Elective Cardiac Surgery Patients Research Articles

Exposure to serum from exclusive heated tobacco product smokers induces mTOR activation and fibrotic features in human cardiac stromal cells

Chronic smokers have increased risk of fibrosis-related atrial fibrillation. The use of heated-tobacco products (HTPs) is increasing exponentially, and their health impact is still uncertain. We aim to investigate the effects of circulating molecules in exclusive HTP chronic smokers on the fibrotic behavior of human atrial cardiac stromal cells (CSCs). CSCs were isolated from atrial tissue of elective cardiac surgery patients, and exposed to serum lots from young healthy subjects, stratified in exclusive HTP smokers, tobacco combustion cigarette (TCC) smokers, or nonsmokers (NS). CSCs treated with TCC serum displayed impaired migration and increased expression of pro-inflammatory cytokines. Cells cultured with HTP serum showed increased levels of pro-fibrotic markers, and reduced expression of connexin-43. Both TCC and HTP sera increased collagen release and reduced secretion of angiogenic protective factors from CSCs, compared to NS sera. Paracrine support to tube-formation by endothelial cells and to viability of cardiomyocytes was significantly impaired. Treatment with sera of both smokers impaired H2O2/NO release balance by CSCs and reduced early phosphorylation of several pathways compared to NS serum, leading to mTOR activation. Cotreatment with rapamycin was able to reduce mTOR phosphorylation and differentiation into aSMA-positive myofibroblasts in CSCs exposed to TCC and HTP sera. In conclusion, the circulating molecules in the serum of chronic exclusive HTP smokers induce fibrotic behavior in CSCs through activation of the mTOR pathway, and reduce their beneficial paracrine effects on endothelial cells and cardiomyocytes. These results point to a potential risk for cardiac fibrosis in chronic HTP users.

Detecting aortic valve stenosis based on the non-invasive blood pressurewaveform-a proof of concept study.

The incidence of aortic valve stenosis (AoS) increases with age, and once diagnosed, symptomatic severe AoS has a yearly mortality rate of 25%. AoS is diagnosed with transthoracic echocardiography (TTE), however, this gold standard is time consuming and operator and acoustic window dependent. As AoS affects the arterial blood pressure waveform, AoS-specific waveform features might serve as a diagnostic tool. Aim of the present study was to develop a novel, non-invasive, AoS detection model based on blood pressures waveforms. This cross-sectional study included patients with AoS undergoing elective transcatheter or surgical aortic valve replacement. AoS was determined using TTE, and patients with no or mild AoS were labelled as patients without AoS, while patients with moderate or severe AoS were labelled as patients with AoS. Non-invasive blood pressure measurements were performed in awake patients. Ten minutes of consecutive data was collected. Several blood pressure-based features were derived, and the median, interquartile range, variance, and the 1st and 9th decile of the change of these features were calculated. The primary outcome was the development of a machine-learning model for AoS detection, investigating multiple classifiers and training on the area under the receiver-operating curve (AUROC). In total, 101 patients with AoS and 48 patients without AoS were included. Patients with AoS showed an increase in left ventricular ejection time (0.02s, p = 0.001), a delayed maximum upstroke in the systolic phase (0.015s, p < 0.001), and a delayed maximal systolic pressure (0.03s, p < 0.001) compared to patients without AoS. With the logistic regression model, a sensitivity of 0.81, specificity of 0.67, and AUROC of 0.79 were found. The majority of the population without AoS was male (85%), whereas in the population with AoS this was evenly distributed (54% males). Age was significantly (5years, p < 0.001) higher in the population with AoS. In the present study, we developed a novel model able to distinguish no to mild AoS from moderate to severe AoS, based on blood pressure features with high accuracy. Clinical registration number: The study entailing patients with TAVR treatment was registered at ClinicalTrials.gov (NCT03088787, https://clinicaltrials.gov/ct2/show/NCT03088787 ). The study with elective cardiac surgery patients was registered with the Netherland Trial Register (NL7810, https://trialsearch.who.int/Trial2.aspx?TrialID=NL7810 ).

Erector spinae plane block reduces opioid consumption and improves incentive spirometry volume after cardiac surgery: A retrospective cohort study.

