Complex Cardiac Surgery Research Articles

Modified Ravitch Procedure for Pectus Excavatum Combined With Complex Cardiac Surgery

Pectus excavatum is common in patients with connective tissue disorders or congenital heart disease undergoing cardiac surgery, and is occasionally severe enough to warrant repair. The optimal surgical strategy is currently debated. We report our experience with simultaneous repair. From January 2012 to January 2020, 11 patients (median age of 35 ± 18 years, range 12-74) underwent a modified Ravitch procedure for severe pectus excavatum performed by a single thoracic surgeon at the time of simultaneous complex cardiac surgery. Eight patients (73%) had a confirmed connective tissue disorder and 2 patients (18%) had recurrent pectus excavatum following a failed Nuss procedure in adolescence. The mean Haller index was 7.3 ± 3.2 (range 3.8-13). The most common concomitant cardiac procedures were valve-preserving aortic root replacement (n=7, 64%) and mitral valve repair (n = 4, 36%). Patients are presented as a case series with descriptive analysis. The median total operative and cardiopulmonary bypass times were 400 minutes (±109 minutes) and 168 minutes (± 43 minutes), respectively. No deaths occurred in-hospital or during follow-up. There were no reoperations for bleeding, tamponade or other indications. No deep or superficial sternal wound infections occurred. Postoperative analgesia regimens were multimodal to facilitate early mobilization and pulmonary hygiene. None of the patients required prolonged ventilation or reintubation for respiratory failure. The mean stay in the intensive care unit was 82 hours (±56 hours) and the mean hospital stay was 9.1 days (2.4 days). Concurrent pectus excavatum repair at the time of cardiac surgery using a modified Ravitch technique can be safely performed by a multi-disciplinary team and should be considered for patients with multiple indications for operation.

Association of Plasma Fibrinogen and Thromboelastography With Blood Loss in Complex Cardiac Surgery.

Postoperative coagulopathic bleeding is common in cardiac surgery and is associated with increased morbidity and mortality. Ideally, real-time information on in-vivo coagulation should be available. However, up to now it is unclear which perioperative coagulation parameters can be used best to accurately identify patients at increased risk of bleeding. The present study analyzed the associations of perioperative fibrinogen concentrations and whole blood viscoelastic tests with postoperative bleeding in 89 patients undergoing combined cardiac surgery procedures. Postoperative bleeding was recorded until 24 hours after surgery. Regression analyses were performed to establish associations between blood loss and coagulation parameters after cardiopulmonary bypass including a prediction model with known confounding factors for bleeding. Coagulation tests show large changes over the perioperative course with the strongest coagulopathic deviations from baseline after cardiopulmonary bypass. After adjustment for multiple confounders, viscoelastic clot strength instead of fibrinogen concentration showed a similar performance for 24 hour blood loss and a better performance for 6 hour blood loss. This makes intraoperative viscoelastic testing a useful tool to strengthen early clinical decision-making with the potential to reduce perioperative blood transfusions.

Autologous fibrin sealant application in cardiac surgery - a single-centre observational study.

IntroductionTo minimize the risk of blood loss and post-transfusion complications in patients undergoing cardiovascular surgery, different strategies are used.AimTo analyse the efficacy of the intraoperative use of autologous fibrin glue to seal suture lines of cardiac and vascular structures.Material and methodsThe early results of 62 patients who underwent complex cardiac operations in extracorporeal circulation were analysed. In a half of them Vivostat autologous fibrin sealant in addition to the routine haemostatic agents was applied (study group), whereas in the second group (matched-pair control group) only standard haemostatics were used. Among many other factors, special attention was paid to postoperative drainage and blood products used.ResultsThe mean age of the patients and prevalence of comorbidities did not differ between groups. Generally, in the study group fewer haemostatic agents were used. For example, Preveleak tissue glue was applied in 3.2% of studied cases compared to one third of control patients (p = 0.008). The thoracic drainage on either day 0 or day 1 was also similar. The number of patients who received blood products did not differ between groups. More importantly, there were no significant differences in in-hospital mortality and prevalence of other postoperative complications.ConclusionsIn this study it was found that application of autologous fibrin glue was safe and might limit use of standard haemostatic agents. Taking into account the lack of potential threats related to the transmission of infections and immune responses, it may be an interesting alternative to the previously used local haemostatics.

