Cardiosurgical Procedures Research Articles

Identifying High-Risk Patients for Severe Pulmonary Complications after Cardiosurgical Procedures as a Target Group for Further Assessment of Lung-Protective Strategies

ObjectiveIt remains unclear if intraoperative lung-protective strategies can reduce the rate of respiratory complications after heart surgery, partly because low-risk patients have been studied in the past. We established a screening model to easily identify a high-risk group for severe pulmonary complications (i.e., pneumonia or ARDS) that may be the ideal target population for the assessment of potential benefits of such measures. DesignRetrospective observational trial. SettingDepartments of cardiac surgery and cardiac anesthesia of university hospital. Participants: Consecutive patients undergoing heart surgery on cardiopulmonary bypass (CPB) and subsequent treatment at a dedicated cardiosurgical ICU between January 2019 and March 2021. InterventionsNone Measurements and main resultsOf 2572 patients undergoing surgery, 84 patients (3.3%) developed pneumonia/ARDS that significantly impacted outcome (i.e., longer ventilatory support (66 vs. 11%), higher reintubation rate (39 vs. 3%), prolonged length of ICU (33±36 vs. 4±10 days) and hospital stay (10±15 vs. 6±7 days), and higher in-hospital (43 vs. 9%) as well as 30-day (7 vs. 3%) mortality). Our screening model for severe pulmonary complications includes LVEF < 52%, EuroSCOREII > 5.9, CPB time > 123 minutes, left ventricular assist device or aortic repair surgery, and bronchodilatory therapy. A cut-off for the predicted risk of 2.5 % showed optimal sensivity and specificity with an AUC of 0.82. ConclusionWe suggest that future research on intraoperative lung protective measures should focus on this high-risk population and primarily aiming at mitigation of severe forms of postoperative pulmonary dysfunction associated with poor outcome and increased resource consumption.

#3169 EXPERIENCE IN INTRAOPERATIVE AUTOLOGOUS BLOOD SALVAGE IN PEDIATRIC CARDIAC SURGERY

Abstract Background and Aims Due to the drastic reduction in the number of voluntary blood donors has led to the need for the development of alternative strategies for allogeneic blood transfusion, which include the use of different strategies for autologous transfusion. Display: a) the use of "Cell-Saver" pediatric cardiac surgery at the Department of Cardiothoracic Surgery, Institute for Health Protection of Mother and Child of Serbia" Dr Vukan Cupic"; b) to analyze the reduced use of allogeneic blood and /or chemo products using "Cell-Saver" pediatric cardiac surgery; c) to evaluate the "cost benefit" of this strategy (e.g. the ratio of prices "set", "Cell-Saver") and pretransfusion rates processing one unit of allogeneic blood; d) to identify increased intraoperative security in complex. reconstructive and redocardiac surgery using the "Cell-Saver" combined with ultrafiltration (conventional or modified), particularly in cyanogenic congenital heart defects, and e) to establish and improve the hemodynamic status of hemoreologic operated child. Method A retrospective study was conducted. Experimental group included 63 patients (aged 12 days - 16 years and 4 months, body weight of patients that ranged between 2.9 kg and 80 kg - the mean body weight was 28.3 kg). In the experimental group patients were performed following cardiac surgery: 46 patients underwent reconstructive surgery (most often reoperations for cyanogenic congenital heart defects); 3 patients who underwent cardiovascular belief, and 3 patients who underwent cardio-surgical procedures had hematological disorders. The control group included 60 patients of similar age and body mass who underwent the cardio-surgical procedure without the use of "Cell-Saver" with application of allogeneic blood and/or chemo products during transfusion care. The following laboratory parameters were accompanied: hematocrit, platelet count, fibrinogen, prothrombin time (PT) and activated partial thromboplastin time (aPTT), after 3, 6, and 12 hours postoperatively compared to the control group. We compared the volume of postoperative bleeding by patients of the experimental group with the control group (1h, 4h, 7h, 11h, 15h, 21h and 24h) and analyzed the amount of used allogeneic and autologous blood and/or hemoglobin products used in the transfusion care during hospitalization the experimental group compared with the control group. Results Postoperative administration of allogeneic blood and/or hemoproducts was statistically significantly lower in the experimental group using "CellSaver" than in the control group. The amount of salvaged blood after surgery ranged from 210 ml - 620 ml. Intraoperative hematocrit "rescued" autologous blood ranged between 0.32 l / l and 0.38 l / l. e range of values preoperative and postoperative hematocrit were lower in the experimental group than in the control group that used "Cell-Saver". The total volume of postoperative drainage content was significantly lower in the experimental group, which used "Cell-Saver" compared to the control group. The postoperative hematocrit was higher in the experimental group patients who used "Cell-Saver", compared with the same operating using allogeneic blood and/or hemoproducts patients in the control group. The mean platelet count, fibrinogen, PT and aPTT results showed no statistically significant difference between the experimental group of patients in whom we used "Cell-Saver" in comparison to the control group. Conclusion The results obtained by the retrospective analysis of above mentioned data indicate a positive therapeutic effect of the application of the "Cell Saver" that is most common in reoperations. With the introduction of the "bell" of small volume, the use of the Cell Saver has become an integral part of the pediatric cardiac surgery - perfusion, regardless of body weight, age and body surface area of the child. The performance of intraoperative "rescue" of autologous blood using the "Cell Saver", while the follow-up of pediatric patients in the perioperative and postoperative period has immeasurable significance of teamwork perfuser, expert specialist nursing, pediatrician, cardiac surgeon and transfusion.