Effective postoperative pain management is vital in cardiac surgery to prevent opioid dependency and respiratory complications. Previous studies on the erector spinae plane (ESP) block have focused on single-shot applications or immediate postoperative outcomes. This study evaluates the efficacy of continuous ESP block vs conventional care in reducing opioid consumption and enhancing respiratory function recovery postcardiac surgery over 72 hours. A retrospective study at a tertiary hospital (January 2021-July 2022) included 262 elective cardiac surgery patients. Fifty-three received a preoperative ESP block, matched 1:1 with a control group (n = 53). The ESP group received 0.5% ropivacaine intraoperatively and 0.16% ropivacaine every 4 hours postoperatively. Outcomes measured were cumulative oral morphine equivalent (OME) dose within 72 hours postextubation, daily maximum numerical rating scale (NRS) ≥3, incentive spirometry volume, and %baseline performance, stratified by surgery type (sternotomy or thoracotomy). Significant OME reduction was observed in the ESP group (sternotomy: median decrease of 113 mg, 95% CI: 60-157.5 mg, p < 0.001; thoracotomy: 172.5 mg, 95% CI: 45-285 mg, p = 0.010). The ESP group also had a lower risk of daily maximum NRS ≥3 (adjusted OR sternotomy: 0.22, p < 0.001; thoracotomy: 0.07, p < 0.001), a higher incentive spirometry volumes (sternotomy: mean increase of 149 mL, p = 0.019; thoracotomy: 521 mL, p = 0.017), and enhanced spirometry %baseline (sternotomy: mean increase of 11.5%, p = 0.014; thoracotomy: 26.5%, p < 0.001). Continuous ESP block was associated with a reduction of postoperative opioid requirements, lower instances of pain scores ≥3, and improve incentive spirometry performance following cardiac surgery. These benefits appear particularly prominent in thoracotomy patients. Further prospective studies with larger sample size are required to validate these findings.

A pilot RCT of an mHealth self-help intervention on readmission rate reduction after adult cardiac surgery: preliminary findings

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): The Royal Melbourne Hospital Background Readmission is multifaceted, potentially avoidable and costly. Patients’ ability to enact self-care behaviors after cardiac surgery are under-investigated. Purpose To evaluate the feasibility of a RCT investigating an mHealth intervention for self-help, and readmission rate reduction. Methods Elective adult (&amp;gt;18 years) elective cardiac surgery (via median sternotomy) patients were eligible for inclusion. Patients had to be discharged home, able to understand spoken English, and own and use a smartphone, tablet or computer. The intervention comprised a narrative online library (Healthily GoShare platform) with videos describing patient and carer experiences focused on preoperative preparation, acute postoperative care (sent within 1 week of discharge) and ongoing recovery Sent 30 days after surgery). Patients were randomised preoperatively 1:1 to the intervention, accessible via a text or email link, or the control group receiving usual care that comprised postoperative education and a brochure. Follow-up phone interviews took place 30, 60 and 90 days after surgery. Results From August 2021 to December 2022, 341 (65%) patients were scheduled for elective surgery, 229 (67.2%) were transferred elsewhere secondary to COVID-19 bed closures, 22 (6.5%) were undergoing reoperation, 13 (3.8%) did not adequately understand spoken English and 7 (2.1%) did not own a smartphone or tablet. Of the 70 (20.5%) eligible patients, 61 (87.1%) agreed to participate and 2 (2.8%) did not proceed. Follow-up (FUP) is complete for 43 (72.9%) patients. Accessed preoperative 14 (63.6%), postoperative 16 (72.7%) and recovery bundles 12 (54.5%) were reported as helpful or very helpful by 95% (n = 21) of participants. A single patient from the intervention group was lost to FUP at 30 days and 5 control group patients at 60 days. 30-day readmission was more frequent in the control (3/21, 14.3%) than intervention group (0/22; p = 0.06). Conclusion(s): Findings to date indicate COVID-19 bed closures have impacted on elective surgical scheduling thus recruitment. The intervention was feasible and acceptable. To be 95% confident the readmission rate is within 10%, assuming a 15% readmission rate, a minimum of 50 patients are required. Follow-up is ongoing.

One-Year Survival after Cardiac Surgery in Frail Older People-Social Support Matters: A Prospective Cohort Study.