Protección miocárdica mediante cardioplejia Custodiol® frente a cristaloide convencional en cirugía cardíaca compleja. Resultados de una serie institucional

IntroductionCustodiol® cold crystalloid cardioplegia offers myocardial protection for up to three hours with one single dose, allowing to perform complex procedures without interruption. There is concern about the adequacy of single dose cardioplegia in terms of myocardial protection. ObjectiveTo compare results of perioperative morbidity and mortality of conventional crystalloid cardioplegia used in our hospital (St.Thomas 2 [ST2]) versus Custodiol in complex cardiac surgery. MethodsA retrospective comparative study was conducted between patients who underwent cardiac surgery with aortic cross-clamping times over 80 minutes, from May 2016 until December 2019. They were divided into two groups of cardioplegia: ST2 group versus Custodiol group. ResultsThe study included 712 patients, of whom 548 were in ST2 group and 164 in Custodiol group. Preoperative variables showed a greater number of women, re-interventions, and emergent cases, with the highest EuroSCORE ii (4.90% vs. 7.19%, p = 0.000) in the Custodiol group.The Custodiol group also had longer cardiopulmonary bypass times (127 vs. 149 minutes, p = 0.000) and aortic cross-clamping times (106 vs. 124 minutes, p = 0.0001), and a greater number of ventricular arrhythmias that needed defibrillation (16.2% vs. 34.6%, p = 0.000).Surgical mortality did not show any differences (3.8% vs. 6.1%, p = 0.152). Hospital stay was two days longer in the Custodiol group.In multivariate analysis, type of cardioplegia did not result in an independent risk factor for post-operative morbidity and mortality. ConclusionsThis hospital centre proposes the use of Custodiol in complex cardiac surgery with prolonged aortic cross-clamping times as a safe alternative to conventional crystalloid cardioplegia, as it offers good myocardial protection for surgeons, with same incidence of post-operative complications.

American Society of ExtraCorporeal Technology: Development of Standards and Guidelines for Pediatric and Congenital Perfusion Practice (2019).

The development of standards and guidelines by professional societies offers clinicians guidance toward providing evidence-based care. The ultimate goals of standards and guidelines are to standardize care and improve patient safety and outcomes while also minimizing risk. The American Society of ExtraCorporeal Technology (AmSECT) currently offers perfusionists several clinical resources, primarily the Standards and Guidelines for Perfusion Practice; however, no document exists specific to pediatric perfusion. Historically, the development of a pediatric-specific document has been limited by available scientific evidence due to smaller patient populations, sample sizes, and variable techniques among congenital perfusionists. In the current setting of evolving clinical practices and increasingly complex cardiac operations, a subcommittee of pediatric perfusionists developed the Standards and Guidelines for Pediatric and Congenital Perfusion Practice. The development process included a comprehensive literature review for supporting evidence to justify new recommendations or updates to the existing AmSECT Adult Standards and Guidelines document. Multiple revisions incorporating feedback from the community led to a finalized document accepted by the AmSECT membership and made available electronically in May 2019. The Standards and Guidelines for Pediatric and Congenital Perfusion Practice is an essential tool for pediatric perfusionists and serves as the backbone for institutionally based protocols, promotes improved decision-making, and identifies opportunities for future research and collaboration with other disciplines. The purpose of this manuscript is to summarize the process of development, the content, and recommended utilization of AmSECT's Standards and Guidelines for Pediatric and Congenital Perfusion Practice.

American Society of ExtraCorporeal Technology: Development of Standards and Guidelines for Pediatric and Congenital Perfusion Practice (2019).

