRICS III primary composite of Death, MI, Stroke, or New-Onset Renal Failure with Dialysis [17.0% vs. 17.0%; OR 1.0 (0.77-1.29); P=0.98]. There was a trend towards higher rates of MI at 6 months amongst SELECT-eligible patients, but this difference failed to reach statistical significance [8.5% vs. 6.3%; OR 2.0 (0.96-1.39); P=0.08). Conclusions In this large international cohort of contemporary cardiac surgical patients, nearly 10% would have met eligibility for SELECT. SELECT-eligible patients undergoing cardiac surgery in TRICS III had a numerically higher rate of MACCE than those enrolled in SELECT, highlighting the high risk nature of this patient subgroup. However, amongst SELECT-eligible and non-eligible patients undergoing cardiac surgery, no significant difference in CV outcomes was uncovered.

A prehabilitation programme is feasible and acceptable for mild-to-moderately frail patients undergoing cardiac surgeries

Abstract Background Preoperative frailty is a strong prognostication in cardiac surgical patients to predict poorer health outcomes. Intervening at the preoperative stage through prehabilitation is gaining increasing research attention. Previous studies tested a single frailty-reversing strategy, either nutritional or exercise, the exercise protocols were mainly aerobic-focused, which deviates from the exercise prescription principles suggested for frailty management, rendering an effective prehabilitation intervention is yet to be developed in cardiac surgical patients. Purpose This study aimed to examine the preliminary effects and explore the feasibility of a multi-component frailty-specific prehabilitation programme for mild-to-moderately frail patients undergoing cardiac surgeries/procedures. We hypothesised that compared with patients who receive usual care, patients awaiting cardiac surgeries who participate in the prehabilitation programme would have improved functional capacity, frailty status, quality of life and psychological outcomes, increased serum albumin and reduced C-reactive protein. Methods This study adopted a mixed-method design comprising a pilot randomised controlled trial and a qualitative study. Adult patients with a Clinical Frailty Scale score between 4 and 6, waiting for coronary artery bypass grafting surgery and/or valve repair/replacement, with at least 5 weeks of procedural waiting time and without contraindications for exercise were recruited. They were randomized in a 1:1 ratio to receive the prehabilitation programme or usual care. The programme comprised a structured preoperative education, nutritional optimization, stress management; and a multi-component exercise training with 3 sessions/week and 60 minutes/session. The exercise training lasted at least 4 weeks and maintained throughout the preoperative period. Results Twenty participants were randomized into the intervention (n = 11) or control (n = 9) group. The programme was feasible, acceptable and no severe adverse events were recorded. The lost to follow-up rate was 7.9%, and the overall attendance was 96%. The intervention group showed significantly greater improvement in functional capacity, frailty status and psychological outcomes than the control group at post-intervention. Participants gave positive comments about the programme and its delivery mode. They expressed that the one-on-one home-based practice enabled them greater confidence to overcome kinesiophobia. Two participants voiced out the preference for exclusive home-based training, rather than having hospital-based training in the first two weeks. Conclusion(s) The prehabilitation programme is feasible and acceptable for patients waiting for cardiac surgeries. It improves the functional performance, frailty status and psychological outcomes in these patients. A full-scale randomised controlled trial is warranted to investigate its longer-term and clinical effects.

Systematic review and meta-analysis on the effects of physical activity-based interventions on frailty status and clinical outcomes in adults with long-term cardiac conditions

Abstract Introduction Frailty is common in patients with long-term cardiac conditions and is associated with poor clinical outcomes, but limited treatment options are available. Previous studies investigating interventions for frailty have shown positive results with physical activity interventions, however, these studies were largely based on general elderly populations. Aim To assess the impact of physical activity-based interventions on frailty and clinical outcomes in frail patients with long-term cardiac conditions. Methods A systematic review and meta-analysis was conducted based on the PRISMA guideline, using Medline, Embase, CENTRAL, PEDro, CINAHL electronic databases for articles published between 2000 and 2023. Studies which recruited adults &amp;gt;18 years with long-term cardiac conditions (including angina, acute coronary syndrome (ACS), valve disease, heart failure (HF), atrial fibrillation, cardiac surgery and congenital heart disease) who underwent physical activity-based interventions were included. The primary outcome was change in frailty (measured using a validated tool) post intervention. We also assessed the effect of interventions on mortality and hospitalisation. Results We screened 2697 records and reviewed 91 full-text articles; 12 studies (14 articles) were included, involving 1394 patients. Median age of participants ranged from 64 to 82 years. Five studies recruited participants with HF, 3 evaluated participants post transaortic valve implantation, 3 recruited cardiac surgical patients and 1 study evaluated participants post ACS. Physical activity-based interventions were multi-domain, including a mixture of aerobic, strength, balance, endurance and respiratory muscle training; the majority (N=10) had individualised exercise prescription. Meta-analysis of 8 randomised controlled trials (RCTs) showed statistically significant improvement in frailty associated with physical activity-based interventions compared to controls [pooled standardised mean difference (95% CI) = -0.34 (-0.59 to -0.08), p = 0.01, I2 = 48%]. Seven RCTs evaluated change in frailty by short physical performance battery (SPPB). Meta-analysis of these studies showed a statistically significant improvement in SPPB associated with physical activity-based interventions compared to controls [pooled mean difference (95% CI) = 0.83 (0.31-1.34), p = 0.002, I2 = 49%]. (Figure) The magnitude of improvement in SPPB exceeded the minimally clinically significant improvement of 0.5. Three studies evaluated the effect of physical activity-based intervention on clinical outcomes, all of which showed neutral effect on mortality and hospitalisation. Conclusion Physical activity-based interventions in patients with frailty and long-term cardiac conditions were associated with significant improvement in frailty status, with neutral effect on mortality and hospitalisation. Figure: Meta-analysis of 7 RCTs assessing effect of physical activity-based interventions on SPPB