There are increasing rates of cardiac surgery in the elderly. Frailty, depression, and social vulnerability are frequently present in older people, and should be considered while assessing risk and providing treatment options. We aimed to analyse the impact of clinically relevant variables on survival at one year, and identify areas of future intervention. We performed a prospective cohort study at a University Hospital, with a sample of 309 elective cardiac surgery patients 65 years old and over. Their socio-demographic and clinical variables were collected. Frailty prevalence was 61.3%, while depression was absent in the majority of patients. Mortality was 1.6% and 7.8% at 30 days and 12 months, respectively. After Kaplan-Meier analysis, severe frailty (p = 0.003), severe depression (p = 0.027), pneumonia until 30 days (p = 0.014), and re-operation until 12 months (p = 0.003) significantly reduced survival, while social support increased survival (p = 0.004). In the adjusted multivariable Cox regression model, EuroSCORE II (HR = 1.27 [95% CI 1.069-1.499] p = 0.006), pneumonia until 30 days (HR = 4.19 [95% CI 1.169-15.034] p = 0.028), re-intervention until 12 months (HR = 3.14 [95% CI 1.091-9.056] p = 0.034), and social support (HR = 0.24 [95% CI 0.079-0.727] p = 0.012) explained time until death. Regular screening for social support, depression, and frailty adds relevant information regarding risk stratification, perioperative interventions, and decision-making in older people considered for cardiac surgery.

Effect of the machine learning-derived Hypotension Prediction Index (HPI) combined with diagnostic guidance versus standard care on depth and duration of intraoperative and postoperative hypotension in elective cardiac surgery patients: HYPE-2 – study protocol of a randomised clinical trial

IntroductionHypotension is common during cardiac surgery and often persists postoperatively in the intensive care unit (ICU). Still, treatment is mainly reactive, causing a delay in its management. The Hypotension Prediction...

Viruses in the Respiratory Tract in Elective Cardiac Surgery Patients

Objectives: Acute respiratory distress syndrome after cardiac surgery is a severe complication that is associated with high morbidity and mortality. The presence of viruses in the respiratory tract is postulated to be one of multiple factors attributing to development of Acute Respiratory Distress Syndrome (ARDS), but studies report conflicting results. Since this possible risk factor can potentially be influenced by screening or vaccination, we aimed to further investigate the role of viruses in the development of ARDS after cardiac surgery. Methods: We conducted an explorative prospective cohort study in 49 randomly chosen asymptomatic adult elective cardiac surgery patients. On four different time points, non-fiberscopic mini-broncho alveolar lavages (miniBAL) were collected and analysed with multiplex PCR testing for 11 types of respiratory viruses. Results and Conclusions: Various (merely low pathogenic) respiratory viruses were detected in 12% of our study population. Respiratory viruses were present both within and out of the influenza-like-illness- season. 19 (39%) of all patients developed acute respiratory distress syndrome. No relationship of viral presence with major pulmonary outcomes (PaO2/FiO2 ratio, development of acute respiratory distress syndrome or mechanical ventilation time) could be demonstrated, though events were too few to allow multivariate analyses. Conclusion: Asymptomatic elective cardiac surgery patients do carry respiratory viruses, though not associated with development of respiratory complications. Further research is warranted, in particular research into the (more pathogenic) diverse subtypes of the respiratory viruses, the relevance of virus load (cycle threshold-values) and even into the diagnostic method (throat swab versus deeper material).

Influenza Season and Outcome After Elective Cardiac Surgery: An Observational Cohort Study

BackgroundAn asymptomatic respiratory viral infection during cardiac surgery could lead to pulmonary complications and increased mortality. For elective surgery, testing for respiratory viral infection before surgery or vaccination could reduce the number of these pulmonary complications. The aim of this study was to investigate the association between influenzalike illness (ILI) seasons and prolonged mechanical ventilation and inhospital mortality in a Dutch cohort of adult elective cardiac surgery patients. MethodsCardiac surgery patients who were admitted to the intensive care unit between January 1, 2014, and February 1, 2020, were included. The primary endpoint was the duration of invasive mechanical ventilation in the ILI season compared with baseline season. Secondary endpoints were the median Pao2 to fraction of inspired oxygen ratio on days 1, 3, and 7 and postoperative inhospital mortality. ResultsA total of 42,277 patients underwent cardiac surgery, 12,994 (30.7%) in the ILI season, 15,843 (37.5%) in the intermediate season, and 13,440 (31.8%) in the baseline season. No hazard rates indicative of a longer duration of invasive mechanical ventilation during the ILI season were found. No differences were found for the median Pao2 to fraction of inspired oxygen ratio between seasons. However, inhospital mortality was higher in the ILI season compared with baseline season (odds ratio 1.67; 95% CI, 1.14-2.46). ConclusionsPatients undergoing cardiac surgery during the ILI season were at increased risk of inhospital mortality compared with patients in the baseline season. No evidence was found that this difference is caused by direct postoperative pulmonary complications.