The development of standards and guidelines by professional societies offers clinicians guidance toward providing evidence-based care. The ultimate goals of standards and guidelines are to standardize care and improve patient safety and outcomes while also minimizing risk. The American Society of ExtraCorporeal Technology (AmSECT) currently offers perfusionists several clinical resources, primarily the Standards and Guidelines for Perfusion Practice; however, no document exists specific to pediatric perfusion. Historically, the development of a pediatric-specific document has been limited by available scientific evidence because of smaller patient populations, sample sizes, and variable techniques among congenital perfusionists. In the current setting of evolving clinical practices and increasingly complex cardiac operations, a subcommittee of pediatric perfusionists developed the Standards and Guidelines for Pediatric and Congenital Perfusion Practice. The development process included a comprehensive literature review for supporting evidence to justify new recommendations or updates to the existing AmSECT Adult Standards and Guidelines document. Multiple revisions incorporating feedback from the community led to a finalized document accepted by the AmSECT member and made available electronically in May 2019. The Standards and Guidelines for Pediatric and Congenital Perfusion Practice is an essential tool for pediatric perfusionists, serves as the backbone for institutionally based protocols, promotes improved decision-making, and identifies opportunities for future research and collaboration with other disciplines. The purpose of this article is to summarize the process of development, the content, and recommended utilization of AmSECT's Standards and Guidelines for Pediatric and Congenital Perfusion Practice. AmSECT recommends adoption of the Standards and Guidelines for Pediatric and Congenital Perfusion Practice to reduce practice variation and enhance clinical safety.

American Society of ExtraCorporeal Technology: Development of Standards and Guidelines for Pediatric and Congenital Perfusion Practice (2019)

The development of standards and guidelines by professional societies offers clinicians guidance toward providing evidence-based care. The ultimate goals of standards and guidelines are to standardize care and improve patient safety and outcomes while also minimizing risk. The American Society of ExtraCorporeal Technology (AmSECT) currently offers perfusionists several clinical resources, primarily the Standards and Guidelines for Perfusion Practice; however, no document exists specific to pediatric perfusion. Historically, the development of a pediatric-specific document has been limited by available scientific evidence because of smaller patient populations, sample sizes, and variable techniques among congenital perfusionists. In the current setting of evolving clinical practices and increasingly complex cardiac operations, a subcommittee of pediatric perfusionists developed the Standards and Guidelines for Pediatric and Congenital Perfusion Practice. The development process included a comprehensive literature review for supporting evidence to justify new recommendations or updates to the existing AmSECT Adult Standards and Guidelines document. Multiple revisions incorporating feedback from the community led to a finalized document accepted by the AmSECT member and made available electronically in May 2019. The Standards and Guidelines for Pediatric and Congenital Perfusion Practice is an essential tool for pediatric perfusionists, serves as the backbone for institutionally based protocols, promotes improved decision-making, and identifies opportunities for future research and collaboration with other disciplines. The purpose of this article is to summarize the process of development, the content, and recommended utilization of AmSECT’s Standards and Guidelines for Pediatric and Congenital Perfusion Practice. AmSECT recommends adoption of the Standards and Guidelines for Pediatric and Congenital Perfusion Practice to reduce practice variation and enhance clinical safety.

Tracheal surgery for airway anomalies associated with increased mortality in pediatric patients undergoing heart surgery: Society of Thoracic Surgeons Database analysis

ObjectivesAirway anomalies are common in children with cardiac disease but with an unquantified impact on outcomes. We sought to define the association between airway anomalies and tracheal surgery with cardiac surgery outcomes using the Society of Thoracic Surgery Congenital Heart Surgery Database. MethodsIndex cardiac operations in children aged less than 18 years (January 2010 to September 2018) were identified from the Society of Thoracic Surgery Congenital Heart Surgery Database. Patients were divided on the basis of reported diagnosis of an airway anomaly and subdivided on the basis of tracheal lesion and tracheal surgery. Multivariable analysis evaluated associations between airway disease and outcomes controlling for covariates from the Society of Thoracic Surgery Congenital Heart Surgery Database Mortality Risk Model. ResultsOf 198,674 index cardiovascular operations, 6861 (3.4%) were performed in patients with airway anomalies, including 428 patients (0.2%) who also underwent tracheal operations during the same hospitalization. Patients with airway anomalies underwent more complex cardiac operations (45% vs 36% Society of Thoracic Surgeons/European Association for Cardiothoracic Surgery Congenital Heart Surgery Mortality category ≥3 procedures) and had a higher prevalence of preoperative risk factors (73% vs 39%; both P < .001). In multivariable analysis, patients with airway anomalies had increased odds of major morbidity and tracheostomy (P < .001). Operative mortality was also increased in patients with airway anomalies, except those with malacia. Tracheal surgery within the same hospitalization increased the odds of operative mortality (adjusted odds ratio, 3.9; P < .0001), major morbidity (adjusted odds ratio, 3.7; P < .0001), and tracheostomy (adjusted odds ratio, 16.7; P < .0001). ConclusionsPatients undergoing cardiac surgery and tracheal surgery are at significantly higher risk of morbidity and mortality than patients receiving cardiac surgery alone. Most of those with unoperated airway anomalies have higher morbidity and mortality, which makes it an important preoperative consideration.