Every day mitral valve reconstruction: What has changed over the last 15 years?

Mitral valve reconstruction (MVR) is one of the cardiosurgical procedures which cannot be substituted by any intervention owing to the quality of the quasi-anatomical, physiological repair. However, technique and strategies have changed over the years. We looked at procedural characteristics and outcome in an all-comer, non-selected cohort of patients. 738 out of 1.977 patients were retrospectively analyzed receiving MVR with and without concomitant procedures. The cohort was divided into three periods. P1: 2004-2009 (134 pts.); P2: 2010-2014 (294 pts.), and P3: 2015-2019 (310 pts.). Early mortality increased from P1 to P2 and decreased from P2 to P3 (9% P1, 13% P2, 10% P3). All patients received an annuloplasty-ring. In P1 resection measures dominated. In P3 artificial chordae were dominant. Age, BMI, and risk scores correlated with early mortality. Survival rates were 66% (5-years), 55% (10-years), 44% (15-years) in P1, 63% (5-years), 50% (10-years) in P2, and 80% (5-years) in P3. Odds ratio for reduced long-term survival were concomitant venous only bypass surgery (10-years 2,701, p = 0.026). 10-year survival was positively influenced by isolated MVR (0.246, p = 0.001), concomitant isolated arterial bypass (IMA) (0.153, p = 0.051), posterior leaflet measure (0.178, p<0.001), and use of artificial chordae (5-years 0.235, p<0.001). Indication for ring implantation remained mandatory while preference changed alongside improved designs. Procedural characteristics changed from mainly resection maneuvers to predominant use of artificial chordae. Long-term results were negatively influenced by co-morbidities and positively influenced by posterior leaflet repair and artificial chordae. MVR underwent a qualitative evolution and remains a valuable cardiosurgical procedure.

Custodiol HTK versus Plegisol: in-vitro comparison with the use of immature (H9C2) and mature (HCM) cardiomyocytes cultures

BackgroundAlthough cardioplegia is used since the ‘70s of the last century, debate on cardioprotection during cardio-surgical procedures is still actual. The selection of a particular method depends mainly on the preferences and experience of a specific center or even surgeon. Crystalloid cardioplegia is an aqueous ion solution similar to intracellular (Custodiol HTK) or extracellular (Plegisol) fluid. The potensional clinical advantages of relatively new idea of cardioplegia solution based on intracellular composition (Custodiol HTK) justifies futher research, but only a few used cultured cells in laboratory conditions.MethodsIn this study, the authors sought to compare Custodiol HTK with Plegisol cardioplegia solutions using an in-vitro model simulating cardioplegic arrest. The efficacy of myocardial protection during ischemia was investigated with susceptible indicators like the appearance of the deleterious effect of reactive oxygen species and oxidative stress markers. Immersed human cardiomyocytes and rat cardiomyoblasts H9C2 in cardioplegia for 4 h were examined for expression of oxidative stress markers (MnSOD, iNOS, HSP27), cardioplegic solutions cytotoxicity, and peroxidation damage of the cell’s lipids and proteins. All tests were performed after 0.5 h, 1 h, 2 h, and 4 h of incubation in identical physical and biological conditions, which is difficult to achieve in clinical trials.ResultsThe lower cytotoxicity index performed on matured cells of human cardiomyocytes and highest dehydrogenase level showed after incubation with Custodiol HTK. This did not apply to tests on immature cells H9C2. Custodiol HTK induced significantly stronger iNOS expression. The decrease of HSP27 concentration has been instantaneous and maintained troughout the study only in both cultures incubated with Custodiol HTK. The other tests: lipid peroxidation, carbonyl groups concentration and MnSOD expression show no clear superiority evidence of used cardioplegic solutions.ConclusionsConsidering proceeded examinations on cultured cardiomyocytes, Custodiol HTK appears to be safer than Plegisol.

