Chest Re-exploration Research Articles

Mid-term outcomes of frozen elephant trunk for chronic aortic dissection.

The aim of the study was to analyze the mid-term outcomes of the frozen elephant trunk (FET) procedure for chronic aortic dissection (СAD). From March 2012 to December 2022, 123 FET procedures were performed in patients with acute and chronic aortic dissection as well as aortic aneurysm. Fifty-five patients with chronic aortic dissection (CAD) were eligible for study. CAD patients were divided into 2 groups: type A (n=32), type B (n=26). Pre-, intra- and postoperative data were collected retrospectively from electronic patient records, with median follow-up period of 21.5 months (range, 1-96). The overall 30-day mortality in CAD patients was 10.3%. The overall survival rate for the entire cohort was 66.5±7.9%, for type A and type B patients was 77.6±8.1% and 53±1.3%, respectively (P = 0.229). Distal stent-graft-induced new entry developed in 2 (3.4%) patients. Freedom from composite outcome (death or/and distal aortic re-intervention) for the entire cohort was 56.8±9.8%, and for type A and type B patients was 66.5±1.2% and 44.8±1.4%, respectively (P = 0.181). The incidence of stroke was 1.7%. Two (3.4%) patients had signs of SCI. Respiratory failure occurred in 14 (23.1%) patients. The rate of dialysis was 15.5% (n=9). The chest re-exploration for bleeding rate was 5.2% (n=3). Early and late outcomes (death or/and distal aortic re-intervention) after the FET in CAD are tolerable without difference between type A and type B.

Very Delayed Surgical Bleeding after Coronary Artery Bypass Graft Causing Cardiac Tamponade and Cardiogenic Shock: A Rare Case Report

Delayed surgical bleeding from the left internal mammary artery (LIMA) bed following coronary artery bypass grafting (CABG) is a rare yet potentially fatal condition that can lead to cardiac tamponade and life-threatening cardiogenic shock. We present a case of extremely delayed active bleeding from the LIMA bed, occurring 5 weeks after conventional CABG, resulting in cardiac tamponade and cardiogenic shock. The 73-year-old patient presented to the emergency room with a 2-day history of general weakness and hypotension. He had undergone CABG 5 weeks ago. Optimal inotropic agents and vasopressors were used for the treatment of shock. In the emergency room, real-time bedside echocardiography showed severe external compression of the right ventricle by a homogeneous, hyperechoic mass. Veno-arterial (V-A) mode extracorporeal membrane oxygenation (ECMO) was promptly instituted to stabilize hemodynamics. Subsequent chest re-exploration, involving blood clot evacuation, was performed, and the bleed from the distal LIMA bed was ligated. Delayed LIMA bed bleeding causing cardiac tamponade and cardiogenic shock is an infrequent occurrence, and the use of V-A mode ECMO successfully provided a window of time for chest exploration.

Left anterior mini-thoracotomy: an alternative approach for pulmonary valve replacement after surgically corrected tetralogy of fallot

IntroductionPulmonary regurgitation (PR) remains a common sequela in patients following surgically corrected TOF, and may lead to progressive right ventricle dilatation and dysfunction. The conventional approach of redo-sternotomy for pulmonary valve replacement (PVR) is associated with increased operative time as well as risks of bleeding and injury to the heart and great vessels. Thus, left anterior mini-thoracotomy has become an alternative approach in eliminating the risks of redo-sternotomy in these patients. This series aimed to determine the outcomes of minimally invasive pulmonary valve replacement after surgical TOF correction.MethodsA retrospective analysis was conducted on 24 patients with severe PR post-surgical TOF correction who underwent left anterior mini-thoracotomy PVR in Penang General Hospital from January 2021 to January 2023.ResultsThe median age was 23.5 years (I.Q.range 17.6-36.3), with a male:female ratio of 1:4. Majority of patients had mild to moderate symptoms prior to surgery and 19 patients (79.1%) were on regular diuretics medication. All patients had severe free-flow PR with evidence of right ventricular dilatation and dysfunction. Magnetic Resonance Imaging and computed tomography of pulmonary artery were performed prior to surgery. Minimally invasive PVR was performed on all patients via left upper anterior mini-thoracotomy and femoral-femoral bypass without cardioplegic arrest. The operative time and cardiopulmonary bypass time were 208 (I.Q.range 172-324) and 98.6 minutes(I.Q.range 87.4-152.4) respectively. The time to wean off inotropes postoperatively was 6.2 hours (I.Q.range1.4-14.8), and no postoperative arrhythmia and chest re-exploration were reported. Most patients stayed in Intensive Care Unit (ICU) for 10.8 hours (I.Q.range 8.4-36.5), and the total hospital stay was 4.2 days (I.Q.range 3.4-7.6). 2 patients (11.1%) required blood transfusion postoperative. There was no paravalvular leak and no mortality during the follow-up period of up to 28 months.ConclusionMinimally invasive PVR after surgical correction of TOF is a safe alternative to the conventional redo-sternotomy approach in patients with favorable anatomy. This approach is able to reduce the risks associated with redo-sternotomy, particularly bleeding and injury to mediastinal structures, with the additional benefit of expedited recovery and hospital discharge. Our series has shown a safe and efficient approach in these patients with favorable outcomes.