Comparable outcomes between genders in patients undergoing surgical ventricular reconstruction for ischaemic heart failure.

AimsFemale sex and heart failure (HF) are considered poor prognostic factors for surgery. We aimed to investigate the association between sex and surgical outcomes in patients with ischaemic HF undergoing surgical ventricular reconstruction and coronary artery bypass grafting.Methods and resultsFrom July 2001 to June 2017, 648 patients [111 women (17%) and 537 men (83%)] were referred to our centre. Follow‐up continued through June 2018. All patients underwent surgical ventricular reconstruction; coronary artery bypass grafting was performed in 582 patients (90%). Primary outcome was defined as all‐cause mortality. Secondary outcome included all‐cause mortality or all‐cause hospitalization. Women were older (70 vs. 65 years, P < 0.0001) with lower body surface area (1.70 vs. 1.86 m2, P < 0.0001). Women had more diabetes (36% vs. 24%, P = 0.005) and a higher New York Heart Association classification (Class III/IV 65.7% vs. 47.8%, P = 0.0006), without any significant difference in medical therapy except for a higher use of oral antidiabetic agents in women (P = 0.029). At baseline, the left ventricular (LV) end‐diastolic volume index was significantly lower in women [median 107.06 (80.6–127.81) vs. 113. 04 (94.33–135.52) mL/m2, P = 0.0078] but not the LV end‐systolic volume index (ESVI) [median 73.45 (51.93–96.79) vs. 77.03 (60.33–95.71) mL/m2, P = 0.1393] and the ejection fraction (median 31% vs. 32%, P = 0.150). Women had a higher rate of anterior remodelling (90.9% vs. 79.1%, P = 0.0129), without evidence of differences in mitral valve insufficiency (P = 0.761 for Grade 0 to 4) and mitral surgery (P = 0.810). After surgery, the percentage of reduction in LV ESVI was higher in women than in men (median ΔLV ESVI −42.06 vs. −31.99, P = 0.0003). Mortality within 30 days occurred in 43 patients (6.64%): 12 women (10.81%) and 31 men (5.77%, P = 0.0522). Over a median follow‐up of 9.8 years, all‐cause mortality occurred in 269 patients (41.64%), without significant difference between women (45.9%) and men (40.7%). There was no evidence of difference of all‐cause death between sexes (log‐rank = 0.2441). When considering mortality and first hospitalization as competing events, Gray's test showed no difference of cumulative incidence functions (all‐cause hospitalization, all‐cause death, and combined endpoint) according to sex (P = 0.909, P = 0.445, and P = 0.429, respectively).ConclusionsIn this study, long‐term outcomes for women and men with ischaemic HF undergoing complex cardiac surgery were equivalent. Albeit older and more symptomatic, women should not be denied this type of cardiac surgery.

Immersive 3D virtual reality imaging in planning minimally invasive and complex adult cardiac surgery.

Increased complexity in cardiac surgery over the last decades necessitates more precise preoperative planning to minimize operating time, to limit the risk of complications during surgery and to aim for the best possible patient outcome. Novel, more realistic, and more immersive techniques, such as three-dimensional (3D) virtual reality (VR) could potentially contribute to the preoperative planning phase. This study shows our initial experience on the implementation of immersive VR technology as a complementary research-based imaging tool for preoperative planning in cardiothoracic surgery. In addition, essentials to set up and implement a VR platform are described. Six patients who underwent cardiac surgery at the Erasmus Medical Center, Rotterdam, The Netherlands, between March 2020 and August 2020, were included, based on request by the surgeon and availability of computed tomography images. After 3D VR rendering and 3D segmentation of specific structures, the reconstruction was analysed via a head mount display. All participating surgeons (n = 5) filled out a questionnaire to evaluate the use of VR as preoperative planning tool for surgery. Our study demonstrates that immersive 3D VR visualization of anatomy might be beneficial as a supplementary preoperative planning tool for cardiothoracic surgery, and further research on this topic may be considered to implement this innovative tool in daily clinical practice. Over the past decades, surgery on the heart and vessels is becoming more and more complex, necessitating more precise and accurate preoperative planning. Nowadays, operative planning is feasible on flat, two-dimensional computer screens, however, requiring a lot of spatial and three-dimensional (3D) thinking of the surgeon. Since immersive 3D virtual reality (VR) is an upcoming imaging technique with promising results in other fields of surgery, we aimed in this study to explore the additional value of this technique in heart surgery. Our surgeons planned six different heart operations by visualizing computed tomography scans with a dedicated VR headset, enabling them to visualize the patient's anatomy in an immersive and 3D environment. The outcomes of this preliminary study are positive, with a much more reality-like simulation for the surgeon. In such, VR could potentially be beneficial as a preoperative planning tool for complex heart surgery.

Comparison of early and late intravenous infusion of milrinone in children upto 1 year undergoing cardiac surgery.

Objective: To compare the effects of early and late use of milrinone in children upto 1 year undergoing complex cardiac surgery. Study design:- prospective randomized study. Methods:&#x0D; A prospective study involved 30 children undergoing congenital corrective cardiac surgery,classified randomly into two groups. Group A: Milrinone infusion was started without loading dose at 0.5mcg/kg/min at the beginning of CPB and continued postoperatively (0.5-0.75 mcg/kg/min) in the paediatric cardiac surgical ICU . Group B: Milrinone was started as a loading dose of 50mcg/kg over 10 min after aortic declamping and continued as infusion postoperatively at 0.5-0.75 mcg/kg/min in the pediatric cardiac surgical ICU.Data were collected at baseline, 1st ,6th and 12th postoperative hours in the ICU. Results: The inotropic supports and mechanical supports were needed more in group B than group A. The comparison of heart rate, CVP were insignificant between the two groups (P&gt;0.05). The mean arterial blood pressure through the first 6 hours postoperatively was higher in group A than group B (P&lt;0.05), but became insignificant through other timepoints. The urine output and central venous oxygen saturation were higher in group A than group B (P&lt;0.05).The serum lactate levels were significantly higher in group B more than group A (P&lt;0.05). Conclusion:Early use of milrinone, lead to easy weaning from Cardiopulmonary bypass, decreased requirement of pharmacological and mechanical support and decreased incidence of low cardiac output syndrome after pediatric cardiac surgery and there was no complications related to milrinone in our study patients.

Extracorporeal hemadsorption versus glucocorticoids during cardiopulmonary bypass: a prospective, randomized, controlled trial

Introduction Cardiopulmonary bypass (CPB) surgery initiates systemic inflammatory response syndrome, which in 2-10% of all cases can be considerably severe. This complex chain of events might contribute to the development of postoperative complications. Different therapeutic interventions that can reduce inflammatory reactions during CPB have been used, in hope for improvement of patient outcome after open-heart surgery. Extracorporeal hemadsorption might reduce the inflammatory reaction in CPB surgery. Glucocorticoids, on the other hand, have been used for years during open-heart surgery for alleviation of systemic inflammation after CPB. We compared intraoperative hemadsorption and methylprednisolone, with usual care, during complex cardiac surgery on CPB, for inflammatory responses, hemodynamics, and perioperative course. Methods Seventy-six patients with prolonged CPB were recruited and randomized, with 60 included in the final analysis. The allocation was into three groups: Methylprednisolone group (n=20; 1g of methylprednisolone added in CPB priming solution), Cytosorb group (n=20; CytoSorb® adsorber, Cytosorbents Europe GmbH, Germany, installed in CPB circuit), and Control group (n=20, usual care, neither methylprednisolone nor CytoSorb® during CPB). Pro-inflammatory (TNF-a, IL-1b, IL-6, IL-8) and anti-inflammatory (IL-10) cytokines, complement C5a, CD64 and CD163 expression by immune cells were analyzed within the first five postoperative days, in addition to hemodynamic and clinical outcome parameters. Results Methylprednisolone group, compared to Cytosorb and Control, had significantly lower levels of TNF-a (until end of the surgery, p Discussion In this clinical trial, we have confirmed that intraoperative use of a median dose of methylprednisolone during CPB more effectively ameliorates systemic inflammatory responses after adult cardiac surgery. This is seen by reductions in pro-inflammatory and increases in anti-inflammatory mediators when compared to both uses of CytoSorb® adsorber for hemadsorption and usual treatment (Control). However, methylprednisolone did not provide better short-term clinical outcome. Hemadsorption itself, compared with usual care, caused higher prolonged expression of CD64 on monocytes and higher expression of CD163 on granulocytes, which only lasted until end of surgery. The use of CytoSorb® adsorber seems to be safe and well-tolerated. We haven't observed an association between its application and significant thrombocytopenia or more significant decrease in albumin concentration.