St. Thomas Modified Cardioplegia Effects on Myoblasts' Viability and Morphology.

Background and Objectives: The cardioplegic arrest of the heart during cardiosurgical procedures is the crucial element of a cardioprotection strategy. Numerous clinical trials compare different cardioplegic solutions and cardioprotective protocols, but a relatively small number of papers apply to in vitro conditions using cultured cells. This work aimed to analyze whether it is possible to use the rat heart myocardium cells as an in vitro model to study the protective properties of St. Thomas cardioplegia (ST2C). Methods: The rat heart myocardium cells-H9C2 were incubated with cold cardioplegia for up to 24 h. After incubation, we determined: viability, confluency, and cell size, the thiol groups’ level by modifying Ellman’s method, Ki67, and Proliferating Cell Nuclear Antigen expression (PCNA). The impact on cells’ morphology was visualized by the ultrastructural (TEM) study and holotomograpic 3D imaging. Results: The viability and confluency analysis demonstrated that the safest exposure to ST2C, should not exceed 4h. An increased expression of Ki67 antigen and PCNA was observed. TEM and 3D imaging studies revealed vacuolization after the longest period of exposure (24). Conclusions: According to obtained results, we conclude that STC can play a protective role in cardiac surgery during heart arrest.

Finite element analysis in the modeling of the heart and aorta structures

Rationale: 3D modeling of various anatomical structures has recently become a separate area of topographical, anatomical, and biomechanical studies. Current in vivo visualization methods and quantitative analysis in silico allow to perform the precise modeling of these processes aimed at investigation into the pathophysiology of cardiovascular disorders, risk prediction, planning of surgical interventions and virtual refinement of their separate stages.Aim: To develop tools for elaboration, analysis and validation of personalized models of various structures of the heart and aortal arch taking into account their morphological characteristics.Materials and methods: We used the results of 14 computed tomography studies from randomized patients without any disease or anomaly of the heart, aortic valve and aortal bulb. The analysis and subsequent transformation of the images were done with Vidar DICOM Viewer, SolidWorks 2016, VMTKLab software. For the FSI modeling of the aortic arch based on the results of functional multiaxial computed (MAC) coronarography (a female patient of 55 years) we developed a personalized model of the ascending aorta and aortic arch at the beginning of the systole. Using HyperMesh software (Altair Engineering Inc., USA) we have built a network of finite element of the luminal area, adventitia, and aortic media. To model mechanical properties of the aortic structures we used an anisotropic hyperelastic material model by Holzapfel – Gasser – Ogden. Material modeling, choice of the limiting antecedents, and analysis of fluid-structure interaction were performed with Abaqus CAE 6.14 software (Simulia, Johnston, USA). Adaptive image meshing by Young was used to elaborate the finite element template of the left ventricle. The algorithm was realized within the IDE PyCharm software media in Python 3.7. The algorithm was realized based on the open-source libraries OpenCV, NumPy, Matplotlib, and SciPy.Results: The first stage of the development of the aortic valve model included the design of its virtual 3D template. Thereafter, a cohesive geometric model was elaborated. Subsequent stage of the work included the transformation of the aortic valve geometric model into the parametric one. This was done through the use of the “Equations” tool within the SolidWorks. No problems with geometry of the model during its deformation were identified. Aortic segment modeling was based on the data obtained by functional MAC coronarography. Based on this and on Inobitec Dicom Viewer software, we generated a multiplane reconstruction of the zone of interest including anatomical structure of the heart and aortic valve. With the resulting set of contours, we created a 3D model, which then was converted into a polygonal stereolithographic model. We developed an algorithm for adaptive meshing to elaborate a polygonal template capable of deformation that can be used for registration both with the net methods (B-Spline) and based on the image characteristics (homologous pixels). Conclusion: The resulting parametric 3D model of the aortic valve anatomical structures is capable of adequate transformation of its geometry under external factors. It can be used in simulators of endovascular cardiosurgical procedures.