Reproducibility and validity of the Portuguese Edmonton Frail Scale version in cardiac surgery patients

IntroductionFrailty is a multidimensional syndrome characterized by the loss of functional reserve, associated with higher mortality and less functional survival in cardiac surgery patients. The Edmonton Frail Scale (EFS) is a comprehensive tool devised for brief frailty detection. To the best of our knowledge, there are no culturally adapted and validated frailty screening tools that enable the identification of vulnerability domains suited for use in the preoperative setting in Portugal. This was the motivation for this study. ObjectivesTo assess the validity and reproducibility of the Portuguese version of the EFS. MethodsProspective observational study, in a sample of elective cardiac surgery patients. The Edmonton Frail Scale (EFS) translation and backtranslation were performed. Demographic and clinical data were collected, and the translated EFS translated, Geriatric Depression Scale, and Mini Mental State Examination Portuguese versions, Katz and Clinical Frailty Scales were administered. To assess validity Mann–Whitney test, Spearman's correlation coefficient, marginal homogeneity test and Kappa coefficient were employed. Reproducibility was assessed estimating kappa coefficient for the frailty diagnosis and the 11 EFS items. Intra-class correlation coefficients and the corresponding 95% confidence interval were estimated using linear mixed effects model. ResultsThe EFS Portuguese version revealed construct validity for frailty identification, as well as criterion validity for cognition and mood domains. Reproducibility was demonstrated, with k=0.62 (95% confidence interval (CI) 0.42–0.82) and intraclass correlation (ICC)=0.94 (95% CI 0.89–0.97) in inter-observer test and k=0.48 (95% CI 0.26–0.70) and ICC=0.85 (95% CI 0.72–0.92) in intra-observer test. ConclusionsThe EFS Portuguese version is valid and reproducible for use, suiting pre-operative frailty screening in a cardiac surgery setting.

Hemostatic effects of a dextran-based priming solution for cardiopulmonary bypass: A secondary analysis of a randomized clinical trial

IntroductionIntravascular fluids administered to patients may influence hemostasis. In patients undergoing cardiac surgery with cardiopulmonary bypass, the heart-lung machine is primed with 1300 ml of fluid. We assessed postoperative coagulation and platelet function in patients randomized to two different priming solutions, one colloid-based (dextran 40) and one crystalloid-based. Materials and methodsEighty-four elective cardiac surgery patients were randomized to either a dextran-based prime or Ringer's acetate with added mannitol. Blood samples were collected before, and 2 and 24 h after cardiopulmonary bypass. Coagulation was assessed by standard coagulation tests and rotational thromboelastometry. Platelet function was assessed with impedance aggregometry. Bleeding volumes and transfusion requirements were recorded. ResultsComparing the groups 2 h after bypass, the dextran group showed lower hemoglobin concentration, hematocrit, platelet count, and fibrinogen concentration, and higher INR and aPTT, as well as longer clot formation time (+41 ± 21 % vs. +8 ± 18 %, p < 0.001) and a larger reduction in fibrinogen-dependent clot strength (−37 ± 12 % vs. -7 ± 20 %, p < 0.001). Adenosine diphosphate-dependent platelet activation was reduced in the dextran group but not in the crystalloid group 2 h after bypass (−14 ± 29 % vs. -1 ± 41 %, p = 0.041). No significant between-group differences in hemostatic variables remained after 24 h, and no significant differences in perioperative bleeding volumes, re-explorations for bleeding, or transfusion rates were observed. ConclusionsCompared to a crystalloid solution, a dextran-based prime had measurable negative impact on hemostatic variables but no detectable increase in bleeding volume or transfusion requirements in cardiac surgery patients.

Impact of pulmonary hypertension hemodynamic presentation on perioperative outcomes in patients undergoing elective cardiac surgery: An observational study

Abstract Background Pulmonary hypertension (PH) is classified by hemodynamic presentation into precapillary, isolated postcapillary, and combined postcapillary and precapillary PH. Whether PH type influences risk stratification in cardiac surgery remains undetermined. We aimed to evaluate the incidence of perioperative (≤30 days) morbidity and mortality in different PH population. Methods This was a retrospective observational study. All patients who underwent right heart catheterization between August 2015 and July 2020 were divided into the noncapillary, precapillary, isolated postcapillary, and combined postcapillary and pre capillary PH groups based on their mean pulmonary arterial pressure, pulmonary artery wedge pressure, and diastolic pressure difference preoperatively. Results Of the 500 patients who underwent elective cardiac surgeries, 487 were analyzed. Overall, 236 patients (48.7%) had PH, and isolated postcapillary PH was the most common presentation. Mild PH proportion was highest in the precapillary PH type (70.8%), followed by isolated postcapillary PH (46.2%), and finally combined postcapillary and precapillary PH (10.7%). Patients with PH had a greater frequency of renal insufficiency and wound infection within 30 days postoperatively. Mean pulmonary arterial pressure &gt;25 mm Hg after cardiopulmonary bypass (CPB) was a risk factor for short-term complications. New York Heart Association Functional Class ≥II, long CPB duration, and isolated postcapillary PH or combined postcapillary and precapillary PH type are independent risk factors for short-term morbidity and mortality after elective cardiac surgery. Conclusions Isolated postcapillary PH and combined postcapillary and precapillary PH patients had a higher complication rate 30 days postoperatively among elective cardiac surgery patients. After CPB, mean pulmonary arterial pressure &gt;25 mm Hg was associated with greater complication frequency.

Novel Platelet Function Analyzer 200 Predicts Blood Transfusion After Elective Cardiac Surgery in Patients Suspended on Dual Antiplatelet Therapy.

The value of platelet function test in timing of cardiac surgery remains uncertain. Researches on correlation between Platelet Function Analyzer 200 (PFA-200) and bleeding after elective cardiac surgery are still inadequate. The objective of this study was to investigate the predictive value of PFA-200 in blood transfusion after cardiac surgery. A total of 71 patients on aspirin and P2Y12 receptor inhibitors undergoing cardiac surgery in Fuwai Hospital were enrolled. Platelet function after discontinuing of antiplatelet drugs was assessed by PFA-200 using closure time (CT). PFA-200 results before surgery were included in the statistics. The primary endpoint was postoperative blood transfusion. Seventeen patients (21.9%) received blood transfusion after cardiac surgery. The preoperative PFA-200 CT value in the transfused group was significantly higher than that in the non-transfused group (147.24 ± 85.54 s vs 98.06 ± 61.59 s, P = .011). Using 106 seconds as the dividing point, the incidence of blood transfusion in the elevated PFA-200 (CT > 106 s) group was significantly higher than those in normal PFA-200 (CT ≤ 106 s) group (10/24 patients, 41.9% vs 7/47 patients, 14.7%, P = .012). Multivariate logistic regression analysis showed that PFA-200 CT value > 106 s was an independent predictor of postoperative blood transfusion (OR: 4.05, 95%CI: 1.19-13.86, P = .026). The platelet function test PFA-200 had a predictive value for postoperative blood transfusion in elective cardiac surgery and had a promising prospect in the timing of cardiac surgery.

ROTEM-GUIDED TRANSFUSION MANAGEMENT FOR ACUTE TYPE A AORTIC DISSECTION: A SINGLE CENTRE EXPERIENCE

ROTEM-GUIDED TRANSFUSION MANAGEMENT FOR ACUTE TYPE A AORTIC DISSECTION: A SINGLE CENTRE EXPERIENCE

Adjunctive use of Ketorolac for Postoperative Pain Management in Elective Cardiac Surgery Patients: A Randomized Control Trial

Objective: To compare between the efficacy of Ketorolac and Paracetamol in the management of post-operative pain following elective cardiac surgery.&#x0D; Study Design: Randomized (single-blind) Control Trial (RCT NCT05361824.) &#x0D; Place and Duration of Study: This study was conducted in the Surgical Intensive Care Unit (SICU) at the National Institute of Cardiovascular Diseases Hospital, Karachi Pakistan, From 1st Jan to 30th Jun 2021.&#x0D; Methodology: Randomization of 60 patients undergoing elective cardiac surgery into either Paracetamol (30 control patients) or Ketorolac (30 treatment patients) was done.In addition, to a low dose, short duration background infusion of Nalbuphine, the control group was administered. Injection Paracetamol 1gm every six-hours. Whereas the treatment group was administered injection Ketorolac 30mg every eight-hours. Assessment of pain was done at 6, 12, 18 and 24 hours post-extubation, using a Visual analog scale (VAS). For the purpose of this study, a score of 4 or less was taken as a cut-off for adequate pain control.&#x0D; Results: VAS score was significantly lower in Ketorolac group as compared to the Paracetamol group at all four-time points with an average rating of 3.2±1.9 vs. 5.3±1.7; p&lt;0.001, 3.5±1.5 vs. 5±1.7; p&lt;0.001, 3.3±1 vs. 5.0±1.4; p&lt;0.001, and 3.0±1.4 vs. 4.3±1.6; p&lt;0.001 at 6, 12, 18, and 24 hours respectively. The total dose of Nalbuphine administered (infusion + bolus doses) over 48 hours post-operatively was 15.3±5.2 vs 25.7±6.8 ml; p&lt;0.001 in the Ketorolac and Paracetamol groups, respectively.&#x0D; Conclusion: The use of Ketorolac in conjunction with Nalbuphine gives better control over post-operative pain in elective cardiac surgeries than Paracetamol and Nalbuphine.

External validation of the age, creatinine and ejection fraction II score for operative mortality prediction in patients undergoing coronary artery bypass graft surgery

Abstract Introduction Age, creatinine, and ejection fraction (ACEF) score is a parsimonious risk model to predict operative mortality in elective cardiac surgery patients. In 2017, the ACEF score was updated to the ACEF II score by adding pre-operative anemia and emergency surgery. The ACEF II score was well-calibrated and had excellent discrimination similar to the euroSCORE II. The score has never been validated in Asian patients. Therefore, we aimed to externally validate the ACEF II score in patients undergoing coronary artery bypass graft in our hospital. Method We retrospectively studied patients who underwent CABG in our hospital. Patients who received non-coronary cardiac surgery during CABG were included in the study. Patients who had missing variables in the ACEF II score calculation were excluded. Due to low number of emergency CABG in our center, urgent surgery was used instead of emergency surgery in the score calculation. Urgent surgery was defined as an operation required during the admission for a reason other than elective surgery. For instance, if CABG was performed during the index admission for MI, the procedure was counted as urgent. The primary outcome was operative mortality (in-hospital mortality or mortality within 30 days after surgery). Discrimination and calibration were assessed. The predictive performance of the ACEF II score was compared with the ACEF score. The reclassification index and clinical utility of the two scores were assessed. Results Of 703 patients included in the study, 182 were female (25.9%), 32% had diabetes with a mean age of 63.8 years. Median creatinine was 1.43 mg/dL, while the median left ventricular ejection fraction was 51.7%. The proportion of urgent CABG was 12.7%. Isolated CABG was performed in 542 patients. The operative mortality was 5.4%. The predicted probability of operative mortality by the ACEF and the ACEF II score was 4.6% and 8.3%, respectively. Calibration-in-the-large of the ACEF score was 0.19 (95% CI −0.16 to 0.55) while it was −0.62 (95% CI −0.99 to −0.24) for the ACEF II score. The ACEF and ACEF II scores had calibration slope of 0.20 (95% CI −0.01 to 0.42) and 0.33 (95% CI 0.13 to 0.53), respectively. After logistic recalibration, the agreement between actual and predicted mortality from the ACEF II score was better than the ACEF score. C-statistic of the ACEF and the ACEF II score was 0.63 (95% CI 0.54–0.71) and 0.63 (95% CI 0.53–0.72), respectively. Compared with the ACEF score, the net reclassification improvement of the ACEF II score was 8.87% [95% CI −0.95 to 18.7%], p-value: 0.0767. The integrated discrimination index of the ACEF II score was higher than the ACEF score (7.46%, 95% CI 0.77–14.16%, p-value 0.0290). Decision curve analysis showed that the clinical utility of both scores was similar. Conclusion Although the discrimination and calibration of the ACEF II score were better than the ACEF score, clinical utility of both scores was similar. Funding Acknowledgement Type of funding sources: None.

Pulse Wave Analysis Using the Pressure Recording Analytical Method to Measure Cardiac Output in Pediatric Cardiac Surgery Patients: A Method Comparison Study Using Transesophageal Doppler Echocardiography as Reference Method.

Cardiac output (CO) is a key determinant of oxygen delivery, but choosing the optimal method to obtain CO in pediatric patients remains challenging. The pressure recording analytical method (PRAM), implemented in the MostCareUp system (Vygon), is an invasive uncalibrated pulse wave analysis (PWA) method to measure CO. The objective of this study is to compare CO measured by PRAM (PRAM-CO; test method) with CO simultaneously measured by transesophageal Doppler echocardiography (TEE-CO; reference method) in pediatric patients. In this prospective observational method comparison study, PRAM-CO and TEE-CO were assessed in pediatric elective cardiac surgery patients at 2 time points: after anesthesia induction and after surgery. The study was performed in a German university medical center from March 2019 to March 2020. We included pediatric patients scheduled for elective cardiac surgery with arterial catheter and TEE monitoring. PRAM-CO and TEE-CO were compared using Bland-Altman analysis accounting for repeated measurements per subject, and the percentage error (PE). We included 52 PRAM-CO and TEE-CO measurement pairs of 30 patients in the final analysis. Mean ± SD TEE-CO was 2.15 ± 1.31 L/min (range 0.55-6.07 L/min), and mean PRAM-CO was 2.21 ± 1.38 L/min (range 0.55-5.90 L/min). The mean of the differences between TEE-CO and PRAM-CO was -0.06 ±0.38 L/min with 95% limits of agreement (LOA) of 0.69 (95% confidence interval [CI], 0.53-0.82 L/min) to -0.80 L/min (95% CI, -1.00 to -0.57 L/min). The resulting PE was 34% (95% CI, 27%-41%). With a PE of <45%, PRAM-CO shows clinically acceptable agreement with TEE-CO in hemodynamically stable pediatric patients before and after cardiac surgery.

Randomised open-label trial comparing intravenous iron and an erythropoiesis-stimulating agent versus oral iron to treat preoperative anaemia in cardiac surgery (INITIATE trial)

BackgroundPreoperative anaemia is a risk factor for adverse postoperative outcomes after cardiac surgery. Iron deficiency is a frequent cause of low preoperative haemoglobin. An effective treatment for preoperative anaemia associated with iron deficiency has not been determined. MethodsWe conducted a single-centre, open-label, pragmatic randomised trial, enrolling 156 elective cardiac surgery patients who had low preoperative haemoglobin (100–130 g L−1) with iron deficiency (serum ferritin <100 μg L−1 or transferrin saturation <30%) to compare intravenous ferric derisomaltose 1000 mg and darbepoetin 200 μg subcutaneously (intervention group) with oral ferrous sulphate 600 mg daily (control group). The primary outcome was transfusion of at least one unit of allogeneic red cells during surgery and within the following 5 days. Secondary outcomes included the change in haemoglobin concentration between randomisation and surgery, red cell transfusion volume, postoperative blood loss, pre-specified postoperative complications, length of hospital stay, and in-hospital death. ResultsThe odds of red cell transfusion were lower in the intervention group compared with the control group (adjusted odds ratio=0.33; 95% confidence interval [CI], 0.15–0.75; P=0.008). Of the secondary outcomes, the only significant difference was the increase in haemoglobin between randomisation and surgery, intervention vs control 9.5 g L−1 (95% CI, 6.8–12.2; P<0.001). ConclusionsIn patients with a low preoperative haemoglobin and iron deficiency, preoperative treatment with a single dose of ferric derisomaltose and darbepoetin decreased the proportion of participants who received a perioperative blood transfusion as a consequence of a greater increase in haemoglobin compared with treatment with oral ferrous sulphate. Clinical trial registrationISRCTN Number: 41421863; EUDRACT number: 2011-003695-36.

Serum biomarkers of brain injury after uncomplicated cardiac surgery: Secondary analysis from a randomized trial.

BackgroundPostoperative cognitive dysfunction is common after cardiac surgery. Postoperative measurements of brain injury biomarkers may identify brain damage and predict cognitive dysfunction. We describe the release patterns of five brain injury markers in serum and plasma after uncomplicated cardiac surgery.MethodsSixty‐one elective cardiac surgery patients were randomized to undergo surgery with either a dextran‐based prime or a crystalloid prime. Blood samples were taken immediately before surgery, and 2 and 24 h after surgery. Concentrations of the brain injury biomarkers S100B, glial fibrillary acidic protein (GFAP), tau, neurofilament light (NfL) and neuron‐specific enolase (NSE)) and the blood–brain barrier injury marker β‐trace protein were analyzed. Concentrations of brain injury biomarkers were correlated to patients’ age, operation time, and degree of hemolysis.ResultsNo significant difference in brain injury biomarkers was observed between the prime groups. All brain injury biomarkers increased significantly after surgery (tau +456% (25th–75th percentile 327%−702%), NfL +57% (28%−87%), S100B +1145% (783%−2158%), GFAP +17% (−3%−43%), NSE +168% (106%−228%), while β‐trace protein was reduced (−11% (−17−3%). Tau, S100B, and NSE peaked at 2h, NfL and GFAP at 24 h. Postoperative concentrations of brain injury markers correlated to age, operation time, and/or hemolysis.ConclusionUncomplicated cardiac surgery with cardiopulmonary bypass is associated with an increase in serum/plasma levels of all the studied injury markers, without signs of blood–brain barrier injury. The biomarkers differ markedly in their levels of release and time course. Further investigations are required to study associations between perioperative release of biomarkers, postoperative cognitive function and clinical outcome.

Perioperative Continuous Noninvasive Cardiac Output Monitoring in Cardiac Surgery Patients by a Novel Capnodynamic Method

To test the clinical performance of a novel continuous noninvasive cardiac output (CO) monitoring based on expired carbon dioxide kinetics in cardiac surgery patients. A prospective feasibility pragmatic clinical study. A single-center, large community hospital. Thirty-two patients undergoing cardiac surgery were studied during the intraoperative (before cardiopulmonary bypass) and postoperative (in the intensive care unit before extubation) periods. CO was measured simultaneously by the continuous capnodynamic method and by transpulmonary thermodilution during changes in the patient's hemodynamic and/or respiratory conditions. The current recommended comparative statistics for CO measurement methods were analyzed, including bias, precision, and percentage error obtained from Bland-Altman analysis, and concordance between methods obtained from the four-quadrant plot analysis to evaluate the trending ability. Bias ± limits of agreement and percentage error were -0.6 (-1.9 to +0.8; 95% CI of 3.73-5.25) L/min and 31% (n=147 measurements) for the intraoperative period, -0.8 (-2.4 to +0.9; 95% CI of 3.03-5.21) L/min and 41% (n=66) for the postoperative period, and -0.6 (-2.1 to +0.8; 95% CI of 3.74-5.00) L/min and 34% (n=213) for the pooled data. The trending analysis obtained a concordance of 82% (n=65) for the intraoperative and 71% (n=24) for the early postoperative periods. Aggregation of both data sets gave a concordance of 79% (n=89). The continuous capnodynamic method was reliable and in good agreement with the reference method, and had an accuracy and trending ability good enough tomake it a possible future alternative for hemodynamic monitoring in the studied population of elective adult cardiac surgery patients.

Acute Kidney Injury in Cardiac Surgery with Cardiopulmonary Bypass

Changes in classification criteria and active introduction of biomarkers of acute kidney injury (KDIGO, 2012) are changing approaches to diagnosis and treatment of postoperative renal dysfunction including cardiac surgery patients operated with cardiopulmonary bypass (CPB). The objective: to compare the detection rate of AKI after surgery with CPB with the use of biomarkers and kidney disease improving global outcomes criteria, as well as to evaluate the cause and localization of structural changes of the nephron.Subjects and Methods. A monocenter observational study among elective cardiac surgery patients (n = 97) was conducted. Inclusion criteria: age over 18 years, duration of surgery (coronary bypass surgery, prosthetic heart valves) from 90 to 180 minutes, no signs of end stage kidney disease. AKI was diagnosed based on changes in serum creatinine and biomarkers (NGAL, IgG, albumin in urine). The studied parameters were recorded 15 minutes after the start and end of anesthesia, as well as 24 and 48 hours after surgery. Retrospectively, the group was divided into three subgroups: 1) patients without AKI after surgery; 2) patients in whom signs of AKI were detected after 24 hours but regressed by the 48th hour; 3) patients in whom AKI persisted during all 48 hours of follow-up.Results. 24 hours after surgery, AKI based on KDIGO criteria was recorded in 56.3% of patients. Using biomarkers, signs of tubular damage (NGAL) at the end of anesthesia were detected in 95.9% of patients; after 24 hours, they were registered in 73.2% of cases. In a subgroup where AKI persisted for more than 24 hours, glomeruli were damaged in addition to tubules which was manifested not only by selective but also by non-selective proteinuria. The duration of CPB, hemodilution (Hb &lt; 90 g/l), the release of free hemoglobin in the blood (&gt; 1.5 mg/l) at low (&lt; 1 g/l) values of haptoglobin were significantly associated with AKI development.Conclusion. The KDIGO criteria do not allow detecting a subclinical form of renal dysfunction which may occur in about 40% of patients after surgery with CPB. AKI can be caused by damage to both the tubular part of the nephron and glomeruli in cases of prolonged CPB with the development of hemolysis, the release of free hemoglobin in the blood, and persisting anemia at the end of the surgery. The NGAL assessment makes it possible to detect subclinical kidney injury in the absence of elevated serum creatinine levels.