A 3-Year Single Surgeon Experience of the Arterial Switch Operation

Background: The arterial switch operation [ASO] is the surgical procedure of choice for correction of the TGA. This is one of the most complex cardiac surgeries, with coronary artery transfer being the most important factor determining the success of the surgery. Objectives: This study aims to investigate the outcomes of ASO operated by a single surgeon and assess the accuracy of echocardiography in identifying the coronary artery pattern before the ASO, this may lead to a better familiarization with the ASO. Methods: A retrospective study was conducted by operative and postoperative case note review of 125 patients from March 2015 to 2018. We assessed the outcomes of the arterial switch operation. Concomitant defects as atrial septal defects, patent ductus arteriosus and small ventricular septal defects were defined as the simple TGA and other defects were defined as the complex TGA. Coronary artery pattern determination by echocardiography prior to the surgery and during the operation was investigated, as well. 30-day mortality, post-operative neurologic complications, cardiac anatomic complications, arrhythmia, plasma lactate level and cardiopulmonary bypass time [CPB time] during the surgery were recorded. Results: The mean age and weight of the patients were 29.09 (1 - 180) days and 3506.48 (2400 - 9700) grams. Most of the patients (64%) were male. 105 (84%) of the patients had simple and 20 (16%) had complex TGA. Unusual coronary pattern during echocardiography was observed in 17 (13.6%) subjects and unusual coronary pattern during the operation was observed in 7 (5.6%) patients. The incidence of the major anatomical lesions was not significant. 20 (16%) had neurologic complications, including seizure in 14 (11.2%) patients, brain hemorrhage was found in 5 (4%) patients, as well as chorea and wrist drop in the remaining patients. Post-operative arrhythmia was observed in 16 (12.8%) patients. The mortality rate was 4% (5 patients). The CPB time was 202.73 ± 36.99 minutes. Conclusions: Our post-operative results of the ASO indicate excellent results. This signifies high experience and knowledge regarding this surgery.

Target-Based Care: An Intervention to Reduce Variation in Postoperative Length of Stay

To derive care targets and evaluate the impact of displaying them at the point of care on postoperative length of stay (LOS). A prospective cohort study using 2years of historical controls within a freestanding, academic children's hospital. Patients undergoing benchmark cardiac surgery between May 4, 2014, and August 15, 2016 (preintervention) and September 6, 2016, to September 30, 2018 (postintervention) were included. The intervention consisted of displaying at the point of care targets for the timing of extubation, transfer from the intensive care unit (ICU), and hospital discharge. Family satisfaction, reintubation, and readmission rates were tracked. The postintervention cohort consisted of 219 consecutive patients. There was a reduction in variation for ICU (difference in SD -2.56, P<.01) and total LOS (difference in SD -2.84, P<.001). Patients stayed on average 0.97 fewer days (P<.001) in the ICU (median -1.01 [IQR -2.15, -0.39]), 0.7 fewer days (P<.001) on mechanical ventilation (median -0.54 [IQR -0.77, -0.50]), and 1.18 fewer days (P<.001) for the total LOS (median -2.25 [IQR -3.69, -0.15]). Log-transformed multivariable linear regression demonstrated the intervention to be associated with shorter ICU LOS (β coefficient -0.19, SE 0.059, P<.001), total postoperative LOS (β coefficient -0.12, SE 0.052, P=.02), and ventilator duration (β coefficient -0.21, SE 0.048, P<.001). Balancing metrics did not differ after the intervention. Target-based care is a simple, novel intervention associated with reduced variation in LOS and absolute LOS across a diverse spectrum of complex cardiac surgeries.

Acute isotonic hyponatremia after single dose histidine-tryptophan-ketoglutarate cardioplegia: an observational study.

Histidine-tryptophan-ketoglutarate cardioplegia is used for prolonged myocardial protection in complex cardiac surgery. Administration leads to acute hyponatremia in a majority of patients, because of its low sodium concentration (15 mmol/L). However, histidine-tryptophan-ketoglutarate solution's osmolality is slightly hypertonic (310 mOsm/kg). Hypothesized was that acute isotonic hyponatremia will be induced, which does not need to be corrected with hypertonic saline. Cardiac surgery patients who received histidine-tryptophan-ketoglutarate cardioplegia were included in this prospective single center study. Serial blood samples were taken from each patient at five different time points: after induction of anesthesia (T1) and 10 minutes (T2), 6 hours (T3), 12 hours (T4), and 18 hours (T5) after administration of histidine-tryptophan-ketoglutarate cardioplegia, respectively. Blood samples were analyzed for sodium concentration, osmolality, and acid-base balance. Twenty-five patients were included. Median blood sodium levels decreased from 140 [138-141] at T1 to 128 [125-130] mmol/L at T2 (p < 0.001). At T3, T4, and T5, median blood sodium concentrations were 136 [134-138], 139 [137-140], and 140 [137-142] mmol/L, respectively. Median osmolality was 289 [286-293] at T1 and increased to 296 [291-299] mOsm/kg (p < 0.001) at T2. At T3, T4, and T5, osmolality was 298 [292-302], 298 [294-304], and 300 [297-306] mOsm/kg, respectively. Median pH decreased from 7.38 [7.36-7.40] at T1 to 7.30 [7.27-7.32] at T2 (p < 0.001). Administration of histidine-tryptophan-ketoglutarate cardioplegia during cardiac surgery leads to acute moderate to severe isotonic hyponatremia, which resolves spontaneously in the first 18 hours perioperatively. Correction with hypertonic saline is not necessary.

Viable Hemostasis Obtained With Prothrombin Complex Concentrate in Patients Who Refuse Standard Allogeneic Blood Transfusion and Undergo Complex Cardiac Surgery: A Case Series.

Human 4-factor prothrombin complex concentrate (4F-PCC) may reduce blood loss during surgery. This case series described perioperative outcomes among 9 patients who refused standard allogeneic blood transfusion, underwent complex cardiac surgery with aortic involvement, and received intraoperative 4F-PCC. Additional intraoperative cointerventions included protamine (n = 9), aminocaproic acid (n = 8), fibrinogen concentrate (n = 6), desmopressin (n = 6), factor VIIa (n = 2), and tranexamic acid (n = 1). Outcomes included postoperative death (n = 1), major postoperative bleeding (n = 1), deep vein thrombosis (n = 2), and ischemic stroke (n = 1). When standard allogeneic blood transfusion is refused, viable hemostasis can be obtained using 4F-PCC during complex cardiac surgeries with a high risk of bleeding.

Severe low cerebral oximetry in difficult cardiopulmonary bypass weaning of low body-weight infant: a case report and literature review

BackgroundFor infants undergoing complex cardiac surgery, hemodynamic management after cardiopulmonary bypass (CPB) is challenging because of severe myocardial edema, vasomotor dysfunction and weak tolerance to a change in blood volume. More importantly, the lack of availability of equipment for advanced monitoring, such as transesophageal echocardiography or transthoracic echocardiography, restricts the accurate assessment of hemodynamics.Case presentationThis is a case of severe hypotension and non-detectable pulse oxygen saturation (SpO2) after CPB in a low-weight infant who had normal blood pressure and oxygen saturation before surgery. Epinephrine and milrinone were administered with cerebral oximetry monitoring rather than blood pressure measurements because cerebral oximetry was more responsive to treatment than blood pressure. Under the guidance of cerebral oximetry, the infant was successfully weaned from CPB and recovered after surgery without adverse neurological events.ConclusionsFor infants who develop refractory hypotension and failure in SpO2 monitoring during the CPB weaning period, cerebral oximetry provides an index for assessing brain perfusion and valuable guidance for appropriate inotropic treatment.