Impact of gender on long-term prognosis after transcatheter edge-to-edge repair for mitral regurgitation

Abstract Background A symptomatic and prognostic benefit by Transcatheter edge-to-edge repair (TEER) for mitral regurgitation (MR) has been proven. A variety of individual factors including female sex has been suggested to be associated with adverse outcome in cardio-surgical procedures. Purpose While gender is factored in common risk factor models for adverse outcome, evidence on sex-specific differences in long-term outcome after TEER for MR is limited. We aimed to investigate the impact of gender on prognosis in a large monocentric cohort with long-term follow-up. Methods We analyzed survival stratified for gender after successful isolated edge-to-edge repair of MR in the period between 06/2010 and 03/2018 (exclusion of combined forms of TMVR) in a monocentric retrospective cohort by performing survival analyses and cox regression analyses. Results Consecutively, 627 patients (47.0% females, 57.4% functional MR; survival status was available in 96.7%) entered the study and were followed for a median follow-up period of 462 days [IQR 142–945 days]. Survival rates were 97.6% at discharge, 75.7% after 1, 54.5% after 3, 37.6% after 5 and 21.7% after 7 years. Risk score as calculated by the Logistic Euroscore I did not differ significantly between females and males (at baseline: 25.0 [IQR 18.0/34.8] vs. 27.0 [18.4/40.1]%, p=0.093) and no relevant differences were found for in-hospital (2.0 vs. 2.7%, p=0.613), 30 days (4.8 vs. 6.5%, p=0.473) and 1-year mortality (27.0 vs. 25.3%, p=0.675). At the time of procedure, women were older (79.9 [IQR 75.6/84.4] vs. 78.3 [72.9/83.4] years, p&amp;lt;0.001), were less often affected by coronary artery disease (53.1% vs. 75.0% p&amp;lt;0.001), diabetes mellitus (23.7% vs. 31.3%, p=0.040) and impaired left ventricular function (44.5±12.9% vs. 38.9±13.4%, p&amp;lt;0.001). Regarding long-term survival, women had a better prognosis after MR-therapy, especially in functional etiology: e.g., 4-year survival in FMR 65.7 vs. 35.7%, p=0.006 (Figure 1). Remarkably, female sex was associated with a lower risk for long-term mortality in the Cox-regression models, especially in the FMR subgroup (total cohort: univariate HR 0.81 [0.62–1.04], p=0.101; FMR: univariate HR 0.68 [0.49–0.96], p=0.028). Conclusion In our cohort of patients undergoing TEER for MR, we found no evidence for an impaired short- and mid-term prognosis for female patients. In contrary and not as indicated by Logistic Euroscore, female sex was associated with better long-term survival in comparison to men despite higher median age, which might be partly explained by a slightly more favorable cardiovascular risk profile. Funding Acknowledgement Type of funding sources: None. Figure 1

Neuroprotective effects of dynamic bubble trap use in patients undergoing pulmonary endarterectomy: a two-arm randomized controlled trial.

BackgroundDuring cardiosurgical procedures that use extracorporeal circulation (ECC), a variety of neurological complications can occur, and postoperative cognitive deficits remain an unsolved problem. Among the sources of these complications are intraoperatively detectable cerebral microemboli, which mainly consist of air. This study’s purpose was to assess neuroprotective effects of reducing these gaseous microemboli using a dynamic bubble trap (DBT) in patients undergoing pulmonary endarterectomy (PEA) for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH).MethodsPatients undergoing PEA were randomly assigned to receive either a DBT (n=47) or no additional device (controls, n=46) during ECC. Neuropsychological testing was performed before and 3 months after PEA. The primary endpoint was cognitive improvement in the DBT group (n=29) compared with the control group (n=42). As secondary endpoint, ischemic brain micro-lesions were analyzed on postoperative days 6 through 10 using diffusion-weighted magnetic resonance imaging (MRI).ResultsAnalysis of interaction effects revealed improved performance in visual long-term memory (P=0.008, η2=0.099), verbal long-term memory (P=0.030, η2=0.067), verbal short-term memory (P=0.014, η2=0.083), and attention and processing speed (P=0.043, η2=0.056) from pre- to post-testing in the DBT group compared to control group. In MRI, postoperative ischemic micro-lesions could only be detected in one patient; another patient suffered a severe bihemispheric embolic stroke.ConclusionsDBT positively influences memory function after PEA. This effect is most likely caused by the reduction of gaseous microemboli.Trial RegistrationThis study is registered in the German Clinical Trials Register, ID: DRKS00021499.

