Complication Of Cardiac Surgery Research Articles

Analysis and prevention strategies of risk factors for postoperative stroke complications in cardiac surgery

Objective To analyze the risk factors associated with postoperative stroke complications in cardiac surgery. Methods A retrospective analysis was conducted on the clinical data of 549 patients who underwent cardiac surgery. Among these patients, 501 did not experience a stroke postoperatively (non-stroke group), while 48 developed a postoperative stroke (stroke group). Patients who experienced a stroke postoperatively were divided into two groups based on the type of surgery: those who underwent surgery with cardiopulmonary bypass (18 patients) and those without cardiopulmonary bypass (30 patients). The clinical characteristics of the two groups of patients with postoperative strokes were compared, and the risk factors influencing the occurrence of postoperative stroke complications in cardiac surgery were analyzed. Results ① Clinical findings: Cardiopulmonary bypass group had lower cortical infarction rates but higher large-area and bilateral infarction rates compared to the non-cardiopulmonary bypass group (p < 0.05). No significant gender, age, or infarction type differences were observed (p > 0.05). ② Univariate analysis: No significant differences were found in gender, smoking, alcohol, lipids, or glucose levels (p > 0.05). However, age, education, hypertension, diabetes, hypotension, and atrial fibrillation showed significant differences (p < 0.05). ③ Multivariate Logistic regression: Age, education, hypertension, diabetes, hypotension, and atrial fibrillation were independent risk factors for postoperative stroke complications (p < 0.05). Conclusion Cardiopulmonary bypass increases risk of large-area and bilateral strokes; non-bypass surgery associates with cortical strokes. Age, educational level, hypertension, diabetes, postoperative hypotension, and atrial fibrillation are all factors independently associated with the occurrence of postoperative cerebral infarctions in cardiac surgery. Early interventions may reduce postoperative strokes.

Personalization of therapy of psychopathological complications of cardiac surgery in artificial circulation conditions

IntroductionThe study of the clinical and phenomenological features of psychopathological complications of cardiac surgery (CS) in artificial circulation conditions (ACC), the development of modern approaches to early diagnosis and prognosis of psychopathology is an effective way to solve this problem has valid medical and social significance.ObjectivesTo increase the effectiveness of prevention of psychopathological disorders in cardiosurgical interventions based on personalization of their correction.MethodsThe examination included the use of socio-demographic, instrumental, biochemical, clinical-psychopathological, psychometric, and statistical methods.ResultsThe study sample consisted of 700 patients who were treated by CS in ACC at the SI “Heart Institute of the MH of Ukraine”.It was found out that the most common complication is postsurgeon cognitive dysfunction (PCD) (72.0% of patients), postsurgeon encephalopathy (PE) (31.0%) is less common, and cerebral infarction (CI) is the least common (12.2%).It was revealed that the core psychopathological symptoms associated with CS are cognitive disorders (72.0% of the examined) and affective symptoms, represented by depressive (38.1%) and anxiety (33.9%) manifestations of mild and moderate expressiveness, and auxiliary constructs – dyssomnic (29.7%), asthenic (17.9%) and somatovegetative (9.0%) disorders. The highest prevalence of psychopathological symptoms was found in patients with CI, somewhat less in patients with PE, and the lowest in patients with PCD.Signs of mild depressive disorder were found in patients who underwent CS in ACC, elevated levels of adynamic depression indicators, depression with fear and agitated depression, as well as increased levels of anxiety: the average level of anxiety, mental and somatic anxiety. The indicators of expressiveness of depression and anxiety in patients with CI turned out to be the highest, in patients with PE – lower, and in patients with PCD – the lowest.We proposed a mathematical model for predicting the development of psychosocial maladjustment (PM) in patients who have undergone CS in ACC. It is based on a comprehensive assessment of three key vectors that can have a mutually potentiating pathogenetically related effect on the course of the formation of PM: surgical, neurological, and psychopathological. A complex of diagnostic, corrective and preventive measures for each of the risk groups has been developed.ConclusionsVerification of the proposed model on a representative sample of patients confirmed its high predictive ability and reliability in use.Disclosure of InterestNone Declared

Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials.

Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.

Risk Factors for Higher Postoperative Myocardial Injury in Minimally Invasive Mitral Valve Surgery Patients: A Cohort Study.

Background: Postoperative myocardial injury, as detected by an elevated concentration of high-sensitivity cardiac troponin I (hs-cTnI), is a common complication in cardiac surgery that may be linked to mortality. The primary aim of this study was to assess the risk factors associated with increased myocardial injury in patients undergoing minimally invasive mitral valve surgery. Methods: In this retrospective monocentric cohort study, we analyzed all patients who underwent elective minimally invasive mitral valve surgery between January 2019 and December 2022 and were subsequently admitted to our intensive care unit. The study population was divided into two groups based on the peak hs-cTnI level: the "lower myocardial injury" group comprised patients whose peak serum hs-cTnI level was less than 499 times the 99th percentile, while the "higher myocardial injury" group included those patients who exhibited hs-cTnI levels equal to or greater than 500 times the 99th percentile. A multivariable logistic regression analysis was performed to identify independent risk factors associated with higher myocardial injury. Results: In our final analysis, we enrolled 316 patients. Patients with higher myocardial injury (48; 15%) more frequently had a preoperative New York Heart Association (NYHA) class ≥3 compared to those with lower myocardial injury [33 (69%) vs. 128 (48%); p < 0.01-OR 2.41 (95% CI 1.24-4.64); p < 0.01]. Furthermore, cardiopulmonary bypass and aortic cross-clamp time were significantly longer in the higher myocardial injury group compared to the lower myocardial injury group [117 (91-145) vs. 86 (74-100) min; p < 0.01-OR 1.05 (95% CI 1.03-1.06); p < 0.01]. Moreover, patients who underwent robotic-assisted mitral valve surgery experienced lower myocardial injury rates [9 (19%) vs. 102 (38%); p = 0.01-OR 0.38 (95% CI 0.18-0.81); p = 0.01] than others. These findings remained consistent after adjustment in multivariate logistic regression. In terms of postoperative outcomes, patients with higher myocardial injury exhibited the highest lactate peak in the first 24 h, a higher incidence of postoperative acute kidney injury and a longer duration of mechanical ventilation. Although no patients died in either group, those with higher myocardial injury experienced a longer hospital length of stay. Conclusions: Higher myocardial injury is relatively common after minimally invasive mitral valve surgery. Prolonged aortic cross-clamp duration and higher NYHA class were independently associated with myocardial injury, while robotic-assisted mitral valve surgery was independently associated with lower postoperative myocardial injury.

Evaluation of the Diagnostic Performance and Efficacy of Wearable Electrocardiogram Monitoring for Arrhythmia Detection after Cardiac Surgery.

Postoperative atrial fibrillation (A-fib) is a serious complication of cardiac surgery that is associated with increased mortality and morbidity. Traditional 24-hour Holter monitors have limitations, which have prompted the development of innovative wearable electrocardiogram (ECG) monitoring devices. This study assessed a patch-type wearable ECG device (MobiCARE-MC100) for monitoring A-fib in patients undergoing cardiac surgery and compared it with 24-hour Holter ECG monitoring. This was a single-center, prospective, investigator-initiated cohort study that included 39 patients who underwent cardiac surgery between July 2021 and June 2022. Patients underwent simultaneous monitoring with both conventional Holter and patchtype ECG devices for 24 hours. The Holter device was then removed, and patch-type monitoring continued for an additional 48 hours, to determine whether extended monitoring provided benefits in the detection of A-fib. This 72-hour ECG monitoring study included 39 patients, with an average age of 62.2 years, comprising 29 men (74.4%) and 10 women (25.6%). In the initial 24 hours, both monitoring techniques identified the same number of paroxysmal A-fib in 7 out of 39 patients. After 24 hours of monitoring, during the additional 48-hour assessment using the patch-type ECG device, an increase in A-fib burden (9%→38%) was observed in 1 patient. Most patients reported no significant discomfort while using the MobiCARE device. In patients who underwent cardiac surgery, the mobiCARE device demonstrated diagnostic accuracy comparable to that of the conventional Holter monitoring system.

ЗНАЧЕНИЕ ИММУНОЛОГИЧЕСКОГО СКРИНИНГА В ПРОГНОЗИРОВАНИИ ИНФЕКЦИОННЫХ ОСЛОЖНЕНИЙ КАРДИОХИРУРГИИ

Incidence of infectious complications in children with congenital heart disease, especially with cyanotic and complex defects, is higher than in the population, which is associated with both hemodynamic and immune disorders. Various types of primary immunodeficiencies in congenital heart disease and the dependence of immune disorders on the morphology of the defect, the severity of circulatory failure and arterial hypoxemia are described. The importance of diagnosing immunological disorders is emphasized to reduce the risk of infectious complications of cardiac surgery, reduce mortality and improve the outcomes of surgical interventions for congenital heart disease. The prognostic value of immune disorders identified by the TREC/KREC method for infectious complications of cardiac surgery has not been studied. The purpose of this research was to assess the possibility of predicting infectious complications of cardiac surgery in children with congenital heart disease based on screening using the TREC/KREC method. Material and methods used: preoperatively, 200 children with congenital heart disease aged 3 days to 12 months old were examined. Instrumental and laboratory methods were used including immunological screening for TREC/KREC DNA. Results: 123 (62.4%) were diagnosed with “acyanotic” congenital heart disease, 74 (37.5%) with various cyanotic congenital heart diseases and 10 (5%) with congenital heart diseases with Down syndrome, Di George syndrome, Williams syndrome or multiple malformations. 184 (92%) underwent various cardiac surgical interventions. Violations of T-cell immunity according to preoperative TREC/KREC screening were observed in 23.5% of cases including in all children with syndromic forms of congenital heart disease, multiple malformations, and significantly more often in cyanotic congenital heart disease, conotruncal defects, and those admitted in critical conditions. Infectious complications of cardiac surgery were observed significantly more often in this group than in children with normal T-cell immunity (in 36% and 3.6%, respectively). Conclusion: the prognostic value of TREC/KREC screening for targeted preparation and postoperative management in order to prevent infectious complications of cardiac surgery has been confirmed.

Atrial Fibrillation following CABG Surgery. Our Experience with 100 Patients

Introduction: Atrial fibrillation (AF) is the most common complication of cardiac surgery, occurring in 10-40% of patients. Postoperative AF (POAF) refers to new-onset AF in a patient without a history of AF that occurs within the first four weeks after cardiac surgery. While POAF can be transient and without consequences, it may lead to severe complications, increasing mortality and morbidity in the postoperative period. Risk factors can be patient-related, intraoperative, and postoperative.&#x0D; This study aimed to estimate the frequency of AF in patients after CABG combined with valvular replacement or not. Identification of patients vulnerable to arrhythmia will allow targeting of those most likely to benefit from prophylactic therapy. &#x0D; Material and Methods: The presented study is a prospective study of 100 patients undergoing elective CABG from February to April 2022 with a mean age of 66 ± 13 years, 30% women, undergoing CABG at the University Hospital Centre “Mother Teresa” Tirana, that developed POAF.&#x0D; Results: Postoperative atrial fibrillation occurred in sixteen patients (16%) at a median of 3.7 days after cardiac surgery (2nd – 7th day). 94% (15) of POAF occurred in CABG only, and 6% (1) in the combined intervention (AVR et CABG).&#x0D; Conclusion: AF is the most common complication after CABG. The occurrence is not dependent on the type of intervention (only CABG or combined with valve replacement), the number of vessels that underwent bypass grafting, or the type of vessel. Electrolytic imbalance should be assessed during the postoperative course of patients who undergo CABG.&#x0D;

The use of cell salvage in adult cardiac surgery at Queen Alia Heart Institute

Background: Objective of the study was to determine the incidence of use cell salvage, indications, efficacy in blood conservation and benefits on recovery after adult cardiac surgery. Methods: This is an observational analysis of adult cardiac surgical patients presenting for cardiac surgery at Queen Alia Heart Institute in the period between September 2023 and December 2023. Patients’ demographics, type of surgery (cardiac pathology), comorbidities, preoperative and postoperative laboratory results, blood transfusion requirements, extubation and intensive care unit (ICU) length of stay were recorded and statistically analysed to determine the effectiveness of cell salvage. Patients were divided into two groups: The cell saver group and the no cell saver group for comparison. Results: Data from 141 adult cardiac surgeries is included in this analysis. Indications for cell saver use were recent anticoagulation (41.4%), more complex surgery (20.7%), high risk of bleeding (13.8%), preoperative anaemia (6.9%), intraoperative major bleeding (6.9%), coagulopathy (6.9%) and rare patient blood type (3.45%). Patients from the cell saver group required blood transfusion 2.1% more than the no cell saver group. There was no significant difference in the length of hospitalization between those who had and those who had not cell saver used during surgery (11.9 and 12 days, respectively). Conclusions: Cell saver was used in one fifth of adult cardiac surgeries. Most common indications for cell saver use during cardiac surgery were recent anticoagulation and more complicated cardiac surgery. The use of cell saver had no impact on postoperative haematocrit or overall time of hospitalization.

Predictors of low cardiac output syndrome after combined mitral and tricuspid valve surgery.

Low cardiac output syndrome (LCOS) is a common complication in cardiac surgery, and we evaluated the incidence of its early occurrence after mitral and tricuspid combined cardiac surgery and its associated risk factors. Retrospective, single institution study. We included 88 consecutive adult patients with severe mitral insufficiency scheduled for elective mitral and tricuspid valve replacement surgery between January 2015 and November 2018. The primary endpoint was the occurrence of LCOS, defined as the need for inotropic support or circulatory assistance after surgery. The secondary endpoint was mortality at 30 days. LCOS occurred in 26 patients (29.5%) of the studied patients and its associated risk factors that appeared in the multivariate analysis were chronic kidney failure [adjusted odds ratio (OR) 3.1; 95% confidence interval (CI) 1.0-9.9, p = 0.05], pre-operative left ventricular heart failure (OR 5.3; 95% CI 1.3-10.9, p = 0.002), pre-operative right ventricular heart failure (OR 3.6; 95% CI 1.1-11.5, p = 0.02), and mitral valve replacement (OR 3.9; 95% CI 1.2-12.6, p = 0.03). LCOS affected the survival of patients (HR = 5.5; 95% CI 1.1-27.7 p = 0.04). LCOS is a frequent complication after mitral and tricuspid combined surgery and is associated with poor prognosis.

ПРОГНОЗИРОВАНИЕ НЕБЛАГОПРИЯТНЫХ КЛИНИЧЕСКИХ ИСХОДОВ ПАЦИЕНТОВ С КАРДИОГЕННЫМ ШОКОМ ПОСЛЕ ОПЕРАЦИЙ НА ОТКРЫТОМ СЕРДЦЕ ПРИ ПОДКЛЮЧЕНИИ ВНУТРИАОРТАЛЬНОЙ БАЛЛОННОЙ КОНТРАПУЛЬСАЦИИ

Aim. To determine preimplantation risk factors and predictors of unfavorable outcome in patients with cardiogenic shock after open-heart surgery, who had an intraoperative system of mechanical circulatory support – intra-aortic balloon contrapulsation. Methods. A retrospective study was conducted at the Republican Scientific and Practical Center “Cardiology” for 2015–2020. It included 66 patients who underwent heart surgery on bypass and who intraoperatively developed cardiogenic shock, refractory to drug therapy, which resulted in the use of intra-aortic balloon counterpulsation. The diagnosis of cardiogenic shock was determined based on the generally accepted criteria, as well as based on the SCAI (Society for Cardiovascular Angiography and Interventions) classification of shock: systolic blood pressure &lt; 90 mmHg for &gt; 30 minutes or the need for infusion of vasopressors or inotropes to achieve the blood pressure of ≥ 90 mm Hg. The Pearson Chi-square test used for nonparametric analysis of qualitative characteristics. The predictors were identified based on logistic regression. Differences were considered significant at p &lt; 0.05 (5%).Results. Risk factors for adverse outcome in case of CS before the use of IABP were: age over 65 years OR = 6.04 [95% CI 1.73 – 21.06], p = 0.003; female gender OR = 3.24 [95% CI 1.064 – 9.873], p = 0.048; vasoactive and inotropic support of more than 42 points OR = 7.85 [95% CI 2.33 – 26.45], p = 0.001; blood lactate of more than 4.7 mmol/l OR = 4.12 [95% CI 1.27 – 13.37], p = 0.014; blood acidity pH &lt; 7.33 OR = 6.34 [95% CI 1.97 – 20.37], p = 0.003; base deficit BE &gt; –5.6 OR = 7.32 [95% CI 2.19 – 24.42], p = 0.001. According to the β-coefficients of the logistic regression equation, predictors were scored as follows: age &gt; 65 years = 2 points, VIP &gt; 42 = 2 points, lactate &gt; 4.7 mmol/L = 1 point. The cumulative probability of 30-day mortality was as follows: 9% when defined as 1 point, 20% – 2 points, 55% – 3 points, 60% – 4 points, 75% – 5 points (Chi-square 24.1; df = 5; p = 0.001). Conclusions. Cardiogenic shock is a fatal complication in cardiac surgery. The use of vasopressor and inotropic drugs has an important role in the treatment of CS; however, escalation of catecholamine doses leads to the progression of multiple organ failure due to hypoperfusion and hypoxia of target organs. Therefore, the use of intra-aortic balloon counterpulsation can improve the results of CS treatment. However, the effect of IABP is limited to increasing cardiac output by no more than 1 l/minute. Based on the calculator we developed, when determining a high risk of an unfavorable outcome of the IABP use, options for circulatory support should be considered including extracorporeal membrane oxygenation, ventricular assist device.

Preoperative Delirium Risk Screening in Patients Undergoing a Cardiac Surgery: Results from the Prospective Observational FINDERI Study

Postoperative delirium (POD) is a common complication of cardiac surgery that is associated with higher morbidity, longer hospital stay, cognitive decline, and mortality. Preoperative assessments may help to identify patients´ POD risk. However, a standardized screening assessment for POD risk has not been established. Prospective observational FINd DElirium RIsk factors (FINDERI) study. Patients aged ≥50 years undergoing cardiac surgery. The primary aim was to analyze the predictive value of the Delirium Risk Screening Questionnaire (DRSQ) prior to cardiac surgery. Secondary aims are to investigate cognitive, frailty, and geriatric assessments, and to use data-driven machine learning (ML) in predicting POD. Predictive properties were assessed using receiver operating characteristics analysis and multivariate approaches (regularized LASSO regression and decision trees). We analyzed a data set of 504 patients (68.3 ± 8.2 years, 21.4% women) who underwent cardiac surgery. The incidence of POD was 21%. The preoperatively administered DRSQ showed an area under the curve (AUC) of 0.68 (95% CI 0.62, 0.73), and the predictive OR was 1.25 (95% CI 1.15, 1.35, p <0.001). Using a ML approach, a three-rule decision tree prediction model including DRSQ (score>7), Trail Making Test B (time>118), and Montreal Cognitive Assessment (score ≤ 22) was identified. The AUC of the three-rule decision tree on the training set was 0.69 (95% CI 0.63, 0.75) and 0.62 (95% CI 0.51, 0.73) on the validation set. Both the DRSQ and the three-rule decision tree might be helpful in predicting POD risk before cardiac surgery.

Tissue inhibitor of metalloproteinase-2 in patients aged 1 month to 1 year with and without cardiac surgery-associated acute kidney injury in congenital heart disease surgery with cardiopulmonary bypass: a single-center retrospective study

Introduction: Acute kidney injury is a common complication of cardiac surgery after management of congenital heart defects. Cardiac surgery-associated acute kidney injury (CS-AKI) results in longer stays of patients in the intensive care unit and hospital. However, using an increase in postoperative creatinine as a means of detecting AKI has some limitations, since significant changes occur after the loss of more than 50% of renal function. In children, the creatinine level is influenced by various factors such as muscle mass, cardiac output, etc. These factors vary significantly among young children and complicate the early diagnosis of AKI. Recent studies have explored biomarkers as potential predictors for the early detection of CS-AKI after cardiac surgery for management of congenital heart disease in children.Objective: To evaluate the urinary tissue inhibitor of metalloproteinase-2 (TIMP2) as a predictor of CS-AKI following management of congenital heart defects in children aged 1 month to 1 year who underwent cardiopulmonary bypass.Methods: A single-center retrospective study included patients aged 1 month to 1 year who underwent cardiopulmonary bypass for the correction of congenital heart defects. The groups were formed based on the presence of CS-AKI. The study group comprised of patients who had CS-AKI (group 1, n = 52), while those without CC-AKI constituted the control group (group 2, n = 98). To ensure minimal systematic errors and comparability between two groups, propensity score matching analysis was performed (52 patients in groups 1 and 2). Preoperative, intraoperative, and postoperative parameters and characteristics were compared.Results: The results showed no differences in baseline or demographic characteristics between the patients. In the study group, 34.6% of patients were diagnosed with CS-AKI. Among them, 67.4% (n = 35) were stage 1, 28.8% (n = 15) were stage 2, and 3.8% (n = 2) were stage 3. The results of the regression analysis show a decrease by 24% and an increase by 9 and 16% in CS-AKI respectively, with an increase in creatinine levels by 1 µmol/l, at baseline and on days 3 and 4. Additionally, male patients have a 76% lower likelihood to develop CS-AKI. It was observed that there was no significant difference in the tissue inhibitor of metalloprotease-2 levels between the groups with and without CS-AKI.Conclusion: Urinary TIMP2 levels were found to be unable to predict the early onset of CS-AKI in congenital heart defect patients ages 1 month to 1 year who underwent cardiopulmonary bypass surgery. Received 24 April 2023. Revised 27 November 2023. Accepted 28 November 2023. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authors: The authors contributed equally to this article.

Mini-Hyper-CVD Plus Venetoclax for Treatment of Older Adults with Newly Diagnosed Ph-Negative B-ALL or T-ALL

Introduction Treatment of Philadelphia chromosome (Ph)-negative acute lymphoblastic leukemia (ALL) in older patients (pts) is challenging due to poor tolerance of conventional chemotherapy and chemo-resistant disease. Pre-clinical work demonstrates that lymphoblasts are BCL2-dependent and sensitive to the BCL2 inhibitor venetoclax (VEN). We hypothesized that VEN plus dose-reduced hyper-CVD (cyclophosphamide, vincristine, dexamethasone) chemotherapy would be well tolerated and effective in older pts. We previously reported the safety and tolerability of VEN plus hyper-CVD in newly diagnosed and relapsed/refractory (R/R) pts (Jain ASH 2019), with a maximum tolerated dose of VEN 600 mg daily on days 1-21 per 28-day cycle. Preliminarily efficacy was promising in newly diagnosed pts, which prompted study extension to phase (P) 2, enrolling newly diagnosed older pts with Ph-negative (neg) B-ALL and T-ALL. Methods Pts with Ph-neg B-ALL or T-ALL were enrolled in a multi-center Phase Ib/II study (NCT03319901). In P1, both R/R pts and newly diagnosed pts ≥ 60 years (yrs) were enrolled. In P2, only newly diagnosed pts ≥ 55 yrs old or ≥ 50 yrs old with BMI ≥ 35 kg/m2 were enrolled. Pts began with VEN ramp-up (P1 over 7d; P2 over 3d) to target dose (P1: dose level [DL]1 400 mg/d; DL2 600 mg/d; P2 400 mg/d), Figure 1. Hyper-CVD, including central nervous system (CNS) prophylaxis with intrathecal chemotherapy, was then given with VEN per DL for 21/28 days per cycle, for up to 8 cycles. Following completion of hyper-CVD courses, pts received VEN plus POMP maintenance for up to 2 yrs. Pts were recommended to receive fewer than 8 cycles of hyper-CVD in the setting of toxicity or to proceed to allogeneic hematopoietic stem cell transplant (HSCT) per physician discretion. This report updates follow-up of the newly diagnosed pts enrolled in P1 and the P2 cohort. Complete remission (CR) was defined as &amp;lt;5% marrow blasts, no evidence of extramedullary or CNS leukemia, ANC &amp;gt;1.0 K/uL and platelets &amp;gt;100 K/uL. Measurable residual disease (MRD) was evaluated by multicolor flow cytometry (MFC) and negative defined as &amp;lt;0.01%. Survival outcomes are presented via Kaplan Meier. Results In total, 30 newly diagnosed pts [P1 11 (DL1=3; DL2=8); P2 18] were treated with a median age of 68 yrs (range, 57-81 yrs, n=12 [40%] ≥70 yrs); n=15 (50%) women, n=4 (13%) Hispanic, and n=1 (3%) Black. Twenty-three (77%) pts had B-ALL and 7 (23%) pts had T-ALL (6/7 early T-cell precursor). Two (6%) pts had central nervous system (CNS) involvement at diagnosis (1-CNS3, 1-CNS2). High risk genetics were present in 56% (13/23) of B-ALL pts: TP53 (n=9 associated with complex [n=3] or hypodiploid [n=5] karyotype), KMT2A (n=1), IKZF1 abnormality (n=2), and Ph-like (n=1). Eight B-ALL pts had received prior chemotherapy for multiple myeloma (n=6; n=4 auto HSCT, n=5 lenalidomide), diffuse large B-cell lymphoma (n=1, RCHOP), and breast cancer (n=1, docetaxel, carboplatin, trastuzumab). The median number of hyper-CVD cycles received was 4 (range 1-8) among the 27 pts who have completed the hyper-CVD phase of treatment (3 pts are currently receiving consolidation). Mortality within 30 days was 3% (n=1). One patient died in CR due to sepsis during cycle 4. Venetoclax did not impair count recovery: median time from C1 to C2 was 34 days (range 27-47). Dose adjustments of VEN occurred in 4 pts (15%). An MRD-neg CR was achieved in 25/30 (83%) pts. The median cycles to achieve both CR and MRD negativity by MFC was one (range: CR 1-2 cycles; MRD negativity 1-4 cycles). Remaining pts had refractory disease (n=4, 13%), or were not assessed (n=1, 3%) due to early death. Of the 25 pts who achieved CR, 11/25 (44%) received allogeneic HSCT in CR1 after a median of 200 days (range 138 to 347). With a median follow-up of 16.4 months, the estimated 12- and 24-month OS are 82.1% (95% CI 66, 98) and 74.6% (95% CI 54, 95), Figure 2; and RFS are 82.9% (95% CI 65, 100.0) and 67.8% (95% CI 44, 92), respectively. At data cut-off, 22 pts (73%) are alive. Death events (n=8, 27%) were due to early mortality (n=1, related to both ALL and infection), post HSCT complications (n=3), refractory ALL (n=1), relapsed ALL (n=1), sepsis in CR (n=1), and complications of cardiac surgery in CR (n=1). Conclusion In this ongoing study, the addition of VEN to hyper-CVD in newly diagnosed ALL was well tolerated with encouraging responses. A future amendment will incorporate blinatumomab consolidation for pts with B-ALL.

A Single-Center Large Cohort of Chronic Neutropenia Patients and a Model for Estimation of Congenital Neutropenias

Chronic neutropenia (CrN) is defined as neutropenia lasting longer than 3 months and has various underlying etiologies, including congenital neutropenia (CN). We aimed to determine the underlying etiologies of patients with CrN and define the characteristics at diagnosis suggestive for CN as a final diagnosis. The study included 197 pediatric and adolescent patients who were diagnosed with CrN between 2010 and 2022 in a single-center. Patients with transient neutropenia, splenomegaly, alloimmune, secondary autoimmune, myelodysplastic syndrome and hematological malignancies, other bone marrow failure syndromes such as Fanconi anemia, and aplastic anemia due to CrN were excluded from the study. The patients included in the study were sub-classified into 5 groups according to their final diagnosis. Group 1, patients with CN (n=64, %32.5) included all genetically verified CrN patients. Group 2, patients with primary autoimmune neutropenia (pIN) group (n=10, %5.1) with anti-granulocyte antibody (AGA) positivity. Group 3, patients with unclassified chronic idiopathic neutropenia (UCIN) (n=73, %37.1). Group 3 included patients who had a clinical severity resembling immune neutropenia, but whose AGA testing was either negative or not available; but the CrN resolved during follow-up. Group 4, included the patients with unclassified chronic benign neutropenia (UCBN) (n=34, %17.3) and included the patients with ongoing neutropenia, who do not have a history of serious infections, no underlying genetic cause for neutropenia, no AGA positivity. Group 5, unspecified congenital neutropenia (UCN) group (n=16, %8,1), was defined as the group of patients whose genetic tests did not detect a mutation in genes related to CN, but history reveales severe infections and a possible CN as an underlying cause. Genetic testing of patients varies from single gene evaluation with Sanger sequencing analysis to Whole Exome Sequencing (WES). The median age at diagnosis of neutropenia of the patients included in the study was 12 (0-168) months 53.8% of the patients were male (n=106). There was consanguinity between parents in 34.5% and at least 1 family member was diagnosed with neutropenia in the in 18.8%. Among the patients in Group 1, HAX-1 mutation was detected in 19 (29.7%) patients and it was found to be the most common genetic defect causing CN. Other common genetic disorders include ELANE mutations (18.8%), Shwachman Diamond Syndrome (10.9%), Hermansky Pudlak Syndrome (7.8%) and glycogen storage type 1 b (6.3%). G6PC3 deficiency, VPS45 deficiency, Barth syndrome and Kabuki syndrome in 2 each (3.1%), ADA2 deficiency, Cohen Syndrome, Poikiloderma with neutropenia, Prolidase deficiency, CLPB deficiency, Majeed syndrome, GINS4 deficiency, reticular dysgenesis, germline RUNX1 mutation were detected in 1 patient. There are 3 patients with acute myeloid leukemia and all of them died before hematopoietic stem cell transplantation (HSCT). Two of these patients were diagnosed with SDS, and one had ELANE mutation. One patient with the HAX-1 mutation developed non-Hodgkin lymphoma and was treated with HSCT and is still alive. There were 7 patients (3.6%) who underwent HSCT. 9 patients (4.6%) died. Except for 3 patients who died from AML and 1 who died after HSCT; 1 patient with Barth syndrome deceased related to associated dilated cardiomyopathy, Another patient with G6PC3 mutation died after complications of cardiac surgery due to associated cardiac anomaly and 3 patients (2 VPS45, 1 CLPB) died due to infections. Patients in Group1 and Group 2+Group3 were compared, in order to answer the question of “Can we create a model that predicts CN?”. Many parameters were compared and a multivariate model was created with statistically significant risk factors. CN was seen 6,3 times more in those with parental consanguinity, 8,9 times in those with a family history of neutropenia, 4,8 times in those with more than 2 hospitalizations due to infection, and 4,1 times more in those with recurrent oral involvement (p&amp;lt;0.05). Patients diagnosed with CN were estimated based on the results of the multifactor logistic regression model. The rate of correct identification of the patients by the model is 88.9%. In conclusion, our study is one of the largest single-center studies and suggests a novel classification of CrN patients.

Plasma indole-3-aldehyde as a novel biomarker of acute kidney injury after cardiac surgery: a reanalysis using prospective metabolomic data

BackgroundAcute kidney injury (AKI) is a frequent complication of cardiac surgery that poses significant risks for both the development of chronic kidney diseases and mortality. Our previous study illustrated that heightened expression levels of faecal and plasma indole metabolites before the operation were associated with ischemic AKI. In this study, we aimed to validate the supposition that plasma indole-3-aldehyde (I3A) could serve as a predictive biomarker for AKI in patients undergoing cardiac surgery.MethodsThis statistical reanalysis utilized AKI metabolomic data from patients scheduled for cardiac surgery between April 2022 and July 2022 in two tertiary hospitals. Faecal and blood samples were prospectively collected before surgery within 24 h, and variables related to the preoperative, intraoperative, and postoperative periods were recorded. AKI diagnosis was based on the Kidney Disease Improving Global Outcomes criteria.ResultsIn this study, 55 patients who underwent cardiac surgery were analyzed, and 27 of them (49.1%) developed postoperative AKI. Before surgery, these patients had significantly higher levels of faecal indole metabolites, including skatole, trans-3-indoleacrylic acid, and 5-methoxyindoleacetic acid. The plasma I3A, clinical model that considered perioperative and intraoperative variables, and their combination had area under the receiver operating characteristic curve (ROC) values of 0.79 (95% CI 0.67–0.91), 0.78 (95% CI 0.66–0.90), and 0.84 (95% CI 0.74–0.94) for predicting AKI, respectively. Furthermore, by utilizing net reclassification improvement and integrated discrimination improvement, plasma I3A showed significant improvements in risk reclassification compared to the clinical model alone.ConclusionsThe dysregulation of gut microbiota metabolism in patients scheduled for cardiac surgery can result in an increase in indoles from tryptophan metabolism, which may be associated with postoperative acute kidney injury (AKI). This suggests that indoles may serve as a predictive biomarker for AKI in patients undergoing cardiac surgery.

Abstract 15292: The Association Between High Serum Uric Acid Level and New-Onset Atrial Fibrillation After Coronary Artery Bypass Grafting

Introduction: Postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery, increasing stroke risk, morbidity, and mortality. At present, the specific pathogenesis of POAF remains to be fully elucidated. Though the potential impact of uric acid on atrial fibrillation has been suggested, the relationship between serum uric acid (SUA) levels and POAF in patients undergoing coronary artery bypass graft surgery (CABG) remains unclear. Hypothesis: This study investigates the potential association between SUA levels and the incidence of POAF in patients who have undergone CABG. Methods: We conducted a retrospective, observational cohort study (NCT05888168) that included 16,682 patients who underwent CABG at Beijing Anzhen Hospital from January 2018 to December 2021. Patients with a previous history of atrial fibrillation or requiring concomitant cardiac surgery were excluded. A cox regression model was used to determine predictors of POAF, with confounding variables adjusted via multivariable adjustment, inverse probability of treatment weighting, and propensity score matching. Results: The analysis encompassed 12,293 patients. SUA level values were 328 [273.6, 389.9] μmol/L and high SUA level (≥370μmol/L) were found in 3919 (31.88%) patients. The incidence of POAF was significantly higher in patients with high SUA level compared to those without (32.69% versus 29.53%, P&lt;0.001). High SUA level was associated with an increased hazard ratio (HR) of POAF (HR [95%CI]: 1.21 [1.13-1.30]). These results were confirmed through inverse probability of treatment weighting and propensity score matching analyses. Conclusions: High SUA level is predictive of POAF in CABG patients, even after adjusting for age, sex, cardiovascular risk factors, medical therapy, echocardiographic parameters, and laboratory markers.

Not So Cool! Peri-Operative Hypothermia and Its Complications in Cardiac Surgery: Insights from an Indian Study

Not So Cool! Peri-Operative Hypothermia and Its Complications in Cardiac Surgery: Insights from an Indian Study

The Effect of Posterior Pericardiotomy on the Incidence of Atrial Fibrillation After Cardiac Surgery-Extended Follow-Up study (PALACS-EF): rationale and design.

Postoperative atrial fibrillation (POAF) is the most common complication of cardiac surgery and has been associated with increased postoperative morbidity and hospital costs. The Posterior left pericardiotomy for the prevention of AtriaL fibrillation After Cardiac Surgery (PALACS) trial found that posterior pericardiotomy significantly reduced the incidence of POAF (17% vs. 32%, P < 0.001). We present the protocol for The Effect of Posterior Pericardiotomy on the Incidence of Atrial Fibrillation After Cardiac Surgery-Extended Follow-Up study (PALACS-EF): a prospective, extended follow-up of the original PALACS trial. The aim of PALACS-EF is to gain more data regarding the effect of posterior pericardiotomy on postdischarge clinical outcomes. The primary outcome is the time to the first occurrence of the composite of all-cause mortality or hospital cardiovascular readmission. The key secondary outcome is the time to the first occurrence of the composite of all-cause mortality and all-cause hospital readmission. Hospital readmission, myocardial infarction, stroke, transient ischaemic attack, heart failure, systemic embolism, or new arrhythmias with onset since 30-day follow-up will also be recorded. All 420 patients enrolled in the PALACS trial will be included; extended follow-up will be conducted via telephone by blinded research personnel utilizing a standardized script to ensure uniformity and completeness of follow-up. If an event has occurred, documentation will be obtained, and an independent adjudication committee blinded to group assignment will adjudicate outcome events. Results will be reported when a median follow-up of 5 years is achieved. PALACS-EF will provide data to answer the question of whether posterior pericardiotomy improves postdischarge outcomes in patients undergoing cardiac surgery, and it will provide information on the relationship between POAF and adverse postdischarge outcomes including mortality, hospitalization, heart failure, and stroke. PALACS: NCT02875405, PALACS-EF: NCT05903222.

Differences in Postoperative Atrial Fibrillation Incidence and Outcomes After Cardiac Surgery According to Assessment Method and Definition: A Systematic Review and Meta-Analysis.

Postoperative atrial fibrillation (POAF) is the most frequent complication of cardiac surgery. Despite clinical and economic implications, ample variability in POAF assessment method and definition exist across studies. We performed a study-level meta-analysis to evaluate the influence of POAF assessment method and definition on its incidence and association with clinical outcomes. A systematic literature search was conducted to identify studies comparing the outcomes of patients with and without POAF after cardiac surgery that also reported POAF assessment method. The primary outcome was POAF incidence. The secondary outcomes were in-hospital mortality, stroke, intensive care unit length of stay, and postoperative length of stay. Fifty-nine studies totaling 197 774 patients were included. POAF cumulative incidence was 26% (range: 7.3%-53.1%). There were no differences in POAF incidence among assessment methods (27%, [range: 7.3%-53.1%] for continuous telemetry, 27% [range: 7.9%-50%] for telemetry plus daily ECG, and 19% [range: 7.8%-42.4%] for daily ECG only; P>0.05 for all comparisons). No differences in in-hospital mortality, stroke, intensive care unit length of stay, and postoperative length of stay were found between assessment methods. No differences in POAF incidence or any other outcomes were found between POAF definitions. Continuous telemetry and telemetry plus daily ECG were associated with higher POAF incidence compared with daily ECG in studies including only patients undergoing isolated coronary artery bypass grafting. POAF incidence after cardiac surgery remains high, and detection rates are variable among studies. POAF incidence and its association with adverse outcomes are not influenced by the assessment method and definition used, except in patients undergoing isolated coronary artery bypass grafting.

Perioperative Oral Management to Prevent Cardiac Surgery Complications

Perioperative Oral Management to Prevent Cardiac Surgery Complications