Impact of duration of cardiopulmonary bypass on recovery after open heart surgery

Background: Objective of the study was to examine the impact of cardiopulmonary bypass (CPB) duration on recovery from cardiac surgery. Methods: This is an observational retrospective study. Data from adult cardiac surgical patients presented at Queen Alia Heart Institute (QAHI) in the duration between September 2023 and February 2024 was retrospectively analysed. The impact of CPB duration was examined. Patients were divided into groups according to CPB duration (0 to 60 minutes, 60 to 120 minutes, 120 to 180 minutes, 180 to 240 minutes and 240 to 300 minutes). For each group intra-operative and post-operative variable were examined. The intra-operative variables studied were need for blood transfusion, haemofiltration and intra-aortic balloon pump. The post-operative variables studied were duration of post-operative mechanical ventilation, intensive care unit (ICU) stay, hospitalization time and mortality. Results: Consecutive data of 202 adult cardiac surgical patients (34 females and 168 males) was analysed. Average age of patients was 57.149 years. Average duration of CPB was 109.9 minutes (ranged from 29 to 300 minutes). Half of the patients (50.5%) had CPB duration between 1 and 2 hours. Blood transfusion was needed in 88 patients (43.6%). Haemofiltration was used in 32 patients (15.8%) and intra-aortic balloon pump (IABP) was used in 29 patients (14.4%). The average postoperative time of mechanical ventilation was 34 hours and the average ICU stay was 5.5 days. Chest re-exploration was needed in 30 patients (15%). Hospital stay was on average 12 days and in-hospital mortality was witnessed in 20 patients (9.9%). Patients who had CPB for less than one hour (17.3%) had the lowest incidence of blood transfusion (37.1%), lowest incidence of haemofiltration (8.6%), low incidence of IABP use (11%). They also had lowest incidence of chest re-opening (5.7%), shortest time of postoperative mechanical ventilation (13 hours) and shortest ICU and hospital stay (4.1 and 8.5 days, respectively). There was a significant increase in postoperative sternal re-opening and postoperative mortality when the duration of CPB exceeded 3 hours. Conclusions: Duration of CPB is a key predictor of recovery and outcome of cardiac surgery. Shorter CPB time was associated with earlier extubation, less ICU stay and shorter hospitalisation time. Prolonged CPB was associated with higher rates of complications, delayed recovery, longer ICU stay, protracted hospitalisation and higher mortality rates.

Early chest re-exploration after adult cardiac surgery

Background: Aim of the study was to determine the rate, causes, consequences of early re-sternotomy after cardiac surgery and to compare between re-opening in the operative theatre and re-opening in the intensive care unit (ICU). Methods: This is an observational retrospective study of adult cardiac surgical patients presenting for cardiac surgery at Queen Alia heart institute in the between September 2023 and February 2024. Incidence, risk factors, causes, site and consequences of early re-sternotomy are studied. Results: Data from 182 patients was analysed. Male patients were 82.4% and female patients were 17.6%. Reopening was needed in 12.1%. Incidence of reopening was highest after combined procedures (33.3%) and aortic surgery (33.3%). Reopening was performed in the operative theatre in 72.3% of cases, while 27.3% had reopening in the ICU. Risk factors for re-opening were longer average CPB (127 minutes vs 107 minutes) and aortic clamp times (71 vs 65 minutes). Patients who had reopening spent on average 55.45 hours on mechanical ventilation, while those who did not were extubated after 32 hours. The overall mortality rate was 11%; however, mortality in the reopening group was much higher (36.4%). Those who were reopened in ICU were at an older age (mean 61.6 vs 56.9 years), required more blood transfusions (mean 2.4 units vs 1.5 units) and had higher mortality (mean 60% vs 23.5%). Conclusions: Incidence of re-opening after cardiac surgery was 12.1%. The two main causes of re-opening were excessive bleeding and haemodynamic instability. Higher incidence of mortality was seen when re-opening took place in the ICU. Predictors for re-opening are old age, more complex (combined) procedures, aortic surgeries and prolonged cardiopulmonary bypass (CPB) and aortic cross clamp (ACC) durations.