The German CArdioSurgEry Atrial Fibrillation Registry: In-Hospital Outcomes.

The aim of this study was to describe outcomes of patients undergoing surgical ablation for atrial fibrillation (AF) as either stand-alone or concomitant cardiosurgical procedures in Germany. Patients with AF undergoing concomitant or stand-alone surgical ablation were included in the registry. Cardiac surgery centers across Germany were invited to participate and sought to enroll 1,000 consecutive patients. Data was obtained through electronic case report forms. The protocol mandated follow-up interviews at 1 year. Between January 2017 and April 2020, 17 centers enrolled 1,000 consecutive patients. Among concomitant surgical patients (n = 899), paroxysmal AF was reported in 55.4% patients. Epicardial radio frequency (RF) bilateral pulmonary vein isolation (PVI) with excision of the left atrial appendage (LAA) was the most common operative strategy. In the stand-alone cohort (n = 101), persistent AF forms were reported in 84.1% of patients. Moderate-to-severe symptoms were reported in 85.1%. Sixty-seven patients had previously underwent at least two failed catheter ablative procedures. Thoracoscopic epicardial RF bilateral PVI and completion of a "box-lesion" with LAA closure were frequently preformed. Major cardiac and cerebrovascular complications occurred in 38 patients (4.3%) in the concomitant group. No deaths were reported in the stand-alone group. At discharge, sinus rhythm was achieved in 88.1% of stand-alone and 63.4% concomitant patients. The CArdioSurgEry Atrial Fibrillation registry provides insights into surgical strategies for AF ablation in a considerable cohort across Germany. This in-hospital data demonstrates that concomitant and stand-alone ablation during cardiac surgery is safe and effective with low complication rates.

Comparison of Perioperative High-Sensitive Troponin T and Troponin I Assays in Cardiac Surgery

Troponin measurements are among the standard parameters for monitoring perioperative myocardial ischaemia after cardiosurgical procedures. As high-sensitive assays continue to replace older analytic parameters with lower sensitivity, this study aimed to compare perioperative profiles of a high-sensitive troponin T assay (hsTnT, Roche Diagnostics, Mannheim, Germany) with a troponin I assay (sTnI, Siemens Healthcare Diagnostics, Eschborn, Germany). A total of 287 consecutive patients undergoing a typical spectrum of cardiac procedures from August 2017 to March 2018 monitored with the hsTnT assay were compared with a propensity-matched collective analysed with the sTnI assay. For side-by side comparison, the peak troponin (Tmax) values were scaled to a z-score distribution before comparison. Despite absolute postoperative hsTnT and sTnI values differing by an order of magnitude, parameters could be scaled to a common distribution with kernel density curves overlapping 92%. Both parameters showed equal behaviour in subgroup analyses regarding relevant perioperative factors, such as type of procedure, cross-clamping time, and type of cardioplegic solution. However, there were some differences regarding pre-existing renal impairment between both parameters. In both groups, renal failure patients with chronic kidney disease stages IV or V as well as patients on haemodialysis exhibited a marked Tmax increase of >100% compared with normal kidney function (hsTnT,+121%; 2,383.5 vs 1,078.8 ng/L; p=0.0006; and sTnI,+149%; 27.3 ng/mL vs 11.0 ng/mL; p=0.009). However, in patients with moderately impaired renal function, those in the hsTnT group, but not in the sTnI cohort, showed significantly increased Tmax values (CKD stages II or III, 1,233.5 ng/L [+14%] and 1,314.1 ng/L [+22%] vs 1,078.8 ng/L; p=0.01 and p=0.03). In these patients, the postoperative interval until Tmax was reached was also significantly increased (14.4 and 19.0 hrs vs 12.4 hrs for chronic kidney disease stages II and III; p=0.0038 and p<0.001), indicating a higher rate of accumulation in the hsTnT parameter. In the context of cardiac surgery, this study found that both parameters behaved in a similar manner under most relevant circumstances. Despite significant difference in the absolute serum concentration, hsTnT and sTnI can be scaled to virtually identical distributions. However, renal impairment did affect both parameters differently with troponin T but not troponin I, showing evidence of accumulation in moderately impaired renal disease.

Preoperative Cognitive Impairment and Postoperative Delirium Predict Decline in Activities of Daily Living after Cardiac Surgery-A Prospective, Observational Cohort Study.

