Cardiothoracic Surgical Services Research Articles

Newborn Screening for High-Risk Congenital Heart Disease by Dried Blood Spot Biomarker Analysis

Congenital heart disease (CHD) is the most common human organ malformation, affecting approximately 1 of 125 newborns globally. Assessing the performance of 2 diagnostic tests using minimal amounts of dried blood spots (DBS) to identify high-risk CHD compared with controls in a Swedish cohort of neonates. This diagnostic study took place in Sweden between 2019 and 2023 and enrolled full-term babies born between 2005 and 2023. All cases were identified through centralized pediatric cardiothoracic surgical services in Lund and Gothenburg, Sweden. Controls were followed up for 1 year to ensure no late presentations of high-risk CHD occurred. Cases were verified through surgical records and echocardiography. High-risk CHD, defined as cases requiring cardiac surgical management during infancy due to evolving signs of heart failure or types in which the postnatal circulation depends on patency of the arterial duct. Using 3-μL DBS samples, automated quantitative tests for NT-proBNP and interleukin 1 receptor-like 1 (IL-1 RL1; formerly known as soluble ST2) were compared against established CHD screening methods. Performance of DBS tests to detect high-risk CHD using receiver operating characteristic curves; Bland-Altman and Pearson correlation analyses to compare IL-1 RL1 DBS with plasma blood levels. A total of 313 newborns were included (mean [SD] gestational age, 39.4 [1.3] weeks; 181 [57.8%] male). Mean (SD) birthweight was 3495 (483) grams. Analyzed DBS samples included 217 CHD cases and 96 controls. Among the CHD cases, 188 participants (89.3%) were high-risk types, of which 73 (38.8%) were suspected prenatally. Of the 188 high-risk cases, 94 (50.0%) passed pulse oximetry screening and 36 (19.1%) were initially discharged after birth without diagnoses. Combining NT-proBNP and IL-1 RL1 tests performed well in comparison with existing screening methods and enabled additional identification of asymptomatic babies with receiver operating characteristic area under the curve 0.95 (95% CI, 0.93-0.98). In this diagnostic study, NT-proBNP and IL-1 RL1 DBS assays identified high-risk CHD in a timely manner, including in asymptomatic newborns, and improved overall screening performance in this cohort from Sweden. Prospective evaluation of this novel approach is warranted.

The implications of 5G technology on cardiothoracic surgical services in India.

The fifth-generation (5G) technology is finally making its long-anticipated arrival in India, where it has evoked much hope to advance healthcare accessibility and delivery to the masses as well as improving patient safety and efficiency. The 5G technology standard for broadband and cellular networks comes with improved coverage capability; better throughput, speed, bandwidth, and signal strength; and low latency. Such salient-advanced features could be the knight in shining armor for the cardiothoracic surgical community in bridging gaps in perioperative care, outreach, education, research, and much more.

An Intensivist-Led Extracorporeal Membrane Oxygenation Program: Design, Implementation, and Outcomes of the First Five Years.

We describe the development, implementation, and outcomes of an intensivist-led adult extracorporeal life support (ECLS) program using intensivists both to perform venovenous (V-V), venoarterial (V-A), and extracorporeal cardiopulmonary resuscitation (ECPR) cannulations, and to manage patients on ECLS throughout their ICU course. All adults supported with ECLS at the University of New Mexico Hospital (UNMH) from February 1, 2017 to December 31, 2021 were retrospectively analyzed. A total of 203 ECLS cannulations were performed in 198 patients, including 116 V-A cannulations (including 65 during ECPR) and 87 V-V cannulations (including 38 in patients with COVID-19). UNMH intensivists performed 195 cannulations, with 9 cannulation complications. Cardiothoracic surgeons performed 8 cannulations. Overall survival to hospital discharge or transfer was 46.5%. Survival was 32.3% in the ECPR group and 56% in the non-ECPR V-A group. In the V-V cohort, survival was 66.7% in the COVID-19-negative patients and 34.2% in the COVID-19-positive patients. This large series of intensivist-performed ECLS cannulations-including V-A, V-V, and ECPR modalities-demonstrates the successful implementation of a comprehensive intensivist-led ECLS program. With outcomes comparable to those in the literature, our program serves as a model for the initiation and development of ECLS programs in settings with limited access to local subspecialty cardiothoracic surgical services.

Intravascular Lithotripsy Catheter Balloon for Calcified Coronary Artery Intervention for the First 10 Cases at Mackay Base Hospital

The intravascular lithotripsy (IVL) catheter balloon is designed to improve the success rate of intervention for coronary artery calcifications (CAC). IVL is highly attractive option for a regional centre such as Mackay without on-site cardiothoracic surgical service for its superior safety data.

COVID-19 and cardiothoracic surgery: A risk-adjusted approach in the context of a global pandemic

In the face of the novel coronavirus pandemic, the impact of COVID-19 infection has disrupted cardiothoracic surgical services globally. A risk-adjusted approach to restructuring the delivery of cardiothoracic surgical services has been proposed in accordance with international guidance to ensure that the surgical standard of care is maintained in the practice of adult and paediatric cardiac surgery, as well as thoracic surgery. The potential influx of COVID-19 patients with cardio-respiratory complications requiring intensive care management and associated surgical procedures falling within the gamut of the thoracic surgeon, is considered. Finally, the protection of healthcare workers, in particular the surgical team exposed to aerosolising procedures, is outlined.

Cardiothoracic Surgical Volume Within the Military Health System: Fiscal Years 2007 to 2017

Cardiothoracic surgical services have been provided at 7 military treatment facilities over the past decade. Accurate case volume data for adult cardiac and general thoracic surgical service lines in the Military Health System is unknown. We queried the Military Health System Data Repository for adult cardiac and general thoracic cases performed at military treatment facilities in the Military Health System and surrounding purchased care markets for fiscal years 2007 to 2017. Cases were filtered and classified into major cardiac and major general thoracic categories. Five military treatment facility markets had sufficient cardiac case data to perform cost analysis. Institutional major cardiac case volume was low across the Military Health System with less than 100 cardiopulmonary bypass cases per year (range, 17-151 cases per year) performed most years at each military treatment facility. Similarly, general thoracic surgical case volume was universally low, with less than 30 anatomic lung resections (range, 0-26) and fewer than 5 esophageal resections (range, 0-4) performed at each military treatment facility annually. Cost analysis revealed that provision of cardiac surgical services is significantly more expensive at most military treatment facilities compared with their surrounding purchased care markets. Adult cardiac and general thoracic surgical volume within the Military Health System is low across all institutions and inadequate to provide clinical readiness for active-duty surgeons. Recapture of major cases from the purchased care market is unlikely and would not significantly increase military treatment facility or individual surgeon case volume.

Two-Year Experience of 14 French Pigtail Catheters Placed by Procedure-Focused Hospitalists.

Recent studies show small-bore chest tubes, commonly 14 French pigtail catheters (PCs), are noninferior to large-bore chest tubes for treating various conditions, and they are associated with better patient comfort. The Medical College of Wisconsin implemented a bedside procedure service (BPS) that has been trained in the placement of PCs as an adjunct to its interventional radiology department. The data regarding consults for PC placement was collected by the BPS over a 2-year period. Primary outcomes reviewed were insertion-related complications (IRCs), unsuccessful attempts (UAs), and adverse outcomes (AOs) because the authors believe these represent the safety and effectiveness of the group. It was determined which services consulted the BPS for PC placement, the indications for consults, and a brief review of declined PC consults. Of the 124 accepted consults, the service had 3 IRCs (2.4%), 2 UAs (1.6%), and 3 AOs (2.4%). A total of 18 consults were declined. The BPS was consulted by 12 services with 8 primary reasons for PC placement. At high-volume, tertiary care centers, and with the support of cardiothoracic surgical and interventional radiology services, procedure-focused hospitalists can safely serve as an adjunct service for PC placement in selected hospitalized patients.

Interhospital Transfer: Transfer Processes and Patient Outcomes.

Though often undertaken to provide patients with specialized care, interhospital transfer (IHT) is associated with worse outcomes for select patients. Certain aspects of the transfer process have been suggested as contributors to these outcomes. We performed a retrospective cohort study including patients ≥ 18 years who underwent IHT to a tertiary care hospital between January 2005 and September 2013. We examined the association between "weekend" transfer, "nighttime" transfer, "time delay" between transfer acceptance and arrival, and admission team "busyness" on the day of transfer, and patient outcomes, including transfer to the intensive care unit (ICU) within 48 hours and 30-day mortality. We utilized multivariable logistic regression models, adjusting for patient characteristics. Secondary analyses examined detailed timing of transfer and evaluated 30-day mortality stratified by service of transfer. Among the 24,352 patients who underwent IHT, the nighttime transfer was associated with increased adjusted odds of ICU transfer (odds ratio [OR] 1.54; 95% CI 1.38, 1.72) and 30-day mortality (OR 1.16; 95% CI 1.01, 1.35). Secondary analyses confirmed the association between nighttime transfer and ICU transfer throughout the week and demonstrated that Sunday (and trend towards Friday) night transfers had increased 30-day mortality, as compared with Monday daytime transfer. Stratified analyses demonstrated a significant association between transfer characteristics and adjusted odds of 30-day mortality among cardiothoracic and gastrointestinal surgical service transfers. Our findings suggest high acuity patients have worse outcomes during off-peak times of transfer and during times of high care team workload. Further study is needed to identify underlying reasons to explain these associations and devise potential solutions.

Association Between System Factors and Acute Myocardial Infarction Mortality.

We conducted a cross-sectional study to assess the association between healthcare system factors and death from acute myocardial infarction (AMI), in terms of access (distance to the hospital, mode of transportation), availability (emergency medical services, hospitals), and capability (emergency medical services' 12-lead electrocardiogram capability, continuous percutaneous coronary intervention [PCI] and cardiothoracic surgical services), after accounting for individual and environmental factors. Data on 14,663 deaths (in-hospital and out of hospital) and live hospital discharges as a result of AMI for 2012 and 2013 among Arkansas residents were obtained from the Arkansas Department of Health. A mixed-effects logistic regression model was used to account for nesting, in which an individual was nested within either a county or a hospital to evaluate the association of system factors with death from AMI. Deaths from AMI were significantly associated with two system factors: a 9.2% increase in the odds of deaths from AMI for every 10-mi increase in distance to the nearest hospital (odds ratio 1.092, 95% confidence interval 1.009-1.181) and a 64% increase in the odds of death from AMI among hospitals without continuous PCI capability (odds ratio 1.64, 95% confidence interval 1.15-2.34), after adjusting for individual and environmental factors. A higher risk of AMI deaths was associated with healthcare system factors, especially distance to nearest hospital, and hospitals' continuous PCI capability, even after adjusting for individual and environmental factors. A coordinated system of care approaches that mitigates gaps in these system factors may prevent death from AMI.

Percutaneous Thrombectomy with the AngioVac Aspiration Device: a Single-Center Experience

Purpose To describe a single-center experience with the AngioVac device (Angiodynamics, Latham, New York), a 22 Fr percutaneous aspiration thrombectomy device designed for venous aspiration, extra-corporeal filtration, and venous re-infusion. Material and Methods Institutional Review Board exemption was obtained for retrospective analysis of the medical records from 13 consecutive cases using the AngioVac device 1 January 2012 through 1 September 2014. Results Mean patient age was 49 years (range 24 to 71 years). Nine patients had thrombus located in the inferior vena cava (IVC), 3 in the right heart, and 1 in the pulmonary artery. Cardiothoracic or peripheral vascular surgical services evaluated the patients and deemed them ineligible for surgery. Nine cases were clinically and angiographically successful. No adjunctive therapy, such as venous stent placement, was required. One patient experienced hyperkalemic cardiac arrest after successful thrombectomy and survived after 5 minutes of advanced cardiovascular life support. Four cases were unsuccessful. One patient with enlarging high volume pulmonary embolism (PE) and right atrial mass, later found to be a tumor thrombus, died due to iatrogenic PE, and 1 patient with pulmonary artery thrombus experienced acute cardiogenic shock after her tricuspid valve was damaged by the advancing cannula. The patient survived open tricuspid valve repair and pulmonary artery thrombectomy. One case was abandoned prior to thrombectomy because sufficient bypass flow could not be established, and 1 case was abandoned after the cleared IVC immediately re-occluded with thrombus. Conclusions In our experience, aspiration thrombectomy using the AngioVac device is safe and effective in removing central caval thromboses. The use of the AngioVac device to remove thrombus in the right heart is effective but may carry a higher risk of severe complication. Pulmonary artery thrombectomy is the most challenging because of the complexity of advancing the cannula through the heart and the high likelihood of an unstable patient.

Sickle cell disease and complex congenital cardiac surgery: a case report and review of the pathophysiology and perioperative management

Sickle cell anemia and thalassemia are hemoglobinopathies rarely encountered in the United States. Compounded with congenital heart disease, patients with sickle cell disease (SCD) requiring cardiopulmonary bypass and open-heart surgery represent the proverbial "needle in the haystack". As such, there is some trepidation on the part of clinicians when these patients present for complex cardiac surgery. SCD is an autosomal, recessive condition that results from a single nucleotide polymorphism in the β-globin gene. Hemoglobin SS molecules (HgbSS) with this point mutation can polymerize under the right conditions, stiffening the erythrocyte membrane and distorting the cellular structure to the characteristic sickle shape. This shape change alters cellular transit through the microvasculature. As a result, circumstances such as hypoxia, hypothermia, acidosis or diminished blood flow can lead to aggregation, vascular occlusion and thrombosis. Chronically, SCD can give rise to multiorgan damage secondary to hemolysis and vascular obstruction. This review and case study details an 11-year-old African-American male with known SCD who presented to the cardiothoracic surgical service with congenital heart disease consisting of an anomalous, intramural right coronary artery arising from the left coronary sinus for surgical consultation and subsequent surgical correction. This case report will include a review of the pathophysiology and current literature regarding preoperative, intraoperative and postoperative management of SCD patients.

G148(P) Defining the Burden of Paediatric Cardiac Disease in Malawi – the Experience from a Tertiary Referral Centre

AimThe literature relating to paediatric cardiac disease in sub-Saharan Africa is sparse and the spectrum of paediatric cardiac disease has not been described in Malawi.A paediatric cardiology clinic with trans-thoracic...

The spectrum of paediatric cardiac disease presenting to an outpatient clinic in Malawi

BackgroundAs progress is made towards attaining Millennium Development Goal 4, further reductions in paediatric mortality will only be achieved by concentrating on the burden of non-communicable or neglected diseases. The literature relating to paediatric cardiac disease in sub-Saharan Africa is sparse. There are no published descriptions of paediatric cardiac disease from Malawi, making it impossible to estimate the contribution it makes to childhood morbidity and mortality.FindingsIn 2008, a paediatric cardiac clinic with echocardiogram scanning was established in Blantyre, southern Malawi. Between January 2009 and February 2011, the age and cardiac diagnosis of every child with an abnormal echocardiogram was recorded in a database. Of 250 children, 139 (55.6%) had congenital heart disease, and 111 (44.4%) acquired heart disease. Ventricular septal defect (VSD) (24%), Tetralogy of Fallot (10%) and patent ductus arteriousus (7.2%) were the commonest forms of congenital heart disease. Rheumatic heart disease (RHD) (22.4%) and dilated cardiomyopathy (13.6%) were the commonest acquired diseases. The mean age of presentation was 3 years 2 months for VSD and 11 years 6 months for RHD.ConclusionsIn this cohort of children from one centre in Malawi, acquired heart disease – in particular rheumatic heart disease was almost as common as congenital heart disease. Most presented late. It is likely that untreated cardiac disease causes a large number of childhood deaths in Malawi. In addition to renewing secondary preventative efforts against rheumatic heart disease, adequate and accessible cardiothoracic surgical services should be established at a regional level.

Outcomes following the surgical ligation of the patent ductus arteriosus in premature infants in Scotland

ObjectiveTo determine morbidity, mortality and associated risk factors following patent ductus arteriosus (PDA) ligation in premature infants.MethodsRetrospective case note audit of premature infants referred to a national paediatric cardiothoracic surgical...

1 Year outcomes following surgical ligation of the patent ductus arteriosus in premature infants in scotland

ObjectiveAnalysis of morbidity, mortality and associated risk factors following ligation of the patent ductus arteriosus (PDA) in premature infants.MethodsRetrospective case note audit of premature infants referred to a national paediatric...

A case study: Boerhaave's Syndrome

JG was a 50-year-old man who had been having epigastric pain and shortness of breath for 2 or 3 days, which he attributed to his history of gastritis and self-treated with antacids. He had several episodes of vomiting but did not note any blood in the emesis. Four hours after awakening with continued sharp right upper quadrant pain, chest pain, worsening dizziness, difficulty breathing, and general malaise, he called 9-1-1. Emergency medical service personnel found him awake and fully oriented, with respiratory rate of 40 breaths per minute, wheezing in both lung fields, and cool, clammy skin. His heart rate was 120 beats per minute with no obtainable blood pressure or pulse oximetry waveform from a probe placed on his fingertip. Intravenous therapy with 900-mL crystalloid bolus and albuterol nebulizer treatment were completed during transport to the local emergency department (ED). On arrival at the community hospital, JG’s initial vital signs were heart rate 126 beats per minute, blood pressure 119/66 mm Hg, respiratory rate 38 breaths per minute, SpO2 92% on room air, and temperature 96.8° F. Additional large bore intravenous access was secured because the staff noted the patient’s skin to be “clammy and mottled.” ED workup included arterial blood gas analysis, chest x-ray, and continued intravenous crystalloid resuscitation. The differential diagnosis was listed as “acute surgical abdomen” by the ED attending and consulting general surgeon. Foley and nasogastric tubes were placed while waiting for the lab results to return. JG’s initial arterial blood gas was reported as pH 7.23, PCO2 24 mm Hg, PO2 72 mm Hg, HCO3 10 meq/L, and base excess (BE) -15.9 The x-ray film showed bilateral pleural effusions, with the worst being on the left. A left tube thoracostomy was performed with a 28-French chest tube. Immediately 1100 mL of a brown fluid drained into the chest drainage unit. Symptoms of shortness of breath continued, as did oxygen saturations of 89% on room air and 93% on 2 L by nasal cannula (NC). He was set up for a contrasted abdominal/chest computed tomography (CT) scan and given oral contrast mixed with methylene blue. After the CT scan, his chest drainage unit contained blue pleural fluid. His blood pressure dropped precipitously to 66/39, heart rate 124 beats per minute, and O2 saturation down to 89% on 2 L NC. While the intravenous fluids were opened wide, arrangements were made to transfer him to Virginia Commonwealth University Health System for evaluation by the cardiothoracic surgical services. The time from arrival in the ED to the transfer request totaled 6 hours. When the air medical crew arrived, JG was normotensive but remained tachycardic and tachypneic. He had received a total of 5 L crystalloid and remained on an NC at 4 L. He was anxious, mucous membranes were dry and cracked, and skin was cool and moist. Review of the 12-lead electrocardiogram revealed only sinus tachycardia with no acute changes. Abdominal assessment revealed a firm abdomen with pain rated 10 on a 10-point scale. Intravenous fluids remained wide open, so the patient was placed on nonrebreather 100% oxygen and rapidly packaged for transport. While loading into the helicopter, JG’s anxiety and work of breathing increased. Once he was secure, the flight crew per-

History of the Cardiothoracic Surgical Service at Baylor University Medical Center

History of the Cardiothoracic Surgical Service at Baylor University Medical Center

Results of continual devaluation of cardiothoracic surgical codes by the HCFA between 1984 and 1999

Background. The devaluation of surgical procedural services by Medicare began in 1989 as a result of the federal government’s adoption of the Resource Based Relative Value Scale, a method of redistribution of payments to physicians from surgical to primary care services. This method gave to the Health Care Financing Administration (HCFA) effective and complete control of Medicare payments to physicians for the first time. The resultant decrease in the nominal dollar value is well understood, but the effect of changes in inflation frequently is not calculated into the reported loss. Methods. A method of determining the true extent of this devaluation using the nominal dollar decrease plus the effect of inflation was presented in 1995. Results. Since then, repeated devaluation by the HCFA and other third parties plus continual inflation has further eroded the remuneration for cardiothoracic surgical services. Three different sets of data are used to determine the devaluation of five cardiothoracic operations. One set shows the change between 1988 and 1998; one the change between 1988 and 1999; and one the change between 1984 and 1999. Conclusions. Depending on the geographic location, it appears that the remuneration for pulmonary procedures between 1988 and 1999 decreased 35% to 60%. Similarly, depending on the years reviewed (between 1984 and 1999) and the geographic location, the fee for cardiac procedures decreased 46% to 69%.

Cardiac Operations in Patients With Cirrhosis

Background. A retrospective review was performed to determine the outcome after cardiac operations in patients with a documented history of noncardiac cirrhosis. Methods. The charts of patients admitted to the cardiothoracic surgical service between 1990 and 1996 were reviewed, and 13 patients with a preoperative history of cirrhosis were identified. The severity of preoperative liver disease was graded according to the criteria of Child. Results. Most of the cases of cirrhosis were alcohol-related. Eight patients were classified as having Child class A and 5 as having Child class B cirrhosis. One hundred percent of patients with Child class B and 25% of those with Child class A cirrhosis had major complications. The postoperative chest tube output and transfusion requirements of these patients were approximately three times higher than average. The overall perioperative mortality rate was 31%. In patients with Child class B cirrhosis, the mortality rate was 80%. No patient with Child class A cirrhosis died. Deaths were related to gastrointestinal and septic complications, and not to cardiovascular failure. Conclusions. These findings suggest that patients with minimal clinical evidence of cirrhosis can tolerate cardiopulmonary bypass and cardiac surgical procedures, whereas those with more advanced liver disease should not be offered operation.

Incidence and Risk of Developing Fungal Prosthetic Valve Endocarditis after Nosocomial Candidemia

PURPOSE: To determine the incidence of prosthetic valve endocarditis (PVE) in fungemic patients with prosthetic heart valves (PHV), estimate the risk of subsequent PVE, and describe risk factors and diagnostic and therapeutic management issues in such patients.PATIENTS AND METHODS: This is a retrospective chart review in a 1,100-bed tertiary referral center with an active cardiothoracic surgical service. Forty-four patients with PHVs developed nosocomial fungemia between January 1985 and April 1995.RESULTS: Of 44 patients, 33 never developed evidence of PVE (group 1), 7 (16%) had evidence of PVE at the time of candidemia (group 2), and 4 (9%) developed PVE a mean of 232 days after candidemia (group 3). Predisposing factors including intravascular lines, prior antibiotic therapy, and an identifiable portal of entry for fungemia were common in group 1 but not group 2. Candidemia occurred significantly later after PHV surgery in group 2 (mean 270 days) as compared to groups 1 and 3 (means 48 and 15.5 days, respectively; P = 0.02). Ten of 11 patients with Candida PVE (group 2 and 3) were treated with amphotericin B and valve replacement. Three relapses after combined therapy were documented in two patients. Mortality was significantly higher for patients without Candida PVE (group 1) as compared to patients with Candida PVE (groups 2 and 3) at 1 month (53% vs 9%), 2 months (69% vs 20%) and 1 year (83% vs 25%) after candidemia.CONCLUSIONS: Patients with prosthetic heart valves who develop nosocomial candidemia are at notable risk of either having or developing Candida PVE months or years later. Late onset candidemia and lack of an identifiable portal of entry should heighten concern about Candida PVE in such patients.