Randomized Controlled Trial of Ultrasound-Guided Parasternal Intercostal Nerve Block and Transversus Thoracis Muscle Plane Block for Postoperative Analgesia of Cardiac Surgical Patients.

Transversus thoracis muscle plane block (TTPB) and parasternal intercostal nerve block (PICNB) inhibit the anterior branches of intercostal nerves and potentially provide adequate analgesia after cardiac surgery. This study aimed to compare these two blocks for a reduction in postoperative opioid consumption after cardiac surgery. This randomized, single-blind trial included 60 adult cardiac surgical patients divided into three groups to receive ultrasound-guided TTPB (group T), PICNB (group P), or no block (group C) before surgery. All patients received standard anesthesia with intravenous etomidate, fentanyl, midazolam, and vecuronium. Postoperative fentanyl consumption in the first 24 hours was the primary outcome variable. Secondary outcomes were pain fentanyl consumption in 48 hours, intensity, analgesia duration, heart rate, mean arterial pressure, and complications. The groups had similar baseline characteristics. The duration of analgesia was longer, while the intensity of pain and opioid consumption were statistically lower (p<0.01) in groups P and T compared to group C. The differences between groups P and T were not statistically significant. Fentanyl consumption in the first 24 hours was 284.00±37.61 µg, 293.00±35.11 µg, and 383.40±57.21 µg in groups P, T, and C, respectively. Other outcome variables were statistically similar among the groups. Both TTPB and PICNB produce equivalent and satisfactory postoperative analgesia, reducing the postoperative fentanyl use in 24 hours for patients undergoing elective cardiac surgery.

Amino acids and the kidney; friends or foes?

Acute kidney injury (AKI) is common in hospitalized patients and is independently associated with morbidity and mortality. Moreover, AKI increases the risk of chronic kidney disease, which is a major healthcare problem. Currently, no single therapy has been proven to be effective in preventing AKI. The role of amino acids in the context of kidney function and AKI prevention has been controversial and most of the evidence is available from nutritional studies. However, knowledge of amino acids in recruiting renal functional reserve and their potential role to protect renal function under stress has recently expanded. The nephroprotective effects of amino acids were first postulated in 1973. Recently, this strategy gained renewed interest and has been more extensively studied, reintroducing their use in clinical situations characterized by a high incidence of AKI. Intravenous amino acids administration for kidney protection is now supported by a large multinational randomized double-blind controlled trial in cardiac surgery and by experimental and observational data. All such data support the rationale for a biologically and clinically important nephroprotective effect. The infusion of amino acids was recently found to reduce the incidence of AKI in cardiac surgery patients and surgical patients. This strategy for the protection of renal function is supported by a multicenter, international, double-blind randomized trial, with a huge potential for additional application in several clinical fields. Several mechanisms of action support the robustness of these findings and are summarized in this manuscript.

Use of coagulation factor concentrates and blood transfusion in cardiac surgery: a retrospective cohort study of adults with hereditary and acquired bleeding disorders

BackgroundCardiac surgery poses a significant risk of perioperative bleeding and allogeneic blood transfusions, particularly in patients with bleeding disorders. Increasingly frequent use of coagulation factor concentrates could impact haemorrhagic risks, thromboembolic events, and costs. We describe the use of coagulation factor concentrates and allogeneic blood products in cardiac surgical patients with hereditary and acquired bleeding disorders to assess pertinent outcomes, including perioperative haemorrhage, thromboembolism, and hospital costs. MethodsWe conducted a retrospective cohort study using the Premier Health Database, including adult cardiac surgical patients diagnosed with hereditary or acquired bleeding disorders compared with those without bleeding disorders. ResultsPatients with acquired bleeding disorders required more extensive use of coagulation factor concentrates and blood products compared with those with hereditary bleeding disorders or without bleeding disorders. The highest exposures to coagulation factor concentrates were found in the acquired bleeding disorders group, with 24% receiving factor VIIa and 11.7% receiving prothrombin complex concentrate. This group also experienced significantly higher rates of complications, including a 15.8% rate of haemorrhage and a 19.2% rate of thromboembolic events. The acquired bleeding disorders group had longer intensive care and hospital stays, and the highest mortality rate (19.2%). The increased use of perioperative replacement of factor VIII and factor IX in the hereditary bleeding disorders group led to increased pharmacy costs but did not significantly impact blood bank charges. ConclusionsAcquired bleeding disorders in cardiac surgery patients are associated with increased use of haemostatic interventions, postoperative complications, and increased healthcare costs. Improved management of perioperative haemostasis and thromboprophylaxis strategies are essential for optimising patient outcomes and reducing expenses.