Cardiac surgery and subsequent treatment in the intensive care unit (ICU) has been shown to be associated with functional decline, especially in elderly patients. Due to the different assessment tools and assessment periods, it remains yet unclear what parameters determine unfavorable outcomes. This study sought to identify risk factors during the entire perioperative period and focused on the decline in activity of daily living (ADL) half a year after cardiac surgery. Follow-ups of 125 patients were available. It was found that in the majority of patients (60%), the mean ADL declined by 4.9 points (95% CI, −6.4 to −3.5; p < 0.000). In the “No decline” -group, the ADL rose by 3.3 points (2.0 to 4.6; p < 0.001). A multiple regression analysis revealed that preoperative cognitive impairment (MMSE ≤ 26; Exp(B) 2.862 (95%CI, 1.192–6.872); p = 0.019) and duration of postoperative delirium ≥ 2 days (Exp(B) 3.534 (1.094–11.411); p = 0.035) was independently associated with ADL decline half a year after the operation and ICU. Of note, preoperative ADL per se was neither associated with baseline cognitive function nor a risk factor for functional decline. We conclude that the preoperative assessment of cognitive function, rather than functional assessments, should be part of risk stratification when planning complex cardiosurgical procedures.

Endocarditis: An Ever Increasing Problem in Cardiac Surgery.

Endocarditis remains one of the most threatening diagnoses in cardiac surgery and is still increasing. Particularly, device-related as well as prosthetic endocarditis appears to be on the rise. Early mortality and periprocedural complications are high jeopardizing the success of surgical efforts. We looked at the development of the numbers and the distribution of endocarditis in an all-comer analysis. From 2003 to 2017, 752 patients with endocarditis were transferred to our cardiosurgical institution (mean age 65 ± 13 years; mean logistic EuroSCORE 28.01%; males 74.33%). A total of 89.49% of them were surgically treated; 30.01% redo cases thereof; and 9.17% had been operated previously for acute endocarditis. While the total number of cardiosurgical procedures remained relatively stable throughout the years, 20 patients were admitted in 2003 and 79 in 2017 yielding more than fourfold increase (p < 0.001). Early mortality of all patients was 25.1%. Septic emboli occurred in 23.7% and 43.8% cerebral emboli thereof. A significant increase of aortic, mitral, and tricuspid valves involvement was observed (p < 0.001). An increase of device-related endocarditis was also noted (p < 0.001). Endocarditis remains a serious problem with high early mortality and morbidity. The vast increase of electrophysiological device implantations has resulted in an increase of tricuspid valve involvement. Liberalization of endocarditis prophylaxis, that is, more restrictive use of antibiotics in 2007 may have at least partially contributed to an increase of the individual risk to suffer from acute endocarditis. A renaissance of a stricter endocarditis-prophylaxis may thus be considered.

Conversion of Atrial Fibrillation after Cardiosurgical Procedures by Vernakalant® as an Atrial Repolarization Delaying Agent (ARDA).

Postoperative, new-onset atrial fibrillation (POAF) is one of the most common complications after cardiosurgical procedures. Vernakalant has been reported to be effective in the conversion of POAF. The aim of this study was to evaluate the efficacy and safety of vernakalant for atrial fibrillation after cardiac operations, and to investigate predictors for the success of vernakalant treatment.Patients and Methods: Post-cardiac surgery patients with new-onset of atrial fibrillation (AF) were consecutively enrolled in this study. Demographic data as well as intraoperative and postoperative parameters were analyzed. Vernakalant administration was primarily started 5.5 hours after new-onset POAF: 3 mg/kg intravenously over 10 min, and in case of non-conversion, a second dose of 2 mg/kg intravenously over 10 min.Results: 129 consecutive patients (70.2 ± 9.1 years) were included: 61 patients with coronary artery bypass graft (CABG) surgery, 49 patients with isolated valve procedures, and 19 patients with combined procedures (CABG and valve). Conversion in sinus rhythm was achieved after the first vernakalant dose in 57 patients (44%), and after the second dose in 41 patients (32%). The mean time to conversion was 13.7 ± 14.1 min. The patients receiving valve procedures depicted a significantly lower conversion rate. The following variables lowered conversion rate: no preoperative beta blocker, postoperative troponin levels >500 ng/L, and systolic blood pressure >140 mmHg. At the first follow-up, 92% of the converted patients showed sinus rhythm, while 80% of the non-responders showed sinus rhythm (P < .01).Conclusions: The POAF was effectively converted by vernakalant. The conversion rate of POAF after valve surgery was lower when compared to isolated CABG.