Impact of Surgical Experience on Operative Mortality After Reoperative Cardiac Surgery

Learning curves and skill attrition with aging have been reported to impair outcomes in select surgical subspecialties, but their role in complex cardiac surgery remains unknown. From 1986 to 2019, 2314 patients underwent reoperative cardiac surgery: coronary artery bypass grafting (n= 543), valve (n= 1527), or combined coronary artery bypass grafting and valve (n= 244). Thirty-four different surgeons in practice between 1 and 39 years were included. Standardized mortality ratio (observed-to-expected) was determined for all surgeons in each post-training year of experience. Risk-adjusted cumulative sum change-point analysis was used to define five distinct career phases: 0 to 4 years, 5 to 8 years, 9 to 17 years, 18 to 28 years, and 29 to 39 years. With 5 to 8 years and 18 to 28 years of experience, standardized mortality ratio was near unity (0.95 and 1.05, respectively) and lowest with 9 to 17 years of experience (0.78, P= .03). In the youngest experience group (0 to 4 years), observed and expected mortality were both highest, and standardized mortality ratio was elevated at 1.29, which approached statistical significance (P= .059). In the oldest experience group (29 to 39 years), expected mortality was low compared with most other groups but observed mortality increased, yielding a significantly elevated standardized mortality ratio at 1.53 (P= .032). Standardized mortality ratios with reoperative cardiac surgery were highest early and late in a surgeon's career and lowest in mid career. As surgeons gain experience, outcomes improve through the first two career decades, then stabilize in the third decade before declining in the fourth decade.

Surgeries in Neonates and Small-Weight Babies With Congenital Heart Diseases: Challenges and Gratification

Background: Complex cardiac surgery in neonates and small-weight babies is a challenge. In addition to the surgical expertise and skill required, accurate diagnosis, management of anesthesia, perfusion, and postoperative critical care are equally challenging. Methods: We have analyzed the data of 4 different examples of complex cardiac surgery in neonates and small-weight babies from February 2012 to July 2019 in our unit. The first group included 118 cases of arterial switch operations for transposition of great arteries with and without ventricular septal defect (group 1). The second group included 52 patients of aortic arch repair from midline using selective cerebral perfusion avoiding total circulatory arrest (group 2). The third group included 75 patients of repair of coarctation of aorta from thoracotomy using the modified end-to-side technique (group 3). The fourth group included 40 neonates and small-weight babies who underwent repair of total anomalous pulmonary venous connection (group 4). Results: In group 1, there was hospital mortality in 6 babies. In group 2, there was no hospital mortality. In group 3, there was 1 hospital death; in group 4, there were 5 hospital deaths. The major contributing cause of death was respiratory or blood-borne infection causing respiratory issues leading to prolonged ventilation. Left diaphragm palsy contributed to morbidity and eventual death in 2 babies. Only 2 patients required tracheostomy to wean off the ventilator. Conclusions: In the present day, it is possible to achieve satisfactory results with acceptable mortality in neonatal cardiac surgery. Morbidity associated with very early repair in neonatal age, low weight, and infection-related issues is manageable with good outcomes.

Implementation of a "threat and error" model in complex neonatal cardiac surgery patients to identify quality improvement opportunities.

Neonates undergoing surgery for congenital heart disease are vulnerable to adverse events. Conventional quality improvement processes centring on mortality and significant morbidity leave a gap in the identification of systematic processes that, though not directly linked to an error, may still contribute to adverse outcomes. Implementation of a multidisciplinary "flight path" process for surgical patients may be used to identify modifiable threats and errors and generate action items, which may lead to quality improvement. A retrospective review of our neonatal "flight path" initiative was performed. Within 72 hours of a cardiac surgery, a meeting of the multidisciplinary patient care team occurs. A "flight path" is generated, graphically illustrating the patient's hospital course. Threats, errors, or unintended consequences are identified. Action items are generated, and a working group is formed to address the items. A patient's flight path is updated weekly until discharge. The errors and action items are logged into a database, which is analysed quarterly to identify trends. Thirty one patients underwent flight path review over a 1-year period; 22.5% (N=7) of patients had an error-free "flight." Eleven action items were generated - four from identified errors and seven from identified threats. Nine action items were completed. Flight path reviews of congenital cardiac patients can be generated with few resources and aid in the detection of quality improvement opportunities. The regular multidisciplinary meetings that occur as a part of the flight path review process can promote inter-professional teamwork.