Survival and Independent Predictors of Mortality Following Coronary Artery Bypass Graft Surgery in a Single-Unit Practice in the United Kingdom Over 20 Years

The types of graft conduits and surgical techniques may impact the long-term outcomes of patients after coronary artery bypass graft (CABG) revascularization. This study observed a long-term survival rate following CABG surgery over 20 years in the United Kingdom. A total of 2979 isolated CABG patients were studied from 1999 to 2020, and postoperative data were obtained from the hospital-recorded mortality by the data quality team of the information department. Postdischarge survival was estimated using the Kaplan-Meier method, and statistical significance was obtained with log-rank tests and the Gehan-Breslow test, and the Holm-Sidak method was used for multiple pairwise comparisons. The study observed male predominance (80%), and the median age was statistically significant (P <0.001) among the groups, 66 years (interquartile range 58-73) and 72 years (interquartile range 66-78) in survivor and non-survivor groups, respectively. In the Holm-Sidak method analysis, the best survival rate (mean 18.7 years) was observed in the total arterial group with significantly decreased survival for the mixed arterial and venous group (mean 16.12 years) and only the vein group (10.44 years). The Cox regression model observed that the New York Heart Association (NYHA) class III-IV (HR 1.57), chest re-exploration (HR 2.14), preoperative dialysis (HR 3.13), and redo surgery (HR 3.04) were potential predictors of the postoperative mortality (P ≤0.05). In our series over 20 years, albeit off-pump and on-pump CABG observed similar survival rates, the total arterial myocardial revascularization population has significantly better long-term survival benefits.

Valve-sparing aortic root replacement using the reimplantation (David) technique: a systematic review and meta-analysis on survival and clinical outcome.

Current guidelines recommend valve-sparing aortic root replacement (VSRR) procedures over valve replacement for the treatment of root aneurysm. The reimplantation technique seems to be the most widely used valve-sparing technique, with excellent outcomes in mostly single-center studies. The aim of this systematic review and meta-analysis is to present a comprehensive overview of clinical outcomes after VSRR with the reimplantation technique, and potential differences for bicuspid aortic valve (BAV) phenotype. We conducted a systematic literature search of papers reporting outcomes after VSRR that were published since 2010. Studies solely reporting on acute aortic syndromes or congenital patients were excluded. Baseline characteristics were summarized using sample size weighting. Late outcomes were pooled using inverse variance weighting. Pooled Kaplan-Meier (KM) curves for time-to-event outcomes were generated. Further, a microsimulation model was developed to estimate life expectancy and risks of valve-related morbidity after surgery. Forty-four studies, with 7,878 patients, matched the inclusion criteria and were included for analysis. Mean age at operation was 50 years and almost 80% of patients were male. Pooled early mortality was 1.6% and the most common perioperative complication was chest re-exploration for bleeding (5.4%). Mean follow-up was 4.8±2.8 years. Linearized occurrence rates for aortic valve (AV) related complications such as endocarditis and stroke were below 0.3% patient-year. Overall survival was 99% and 89% at 1- and 10-year respectively. Freedom from reoperation was 99% and 91% after 1 and 10 years, respectively, with no difference between tricuspid and BAVs. This systematic review and meta-analysis shows excellent short- and long-term results of valve-sparing root replacement with the reimplantation technique in terms of survival, freedom from reoperation, and valve related complications with no difference between tricuspid and BAVs.

A Retrospective Multicenter Experience: Does Packing the Surgical Field Help to Stop Bleeding After Cardiac Surgery.

Intractable bleeding after cardiac surgery is a well-documented complication. When conservative measures fail to control bleeding, re-exploration is required, and, in some cases, chest packing may be needed. The study included 148 patients admitted to eight cardiac surgery centers in Egypt with severe postoperative bleeding. All patients underwent chest re-exploration and chest packing to control postoperative bleeding. The mean age was 62.7 ± 5.6 years. Their mean BMI was 27.1 ± 3.9 kg/m2. One-hundred-ten (74.3%) of included patients were hypertensive, while 49 (33.1%) patients were diabetic. Twenty-seven (18.2%) patients had initially had a triple valve replacement. Sepsis was prevalent among 31 (20.9%) of included patients. Twenty (13.5%) patients died. Intractable bleeding is a well-documented complication following cardiac surgery. Chest re-exploration is required in certain situations when the traditional conservative options fail to stop bleeding. Chest packing is a modality that can be considered to control bleeding in certain situations.

Early clinical outcomes of surgical myocardial revascularization in patients with preoperative platelet dysfunction

Background/Aim. Coronary artery bypass grafting (CABG) is the treatment of choice for a significant number of patients with ischemic heart disease. Some of the postoperative complications are closely linked with the preoperative antiplatelet therapy (APT). The aim of this study was to compare the early clinical outcomes of CABG in patients with preserved platelet (PLT) function and patients with PLT function impaired by the residual therapeutic effect of APT. Methods. A total of 181 patients with isolated CABG were enrolled in this prospective, nonrandomized, observational study. Patients were divided into four groups: control group (arachidonic acid-dependent PLT aggregation group), with aspirin-induced platelet inhibition (ASPI) test ? 790 aggregation units (AU)/min; mild (M) acetylsalicylic acid (ASA) effect (MASAE) group, with ASPI test = 410?789 AU/min; pronounced (P) ASA effect (PASAE) group, with ASPI test ? 409 AU/min; dual (D) APT (DAPT) group, with ASPI test ? 789 AU/min and adenosine diphosphate (ADP) test ? 405 AU/min. Preoperative data, intraoperative characteristics, and postoperative outcomes were obtained and com-pared between the groups. Results. A significant difference was found regarding the average time of APT cessation be-tween groups (p &lt; 0.001). The DAPT group had a significantly higher frequency of drainage compared to the control (p = 0.004), MASAE (p = 0.001), and PASAE (p = 0.006) groups. The PASAE group had a significantly higher rate of chest reexploration compared to the MASAE group (p = 0.032). The DAPT group required significantly more packed red blood cells (PRBC) compared to the control (p &lt; 0.001) and MASAE (p = 0.009) groups. The PASAE group received significantly more PRBC compared to the control (p &lt; 0.001) and MASAE (p = 0.019) groups. The DAPT group required higher amounts of PLTs compared to the control (p &lt; 0.001), MASAE (p = 0.002), and PASAE (p &lt; 0.001) groups. The DAPT group received higher amounts of cryoprecipitate compared to the control (p = 0.002), MASAE (p = 0.009), and PASAE (p = 0.016) groups. Conclusion. Patients with a residual effect of DAPT, as well as patients with a pronounced residual effect of ASA, have a higher risk of postoperative bleeding and chest reexploration, as well as increased transfusion demands.

Comparison of Four Machine Learning Techniques for Prediction of Intensive Care Unit Length of Stay in Heart Transplantation Patients.

BackgroundPost-operative heart transplantation patients often require admission to an intensive care unit (ICU). Early prediction of the ICU length of stay (ICU-LOS) of these patients is of great significance and can guide treatment while reducing the mortality rate among patients. However, conventional linear models have tended to perform worse than non-linear models.Materials and MethodsWe collected the clinical data of 365 patients from Wuhan Union Hospital who underwent heart transplantation surgery between April 2017 and August 2020. The patients were randomly divided into training data (N = 256) and test data (N = 109) groups. 84 clinical features were collected for each patient. Features were validated using the Least Absolute Shrinkage and Selection Operator (LASSO) regression’s fivefold cross-validation method. We obtained Shapley Additive explanations (SHAP) values by executing package “shap” to interpret model predictions. Four machine learning models and logistic regression algorithms were developed. The area under the receiver operating characteristic curve (AUC-ROC) was used to compare the prediction performance of different models. Finally, for the convenience of clinicians, an online web-server was established and can be freely accessed via the website https://wuhanunion.shinyapps.io/PredictICUStay/.ResultsIn this study, 365 consecutive patients undergoing heart transplantation surgery for moderate (NYHA grade 3) or severe (NYHA grade 4) heart failure were collected in Wuhan Union Hospital from 2017 to 2020. The median age of the recipient patients was 47.2 years, while the median age of the donors was 35.58 years. 330 (90.4%) of the donor patients were men, and the average surgery duration was 260.06 min. Among this cohort, 47 (12.9%) had renal complications, 25 (6.8%) had hepatic complications, 11 (3%) had undergone chest re-exploration and 19 (5.2%) had undergone extracorporeal membrane oxygenation (ECMO). The following six important clinical features were selected using LASSO regression, and according to the result of SHAP, the rank of importance was (1) the use of extracorporeal membrane oxygenation (ECMO); (2) donor age; (3) the use of an intra-aortic balloon pump (IABP); (4) length of surgery; (5) high creatinine (Cr); and (6) the use of continuous renal replacement therapy (CRRT). The eXtreme Gradient Boosting (XGBoost) algorithm presented significantly better predictive performance (AUC-ROC = 0.88) than other models [Accuracy: 0.87; sensitivity: 0.98; specificity: 0.51; positive predictive value (PPV): 0.86; negative predictive value (NPV): 0.93].ConclusionUsing the XGBoost classifier with heart transplantation patients can provide an accurate prediction of ICU-LOS, which will not only improve the accuracy of clinical decision-making but also contribute to the allocation and management of medical resources; it is also a real-world example of precision medicine in hospitals.

A Standardized Approach Improves Outcomes of Extracorporeal Membrane Oxygenation for Postcardiotomy Shock.

Postcardiotomy shock (PCS) has historically been associated with substantial morbidity and mortality. Mortality at discharge is reportedly more than 60%. We investigated the outcomes of our standardized approach to veno-arterial extracorporeal membrane oxygenation (ECMO) management for PCS. We retrospectively reviewed 60 consecutive PCS patients who required ECMO following major cardiac surgery from January 2017 to September 2019. Index surgery included CABG (n = 10), valve (n = 23), valve and CABG (n = 12), root surgery (n = 10), and other (n = 5). Median lactate level, systolic blood pressure, and mean pulmonary artery pressure before ECMO were 4.0 mmol/L, 80 mm Hg, and 29 mm Hg, respectively. Fifty-nine patients (98%) were on two vasopressors, and 54 (90%) were on at least two inotropes. Vasoactive-Inotropic Score was 30 (IQR, 25-49). Eighty percent of patients received peripheral ECMO. Median ECMO flow index was 1.61 (IQR, 1.4-2.0) L/min/m2. Anticoagulation was not given in 12 (20%) patients during ECMO support. Major adverse events included chest re-exploration (15%), stroke (6.7%), renal replacement therapy (22%), and limb ischemia (5%). In-hospital mortality was 33%. This study suggests that a standardized approach with a dedicated ECMO team is feasible and may improve outcomes of PCS.

Early Chest Re-Exploration for Excessive Bleeding in Post Cardiac Surgery Patients: Does It Matter?

IntroductionRe-explorations after open-heart surgery are often required if the patient is bleeding or shows features of cardiovascular instability and does not improve with conservative measures. Our study aims to determine whether timely re-exploration of patients who are bleeding has an impact on the morbidity and mortality of the patients.MethodsA retrospective analysis of 75 patients that underwent open-heart surgery and subsequently underwent chest re-exploration for excessive bleeding between March 2018 and March 2020. Patients who were reopened post-op for indications other than excessive bleeding were excluded.ResultsA total number of cases were 700, out of which 75 (9.3%) patients were reopened, as compared to the literature, which shows worldwide 2-11% being reopened. Post-operative drain output was 1000ml to 1500ml in 47 (62.7%) and more than 1500ml in 28 (37.3%) patients before they were reopened. In 67 (89.3%) patients, three to five units of blood were transfused, and in eight (10.7%) patients, more than five units of blood were transfused. We believe our mortality in the reopened patients was low, because of timely intervention and early re-exploration, and is probably the reason why our figures land in a higher range (2-11%) of reopened cases (9.3%). Reopening time was less than five hours in 49 (65.3%) patients and less than 10 hours in 26 (34.7%) patients in our study. We tried to minimize the loss of blood and re-explored the patients before they lose excessive blood, the average time for reopening in our study was less than 10 hours. The average intensive care unit (ICU) stay was 4.2 days (range three to six days). Wound infections were reported in one of three patients. There was no mortality in these patients. Surgical site of bleeding was identified in 54 (72%) patients and no particular site was found in 21 (28%) patients. Suggesting that it is common to have a surgical bleeder than coagulopathy induced bleeding in post-cardiac surgery patientsConclusionsWe believe our low mortality (0%) is due to early reopening in patients who are bleeding excessively after cardiac surgery.

Early results of surgery for aortic valve disease in patients with severe left ventricular dysfunction

Aim. This study aimed to analyse the early results of aortic valve replacement in patients with severe left ventricular dysfunction: i.e. a left ventricle ejection fraction (LVEF) ≤30%.Methods. This retrospective study included 145 adult patients with isolated aortic valve disease and LVEF ≤30% who underwent aortic valve replacement from 2005 to 2019 at our institution. Patients who required any concomitant or redo surgery were excluded from the study.Results. There were three perioperative deaths (in-hospital mortality, 2.1%) due to multiple organ failure syndrome (two patients) or acute heart failure (one patient). Postoperative heart failure was the prevailing non-lethal complication (73% of cases). Other complications occurred less frequently: nine patients (6.2%) had acute kidney injury (four of whom required hemodiafiltration), one patient (0.7%) suffered a stroke, six patients (4%) required chest re-exploration for bleeding and two patients (1.4%) experienced sternal infection of the surgical wound. Patient LVEF improved significantly from 22.6% ± 5.3% to 35.8% ± 11.0% postoperatively (a 37% mean increase; p = 0.02), and most patients (73%) were classified as New York Heart Association class I–II by the time of discharge.Conclusion. Our study showed excellent results of surgery for aortic valve disease in patients with severe left ventricular dysfunction. Postoperatively, there was a marked increase in LVEF and significant clinical improvement. Received 1 May 2020. Revised 12 May 2020. Accepted 18 May 2020. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributionsConception and design: S.S. Babeshko, K.O. Barbukhatti, V.A. PorkhanovData collection and analysis: S.S. Babeshko, D.I. ShumkovDrafting the article: S.S. Babeshko, Y.P. SamurganovStatistical analysis: S.S. Babeshko, D.I. ShumkovCritical revision of the article: S.S. Babeshko, Y.P. Samurganov, K.O. BarbukhattiFinal approval of the version to be published: S.S. Babeshko, Y.P. Samurganov, D.I. Shumkov, K.O. Barbukhatti, V.A. Porkhanov

Risk factors for ventilator-associated pneumonia following cardiac surgery

Ventilator-associated pneumonia (VAP) following cardiac surgery is a preventable complication associated with adverse outcomes. We aimed to assess risk factors and outcomes of VAP following cardiac surgery. A matched 1:3 case:control study, including adult patients undergoing cardiac surgery through sternotomy between Sep-2014 to Mar-2017 was conducted in a tertiary-care hospital in Israel. Cases included all patients developing VAP within 30 days after surgery, defined using consensus criteria. Controls were matched for age, gender and surgery type. Operative data were collected prospectively, other data were collected retrospectively. Cox regression was used for adjusted analysis of matched data. Out of 946 operated patients, we identified 57 patients with VAP after cardiac surgery (17.7 episodes per 1000 ventilator-days) matched to 149 controls. Significant independent risk factors for VAP included congestive heart failure (OR 2.357 95%CI 1.052-5.281), Chest re-exploration in ICU (OR 10.213 95%CI: 2.235-46.678), preoperative glucose levels (OR 1.1010 per 1 mg/dl increase 95%CI: 1.004-1.019) intraoperative red blood cell transfusions (OR 1.542 per 1 unit 95%CI: 1.109-2.094) and pulmonary hypertension (OR 2.261 95%CI 1.048-6.554). VAP was most commonly caused by Gram-negative pathogens. VAP was associated with higher mortality, longer length of stay, longer need for ventilator support and longer stay in ICU setting. Postoperative VAP in cardiac surgery patients is associated with severe clinical outcomes. We identified risk factors that can aid in preventive measures implementation for high risk patients.

PS02.209: PROGNOSTIC VALUE OF CHEST-TUBE AMYLASE IN DETECTING EARLY ANASTOMOTIC LEAKAGE AFTER IVOR-LEWIS ESOPHAGECTOMY

Abstract Background Intrathoracic anastomotic leaks after esophagectomy are a significant cause of postoperative morbidity and death. Early detection and timely management is crucial but existing diagnostic methods are either invasive or have a low sensitivity. The aim of this study was to evaluate the effectiveness of daily drain amylase levels in detecting early anastomotic leaks after Ivor-Lewis esophagectomy compared with C-Reactive Protein (CRP) levels. Methods Between June 2015 and September 2017, 126 Ivor-Lewis esophagectomies for cancer were performed in our surgical department. In 80 of these patients, drain amylase levels were collected as long a right-sided chest-tube was in place. Chest-tubes were removed at a secretion volume &lt; 300 ml/24 h. CRP levels were measured daily. If bile was detected in the chest-tube and/or after re-exploration of the chest, no further data were collected. Early anastomotic leaks were defined as occurring as long as the chest tubes were in site, in the mean the 5th postoperative day (POD). According to the collected data, drain amylase levels &gt; 350 U/l, and CRP &gt; 30 mg/dl were considered positive. Sensitivity and specificity in detecting anastomotic insufficiency for both drain amylase and CRP were calculated. Results A clinically significant anastomotic leak occurred in 7,1% (9/126) of all esophagectomy patients with 0,8% (1/126) postoperative 30-days mortality. An early anastomotic disruption occurred in 4 of the 80 analysed patients. Three of them had a positive chest-drain amylase level and none a positive CRP level on POD1. The same three patients had on POD 2 a positive CRP level or presented bile in the chest-tube. The fourth patient presented at POD 2 bile in the chest tubes. On POD 1 he presented neither positive amylase nor CRP. The sensitivity and specificity for drain amylase and CRP within the first 3 POD was 0,75 and 0,98 vs 0,75 and 0,85 respectively. The accuracy for both amylase and CRP were calculated at 0,97 vs 0,85. Conclusion Chest-tube amylase levels after Ivor-Lewis esophagectomy are more accurate for the detection of early esophageal anastomotic leaks than CRP. This could facilitate early detection of anastomotic leaks up to 24 hours earlier than elevated blood CRP levels. Disclosure All authors have declared no conflicts of interest.

Strategies for Prevention and Management of Bleeding Following Pediatric Cardiac Surgery on Cardiopulmonary Bypass: A Scoping Review.

We aimed to systematically describe, via a scoping review, the literature reporting strategies for prevention and management of mediastinal bleeding post pediatric cardiopulmonary bypass surgery. MEDLINE, EMBASE, PubMed, and Cochrane CENTRAL Register. Two authors independently screened publications from 1980 to 2016 reporting the effect of therapeutic interventions on bleeding-related postoperative outcomes, including mediastinal drain loss, transfusion, chest re-exploration rate, and coagulation variables. Inclusions: less than 18 years, cardiac surgery on cardiopulmonary bypass. Data from eligible studies were extracted using a standard data collection sheet. Overall, 299 of 7,434 screened articles were included, with observational studies being almost twice as common (n = 187, 63%) than controlled trials (n = 112, 38%). The most frequently evaluated interventions were antifibrinolytic drugs (75 studies, 25%), blood products (59 studies, 20%), point-of-care testing (47 studies, 16%), and cardiopulmonary bypass circuit modifications (46 studies, 15%). The publication rate for controlled trials remained constant over time (4-6/yr); however, trials were small (median participants, 51; interquartile range, 57) and overwhelmingly single center (98%). Controlled trials originated from 22 countries, with the United States, India, and Germany accounting for 50%. The commonest outcomes were mediastinal blood loss and transfusion requirements; however, these were defined inconsistently (blood loss being reported over nine different time periods). The majority of trials were aimed at bleeding prevention (98%) rather than treatment (10%), nine studies assessed both. Overall, this review demonstrates small trial sizes, low level of evidence, and marked heterogeneity of reported endpoints in the included studies. The need for more, higher quality studies reporting clinically relevant, comparable outcomes is highlighted. Emerging fields such as the use of coagulation factor concentrates, goal-directed guidelines, and anti-inflammatory therapies appear to be of particular interest. This scoping review can potentially guide future trial design and form the basis for therapy-specific systematic reviews.

The use of preoperative aspirin in cardiac surgery: A systematic review and meta-analysis.

Despite the fact that aspirin is of benefit to patients following coronary artery bypass grafting (CABG), continuation or administration of preoperative aspirin before CABG or any cardiac surgical procedure remains controversial. Therefore, we performed a systematic review and meta-analysis to assess the influence of preoperative aspirin administration on patients undergoing cardiac surgery. Medline database was searched using OVID SP interface. Similar searches were performed separately in EMBASE, PubMed, and Cochrane Central Registry of Controlled Trials. Twelve randomized controlled trials and 28 observational studies met our inclusion criteria and were included in the meta-analysis. The use of preoperative aspirin in patients undergoing CABG at any dose is associated with reduced early mortality as well as a reduced incidence of postoperative acute kidney injury (AKI). Low-dose aspirin (≤160 mg/d) is associated with a decreased incidence of perioperative myocardial infarction (MI). Administration of preoperative aspirin at any dose in patients undergoing cardiac surgery increases postoperative bleeding. Despite this effect of preoperative aspirin, it did not increase the rates of surgical re-exploration due to excessive postoperative bleeding nor did it increase the rates of packed red blood cell transfusions (PRBC) when preoperative low-dose aspirin (≤160 mg/d) was administered. Preoperative aspirin increases the risk for postoperative bleeding. However, this did not result in an increased need for chest re-exploration and did not increase the rates of PRBC transfusion when preoperative low-dose (≤160 mg/d) aspirin was administered. Aspirin at any dose is associated with decreased mortality and AKI and low-dose aspirin (≤160 mg/d) decreases the incidence of perioperative MI.

Abciximab/Heparin Therapy for Left Ventricular Assist Device Implantation in Patients With Heparin-Induced Thrombocytopenia

Optimal anticoagulation strategy remains uncertain in patients with heparin-induced thrombocytopenia (HIT) and undergoing left ventricular assist device (LVAD) implantation. We describe our protocol of abciximab and heparin in these patients. Our protocol is to administer abciximab, 0.25 mg/kg loading dose, followed by continuous infusion of 0.125 μg · kg-1 · min-1 throughout cardiopulmonary bypass. Full-dose heparin is then given with subsequent additional doses to maintain an activated clotting time of 400 seconds or longer. The abciximab infusion is stopped 15 minutes after heparin reversal with protamine, and platelets are transfused. Six patients underwent LVAD implantation with this protocol in our program. HIT was confirmed in 4 patients was suspected in 2, which was negative after the operation. One patient received a HeartMate XVE (Thoratec Corp, Pleasanton, CA) and the others received HeartMate II (Thoratec Corp). There were no thromboembolic complications. One patient required chest reexploration for bleeding and temporary right VAD support. Postoperative anticoagulation with argatroban was restarted on median postoperative day 3 (range, days 1 to 6) and warfarin was started on day 5 (range, days 3 to 12). Median postoperative intensive care unit stay was 9 days (range, 5 to 76 days), and hospital stay was 22 days (range, 18 to 132 days). After the initial LVAD implantation, 1 patient required HeartMate XVE LVAD exchange to HeartMate II and subsequent heart transplant, both of which were performed with the abciximab/heparin protocol. A HeartMate II device was explanted in another patient after myocardial recovery. The remaining 4 patients are alive on device support. This is the first report of a novel abciximab/heparin protocol for LVAD implantation in patients with HIT. The preliminary results suggest the feasibility and safety of this protocol.

Improved outcomes from extracorporeal membrane oxygenation versus ventricular assist device temporary support of primary graft dysfunction in heart transplant

Primary graft dysfunction (PGD) is one of the most common causes of early death after orthotopic heart transplantation. Mechanical circulatory support devices are required for severe forms of PGD. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) and temporary ventricular assist device (VAD) support have both been reported to be useful for severe PGD. Between January 2007 and December 2015, 597 patients received a heart transplant at our center. Of those, severe PGD developed in 44 patients (7.4%), and they received a continuous-flow external VAD (n = 17) or VA-ECMO (n = 27) support within 24 hours after transplant. We compared early and late outcomes between groups. Baseline characteristics were similar between groups. Implantation of the temporary VAD required longer cardiopulmonary bypass time compared with VA-ECMO (323 ± 86 minutes vs 216 ± 65 minutes, p < 0.0001). Patients who received a VAD were more likely to have longer support time (14 ± 17 days vs 5.2 ± 3.9 days, p = 0.011), a higher incidence of major bleeding requiring chest reexploration (77% vs 30%, p = 0.0047), and a higher incidence of renal failure requiring renal replacement therapy (53% vs 11%, p = 0.0045) after surgery. Overall hospital mortality was 27%. In-hospital mortality for VAD and VA-ECMO patients were 41% and 19%, respectively (p = 0.16). Ten patients (59%) were weaned from VAD support, and 24 (89%) were weaned from VA-ECMO support after adequate graft function recovery (p = 0.03). The 3-year post-transplant survival was 41% in the VAD group and 66% in the VA-ECMO group (p = 0.13). For severe PGD, support with VA-ECMO appears to result in better clinical outcomes compared with VAD.

(123) - Heparin-Free Off-Pump LVAD Implantation Reduces Early Adverse Events Compared with On-Pump Implantation

Left ventricular assist device implantation is associated with a relatively high incidence of bleeding and right ventricular failure (RVF). These adverse events increase resource use, hospital stay and compromise survival. An off-pump implant technique without using intra-operative systemic heparin was developed to reduce these adverse events. Early outcomes of patients implanted with the HeartWare HVAD using cardiopulmonary bypass (CPB) or the heparin-free off-pump implant technique were compared. A retrospective analysis of 57 consecutive patients who underwent HeartWare HVAD implantation from October 2009 to October 2015 was carried out. Demographic and perioperative clinical variables were analyzed using Fisher’s exact test and Wilcoxon Rank-Sum test. HeartWare HVADs were implanted using CPB (Group CPB, n = 34) or the heparin free off pump technique (Group HFOP, n = 23); in the latter group, 7 were performed with a full sternotomy and 16 with minimal access using hemi-sternotomy plus left anterior thoracotomy. All patients required inotropic therapy for stage-D heart failure. Group HFOP had significantly higher pre-operative mean transpulmonary gradient and higher INTERMACS profile. In the peri-implant period, 13 (56.5%) patients in the HFOP group did not require Red Cell transfusion and none required FFP or platelet transfusion. Post-operatively, Group CPB had significantly higher rate of hemorrhage (P=0.007), chest re-exploration (P=0.002), Red Cell (P=0.013) and blood products (P=0.002) transfusion. There was a trend towards shorter ICU stay and lower incidence of RVF in the HFOP group. Overall 30-day and 1-year survivals were 96.4% and 81% respectively with no difference between groups. HFOP implantation of HVAD in patients with higher INTERMACS profile is associated with less bleeding, blood product usage and a trend towards less RV failure and shorter ICU stay. Use of this technique should be further explored in a larger clinical trial.Tabled 1HVAD TableClinical VariablesGroup HFOP (N= 23) Mean ± SDGroup CPB (N=34) Mean ± SDP-ValueAge50.3 ± 15.048.3 ± 9.70.576Sex (Male)82.6%76.5%0.744Dilated cardiomyopathy43.7%56.2%0.796Preoperative TPG (mm Hg)15.7±4.612.6 ± 4.10.012INTERMACS Profile2.3±0.481.8 ±0.690.018Inotropes duration (days)7.2 ± 6.58.8 ± 6.70.357Red blood cells (ml)399.3 ± 693.71992.5 ±3488.60.013Platelets (ml)0315.1 ± 410.90.005Fresh frozen Plasma (ml)0320.9 ± 559.00.002Re-exploration of chest4.3%41.2%0.002Post-operative hemorrhage (ml)202.4 ± 105.2476.2 ± 239.40.007Need for RVAD4.3%23.5%0.069Need of Ventilation (Hours)33.9 ± 35.345.9 ± 33.80.215ICU stay (days)8.8 ± 5.312.2 ± 7.60.0595Late drive line infection17.0%20.5%1Late bleeding complications8.7%14.7%0.68930-day mortality4.3%2.9%1One year survival82.6%79.4%1 Open table in a new tab