Sternal Application of Vancomycin Greatly Reduces the Incidence of Sternal Wound Complications in Patients undergoing Cardiosurgical Procedures

Sternal Application of Vancomycin Greatly Reduces the Incidence of Sternal Wound Complications in Patients undergoing Cardiosurgical Procedures

Fungal infections in children in the early postoperative period after cardiac surgery for congenital heart disease: a single-centre experience.

Postoperative infections are still an important problem in cardiac surgery, especially in the paediatric population, and may influence the final outcome of congenital heart disease treatment. Postoperative infections with fungi are uncommon. The aetiology is poorly understood, and the proper diagnosis and treatment is unclear. In this single-centre study, the frequency of invasive fungal disease in children who underwent surgical management of congenital heart diseases was determined along with the risk factors for infection, treatment options and outcomes. All consecutive paediatric patients (<18 years of age) who underwent cardiac surgery for congenital heart disease between September 2008 and December 2015 in a paediatric cardiac centre in Poland were identified. Those who developed invasive fungal disease in the early postoperative period (30 days) were identified. Of the 1540 cardiosurgical procedures for congenital heart disease, 6 were complicated by fungal infection (0.39%). One patient had a high probability of fungal infection, but the diagnosis was unproved. Nevertheless, the patient was successfully treated with antifungal treatment. Five had proven invasive fungal disease. Of these, 3 were diagnosed with candidaemia. All had undergone cardiopulmonary bypass. Of the remaining 2 patients, 1 was a preterm newborn with complete atrioventricular septal defect who developed rib fungal invasion. The remaining patient had pulmonary atresia with ventricular septal defect and developed Fournier's gangrene after surgery. None of the patients died due to infection in the early postoperative period. However, the child with rib fungal invasion died 39 days after surgery as a result of multiorgan failure. Fungal infections in paediatric patients after cardiac surgery may markedly influence morbidity and mortality. Fungal infection prophylaxis in this specific group of children may reduce morbidity, whereas early empirical treatment followed by a targeted approach may improve outcomes. The 'hit fast, hit hard' treatment strategy may be the best rescue option for children who develop invasive fungal disease after cardiac surgery.

Heater–cooler units: contamination of crucial devices in cardiothoracic surgery

Several cases of Mycobacterium chimaera infection have recently been reported in cardiosurgical patients. So-called heater-cooler units (HCUs) used in cardiosurgical procedures are suspected to be the reservoir for pathogen growth and dissemination. To assess the contamination status of HCUs at our facility. Air sampling for mycobacteria was conducted at different distances from the machines and in the area around the operating table. Air sampling was also conducted for non-fermenters as a surrogate parameter for water-associated pathogens. Mycobacterium chimaera was detected in the water tanks of the HCUs. When the devices were operating, M.chimaera was also found in their exhaust air, as well as in the area around the operating table. Non-fermenters were identified at different distances from the running HCU and the area around the operating table. Cultures remained negative when the devices were switched off. Exhaust air from HCUs may be a pathway of pathogen transmission to patients undergoing open chest heart surgery. Although, for technical reasons, relocation of HCUs is difficult to achieve, only strict separation of the HCU from the operating room appears to enhance patient safety. Using non-fermenters as a surrogate parameter may be considered a viable option for a timely risk assessment. The design of HCUs should be modified to keep susceptibility to contamination at a minimum.

Anatomical Variations in the Sinoatrial Nodal Artery: A Meta-Analysis and Clinical Considerations.

Background and ObjectiveThe sinoatrial nodal artery (SANa) is a highly variable vessel which supplies blood to the sinoatrial node (SAN). Due to its variability and susceptibility to iatrogenic injury, our study aimed to assess the anatomy of the SANa and determine the prevalence of its anatomical variations.Study DesignAn extensive search of major electronic databases was performed to identify all articles reporting anatomical data on the SANa. No lower date limit or language restrictions were applied. Anatomical data regarding the artery were extracted and pooled into a meta-analysis.ResultsSixty-six studies (n = 21455 hearts) were included in the meta-analysis. The SANa usually arose as a single vessel with a pooled prevalence of 95.5% (95%CI:93.6–96.9). Duplication and triplication of the artery were also observed with pooled prevalence of 4.3% (95%CI:2.8–6.0) and 0.3% (95%CI:0–0.7), respectively. The most common origin of the SANa was from the right coronary artery (RCA), found in 68.0% (95%CI:55.6–68.9) of cases, followed by origin from the left circumflex artery, and origin from the left coronary artery with pooled prevalence of 22.1% (95%CI:15.0–26.2) and 2.7 (95%CI:0.7–5.2), respectively. A retrocaval course of the SANa was the most common course of the artery with a pooled prevalence of 47.1% (95%CI:36.0–55.5). The pooled prevalence of an S-shaped SANa was 7.6% (95%CI:2.9–14.1).ConclusionsThe SANa is most commonly reported as a single vessel, originating from the RCA, and taking a retrocaval course to reach the SAN. Knowledge of high risk anatomical variants of the SANa, such as an S-shaped artery, must be taken into account by surgeons to prevent iatrogenic injuries. Specifically, interventional or cardiosurgical procedures, such as the Cox maze procedure for atrial fibrillation, open heart surgeries through the right atrium or intraoperative cross-clamping or dissection procedures during mitral valve surgery using the septal approach can all potentiate the risk for injury in the setting of high-risk morphological variants of the SANa.

A new diagnostic IR-thermal imaging method for evaluation of cardiosurgery procedures

Two methods for monitoring the state of the myocardium during cardiosurgical interventions based on thermal IR imaging are presented below. These methods, called static thermography and active dynamic thermography (ADT), use information about the distribution of temperature on the surface, and an external excitation source to induce thermal transient processes in a tested object. Recording the time series of thermograms allows calculating parametric images – the distribution of the thermal time constant on the visible surface of the myocardium – correlated with the physiological state of the tested tissues. The temperature allows monitoring of vascularization in each phase of cardiosurgical interventions. This is a perfect method for the evaluation of the quality of the inserted graft, as well as the efficiency of cardioplegia, and the quality of many surgical procedures in clinical practice. Such monitoring is prompt, easy and objective, especially if dynamic processes are investigated. During LAD occlusion, the ADT procedure was applied using a cooling external excitation source. In summary, the calculated time constant images provide data of the tested structure and functional information of myocardium infarct. This allows tracking changes in the blood flow in the myocardium and enables the inspection of the quality of the intervention during cardiosurgical procedures.

Clinical course and long-term outcome following venoarterial extracorporeal life support-facilitated interhospital transfer of patients with circulatory failure

BackgroundInterhospital transfer of patients experiencing circulatory failure and shock has a significant risk of cardiovascular deterioration and death. Extracorporeal life support (ECLS) is a rescue tool for hemodynamic stabilization that makes patient transportation much safer. MethodsDemographic data, clinical course, and outcome data were reviewed for patients who underwent placement of a venoarterial ECLS in a remote hospital and were transported to our tertiary care facility. Results68 patients were transported to our center with ECLS. The majority of these patients (79%) underwent cardiopulmonary resuscitation during or immediately prior to ECLS initiation. The mean patient age was 52 years, and 53 patients were male. The most common underlying diagnosis was acute coronary syndrome (60%). Overall, 23 patients underwent consecutive cardiosurgical procedures, including coronary artery bypass grafting in 12, and left ventricular assist device and biventricular assist device implantation in 11. The median duration of ECLS was 5 days. None of the patients died during transportation. Twelve of the surgically treated patients survived, as well as 21 patients with non-surgical treatment, which resulted in an overall survival of 33 patients (48.5%). ConclusionECLS-facilitated patient transfer enables safe interhospital transfer of critically ill patients. In this study, a relevant percentage of patients were in need of a cardiosurgical intervention. The long-term survival rate of these patients supports the further use of this time-, cost- and personnel-demanding strategy.

Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention

OBJECTIVE: To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS). STUDY DESIGN: Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index. SETTING: Transnational registry in Spain. SUBJECTS: We included 928 patients aged ≥80 years with severe symptomatic AS. INTERVENTIONS: Aortic-valve replacement (AVR), transcatheter aortic-valve implantation (TAVI) or conservative therapy. MAIN OUTCOME MEASURES: All-cause death. RESULTS: Mean age was 84.2 ± 3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%) and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk [322 (47.1%)], other medical motives [193 (28.2%)], patient refusal [134 (19.6%)] and family refusal in the case of incompetent patients [35 (5.1%)]. The mean time from treatment decision to AVR was 4.8 ± 4.6 months and to TAVI 2.1 ± 3.2 months, P < 0.001. During follow-up (11.2-38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18 and 24 months were 81.8%, 72.6%, 64.1% and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49-0.93; P = 0.016) and AVR HR 0.56 (95% CI 0.39-0.8; P = 0.002). CONCLUSION: Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis.