Emergency Cardiac Operations Research Articles

Hemoadsorption of Rivaroxaban and Ticagrelor during Acute Type A Aortic Dissection Operations.

Objective: To analyze the results of hemoadsorption in patients with cardiac surgery to thoracic aortic surgery, who had been loaded beforehand with either Factor Xa inhibitor rivaroxaban or P2Y12 receptor antagonist ticagrelor.Methods: We investigated 21 of 171 consecutive patients (median age 71 [interquartile range 62, 76] years) who underwent emergency cardiac operations for acute type A aortic dissection between 2014 and 2020. These patients were pretreated with rivaroxaban (n = 9) or ticagrelor (n = 12). In ten of 21 cases (since 2017), we installed a hemoadsorber into the heart–lung machine and compared the results to eleven patients done without hemoadsorber before that time.Results: The operation time was significantly shorter in the adsorber group (286 ± 40 min vs. 348 ± 79 min; p = 0.045). The postoperative 24-hour drainage volume was significantly lower after adsorption (p <0.001; 482 ± 122 ml vs. 907 ± 427 ml) and no rethoracotomy had to be performed (compared to two rethoracotomies [18.9%] among patients without adsorber use). Also, patients without hemoadsorption required significantly more platelet transfusions (p = 0.049).Conclusions: In patients with acute type A aortic dissection who were pretreated with rivaroxaban and ticagrelor, the intraoperative use of CytoSorb hemoadsorption during cardiopulmonary bypass is reported for the first time. The method was found to be effective to prevent from bleeding and to improve the outcome in aortic dissection.

COVID-19 PANDEMIC EXPERIENCE IN THE UNITED KINGDOM – A NATIONAL SURVEY ABOUT CARDIAC CASES, WORK PATTERNS OF CARDIAC ANAESTHETISTS AND SUPPORT

IntroductionThe COVID-19 pandemic started in Hubei Province, China in 2019 with the first confirmed cases in the UK in January 2020. On May 21st 2020, there were 158,488 confirmed cases in England and Wales with 33,081 deaths in SARS-CoV-2 positive patients (1). From March 2020 onwards, emergency cardiac operations were prioritised and individual work patterns adjusted. The skill set of cardiac anaesthetists, often including an expertise in critical care medicine, extracorporeal membrane oxygenation and echocardiography, was useful for the multidisciplinary medical care of COVID-19 patients in critical care units. The aim of this survey was to assess individual cardiac anaesthetic experiences during the first wave of the COVID-19 pandemic in the UK.MethodsWe conducted a survey, supported by the Association for Cardiothoracic Anaesthesia and Critical Care (ACTACC). A 16-question survey related to the first UK COVID-19 surge in April and May 2020 was sent to the membership of ACTACC in 36 cardiac centres in July 2020. Data was collected and collated using the web-based survey platform “Survey Monkey” (Palo Alto, CA).ResultsThere were 80 completed responses, indicating a response rate of about 20%. The majority of anaesthetists continued cardiac anaesthesia with emergency cases (53%) and urgent cases (65%) only at their centres. Every 5th cardiac anaesthetist (22%) was re-deployed to a different unit in their hospital or to a different hospital. The clinical work pattern changed at least moderately for the majority of cardiac anaesthetists (86%). The majority of anaesthetists (90%) felt appropriately supported when they stepped outside of their usual clinical role during the pandemic and 95% felt that their existing skillset was appropriately used. The workload increased in a majority of cardiac anaesthetists (53%), but it also decreased for some (35%). Non-resident on-calls increased for about 1/3 (36%) of respondents and resident on-calls increased for 50% of cardiac anaesthetists. A majority of anaesthetists (85%) wore PPE during their clinical work and 95% felt that the supply of PPE was adequate. The most useful source of information during the pandemic was peer discussion, chosen by more than half of cardiac anaesthetists (54%).DiscussionThe results of this national survey for cardiac anaesthetists during the first COVID-19 wave in the UK demonstrate that work patterns for cardiac anaesthetists changed dramatically. These changes may have an effect on psychological wellbeing of cardiac anaesthetists (2). However, the majority of anaesthetists felt well supported in their clinical work. Peer discussions scored high as useful sources of information, suggesting that professional networks are crucial to both, personal wellbeing and good patient care. One limitation of this survey is a low response rate, with potentially more extreme experiences in the non-responder group, emphasising the importance of support measures and the challenge of gauging that they are effective.We conclude, that with subsequent COVID-19 peaks, there is a continued need to address potential effects of major changes of work patterns by cardiac anaesthetists on burnout, psychological wellbeing and resilience.

COVID-19 related mortality in post-operative cardiac surgical patients

BackgroundCOVID-19 has caused a global pandemic of unprecedented proportions. Elective cardiac surgery has been universally postponed with only urgent and emergency cardiac operations being performed. The National Health Service in the United Kingdom introduced national measures to conserve intensive care beds and significantly limit elective activity shortly after lockdown.Case presentationWe report two cases of early post-operative mortality secondary to COVID-19 infection immediately prior to the implementation of these widespread measures.ConclusionThe role of cardiac surgery in the presence of COVID-19 is still very unpredictable and further studies on both short term and long term outcomes are warranted.

Cytosorb Adsorption During Emergency Cardiac Operations in Patients at High Risk of Bleeding

The purpose of this study was to analyze the results of Cytosorb (CytoSorbents, Monmouth Junction, NJ) adsorption during emergency open heart operations in patients at high risk of bleeding due to treatment with coagulation-active substances. We investigated 55 consecutive patients (median age 70 years; interquartile range: 60 to 77) who underwent emergency cardiac surgery at our institution between June 2016 and June 2018. All patients were receiving therapy with either ticagrelor (n= 43) or rivaroxaban (n= 12). In 39 of 55 cases, we routinely installed standardized Cytosorb adsorption into the heart-lung machine. Bleeding complications during and after surgery were analyzed in detail and compared with 16 patients without adsorption. In the Cytosorb adsorption group, no rethoracotomies had to be performed. Drainage volumes in 24 hours were only 350 mL (interquartile range: 300 to 450 mL) after ticagrelor administration and 390 mL (interquartile range: 310 to 430 mL) after rivaroxaban therapy. In the majority of patients, transfusions of blood products were not needed. Compared with that group, among the group of patients without adsorption, multiple bleeding complications occurred. These were associated with longer total operation (p= 0.0042), higher drainage volumes (p= 0.0037), more transfusions of red blood cells (p= 0.0119) and platelets (p= 0.0475), a significantly higher rethoracotomy rate (p= 0.0003), significantly prolonged stay in the intensive care unit (p=0.0141), and a longer hospital stay (p= 0.0244). The intraoperative use of Cytosorb adsorption of ticagrelor and rivaroxaban in emergency open heart operations is reported for the first time. The data show that the strategy is safe and is an effective method to reduce bleeding complications. We recommend the use for safety in patients with ticagrelor or rivaroxaban undergoing emergency cardiac surgery.

Aortic Mispuncture during Routine Catheterization Requires Emergency Cardiac Operation

Transseptal puncture for left heart catheter or left atrial appendage occlusion is a highly standardized routine intervention in interventional cardiology. However, mispuncture is rare but can be life threatening at worst. Here, we report the case of a combined mispuncture of the right atrium and the ascending aorta resulting in a pericardial effusion with a hemodynamic effective tamponade requiring urgent cardiac operation for successful life saving.

Perioperative transoesophageal echocardiography: past, present &amp; future

Perioperative transoesophageal echocardiography: past, present &amp; future

An atrial-aortic malpuncture during routine transseptal cardiac catheterization required emergency cardiac operation: A case report

Introduction: Transseptal puncture for left heart catheter or atrial septal defect closure represents a highly standardized routine intervention in interventional cardiology. However, malpuncture is rare but can be life threatening. Here we report the case of a fatal malpuncture of the intraatrial septum resulting in a pericardial effusion with a haemodynamic effective tamponade requiring urgent cardiac operation for life saving.

Cardiac Surgery in Select Nonagenarians: Should We or Shouldn’t We?

Patients aged 90 years and older represent a rapidly growing subset of the population, many of whom are functionally limited by cardiovascular disease. Clinical decision making about cardiac surgical intervention in nonagenarians is hindered by a paucity of data examining survival outcomes in this population. A consecutive series of nonagenarians who underwent cardiac operations between 1995 and 2004 were retrospectively reviewed. Data collection included baseline preoperative clinical status, intraoperative characteristics, and perioperative course. Area under the Kaplan-Meier survival estimate method was used to calculate mean survival. Cardiac surgical procedures were done in 49 patients (51% male); their mean age was 91.9 years (range, 90 to 97 years). Operative mortality was 8% (n = 4). Multivariate Cox proportional hazards models found preoperative chronic renal insufficiency (hazard ratio [HR], 4.88; 95% confidence interval [CI], 1.53 to 15.55; p = 0.007) and ejection fraction (HR, 0.96; 95% CI, 0.93 to 1.00; p = 0.033) were independently associated with death. Overall mean survival was 5.1 +/- 0.5 years (median, 5.2 years). Quality of life outcomes were similar to that of two related norm-based populations based on age and disease process. Cardiac surgical procedures can be performed safely and with therapeutic benefit in carefully selected nonagenarians. We consider physiologic indicators, social factors, and patient preferences to be the main determinants in the patient selection process. Our results support the need for more proactive intervention in symptomatic nonagenarian patients as it relates to earlier consideration of elective, rather than emergency cardiac operations.

Successful removal of migrated acupuncture needles in a patient with cardiac tamponade by means of intraoperative transesophageal echocardiographic assistance

Clinical Summary A 49-year-old woman was admitted to our hospital after having chest pain and was then hospitalized 2 hours later after syncope. She had a history of recurrent episodes of pulmonary thromboembolism that arose from deep vein thrombosis. A Bird’s Nest filter (Cook Co, Leechburg, Pa) was implanted in her inferior vena cava for the prevention of embolism about 6 years ago. Four weeks before admission, she felt bilateral shoulder pain and subsequently received acupuncture treatments to relieve the pain. She was treated with acupuncture on her shoulder and upper back 2 hours before symptom onset. Her blood pressure was 70/48 mm Hg in the emergency department, where a transthoracic echocardiogram showed a large amount of pericardial effusion with tamponade features. After detecting fine and linear foreign material sized approximately 5 cm penetrating the interventricular septum and right ventricular wall (Figure 1, A), a pericardiocentesis was immediately performed. After draining about 600 mL of fresh blood from the pericardial cavity, blood pressure was normalized. The foreign material was seen in the fluoroscopic and computed tomographic examinations (Figure 1, B and C); however, there was no evidence of migration of Bird’s Nest filter (Cook Inc, Bloomington, Ind). The emergency cardiac operation was done to remove the foreign bodies with intraoperative transesophageal echocardiographic guidance (Sonos 2000; Hewlett-Packard Co, Andover, Mass) with a multiplane probe. The transesophageal echocardiogram showed a needle-shaped mass crossing the interventricular septum. After the pericardiectomy, the needle-shaped foreign material was seen penetrating the right ventricular wall and was removed successfully. Despite of the removal, an intraoperative transesophageal echocardiography revealed another needle-shaped foreign body crossing from the interventricular septum to the left ventricular cavity (Figure 2, A). After a cardiopulmonary bypass, her left atrium was opened, and the foreign body was successfully removed. The removed foreign bodies were thin, needle-shaped materials (Figure 2, B). The materials were proved to be acupuncture needles after a comprehensive analysis from the Department of Acupuncture, College of Oriental Medicine, Kyung Hee University and the Department of Biomedical Engineering, Inje University. She was discharged after the operation without any complication.

Feasibility of Simplifying Balloon Mitral Valvuloplasty by Obviating Left-Sided Cardiac Catheterization Using On-line Guidance With Transesophageal Echocardiography

The purpose of this study was to evaluate the feasibility of simplifying balloon mitral valvuloplasty through the obviation of left-sided cardiac catheterization using on-line guidance with transesophageal echocardiography in patients with mitral stenosis. A tertiary care medical center Patients who were eligible for balloon mitral valvuloplasty were enrolled into the study if they had no evidence of ischemic heart disease. Sixty-six patients (50 women and 16 men) met the criteria. Balloon mitral valvuloplasty was performed through right-sided cardiac catheterization using adjunctive on-line guidance with transesophageal echocardiography. Left-sided catheterization was obviated. Balloon mitral valvuloplasty was smoothly performed in all patients. Successful dilatation (postprocedural mitral orifice area, > 1.5 cm(2); or increment in mitral orifice area, >or= 50%) was achieved in 50 patients (75.8%). The mean (+/- SD) mitral orifice area increased from 1.08 +/- 0.23 cm(2) to 1.68 +/- 0.39 cm(2) (p = 0.0000). There were no in-hospital deaths, no patients with cardiac tamponade, or complications necessitating an emergency cardiac operation. The mean fluoroscopy time was 7.6 +/- 3.9 min, and the total procedure time was 50.2 +/- 15.0 min. It is feasible and safe to simplify balloon mitral valvuloplasty by obviating left-sided cardiac catheterization in selected patients with mitral stenosis using adjunctive on-line guidance with transesophageal echocardiography.

Cardiac Transplantation 40 Years After a Stab Wound to the Heart

Cardiac Transplantation 40 Years After a Stab Wound to the Heart

Abciximab and Excessive Bleeding in Patients Undergoing Emergency Cardiac Operations

Background. Abciximab (ReoPro; Eli Lilly and Co, Indianapolis, IN) is a monoclonal antibody that binds to the platelet glycoprotein IIb/IIIa receptor and produces powerful inhibition of platelet function. Clinical trials of abciximab in patients undergoing coronary angioplasty have demonstrated a reduction in thrombotic complications and have encouraged the widespread use of this agent. We have observed a substantial incidence of excessive bleeding among patients who receive abciximab and subsequently require emergency cardiac operations. Methods. The records of 11 consecutive patients who required emergency cardiac operations after administration of abciximab and failed angioplasty or stent placement were reviewed. Results. The interval from the cessation of abciximab administration to operation was critical in determining the degree of coagulopathy after cardiopulmonary bypass. The median values for postoperative chest drainage (1,300 versus 400 mL; p < 0.01), packed red blood cells transfused (6 versus 0 U; p = 0.02), platelets transfused (20 versus 0 packs; p = 0.02), and maximum activated clotting time (800 versus 528 seconds; p = 0.01) all were significantly greater in the early group (cardiac operation <12 hours after abciximab administration; n = 6) compared with the late (cardiac operation >12 hours after abciximab administration; n = 5) group. Conclusions. This report suggests that the antiplatelet agent abciximab is associated with substantial bleeding when it is administered within 12 hours of operation.

Management of Patients with Heparin-Associated Thrombocytopenia and Thrombosis Requiring Cardiac Surgery

Heparin-associated thrombocytopenia and thrombosis (HATT) is a serious complication of heparin therapy that results in intravascular platelet aggregation with arterial or venous thrombosis. Platelet aggregation to heparin in vitro is used to confirm the diagnosis. Cessation of heparin therapy with avoidance of reexposure to heparin is an important principle in the management of HATT. However, certain patients with HATT may require reexposure to heparin for emergency cardiac operations requiring cardiopulmonary bypass while still demonstrating positive in vitro platelet aggregation with heparin. The present report describes the management of 2 such patients. In each patient aspirin was shown to inhibit platelet aggregation to heparin in vitro; therefore, aspirin and dipyridamole were administered to each patient before heparin reexposure and continued throughout the perioperative period. Cardiopulmonary bypass with full heparinization was achieved without thrombotic or hemorrhagic complications in both patients. Despite the presence of a heparin-dependent platelet-aggregating factor in the plasma of these 2 patients, inhibition of platelet aggregation with aspirin and dipyridamole allowed uneventful reexposure to heparin.

AV-15 新生児・乳児早期における緊急心臓血管手術の検討

AV-15 新生児・乳児早期における緊急心臓血管手術の検討

AV-3 4ヵ月未満児の緊急心臓手術の検討

AV-3 4ヵ月未満児の緊急心臓手術の検討

AV-10 薪生児・乳児(1才未満)の緊急心臓手術例の検討

AV-10 薪生児・乳児(1才未満)の緊急心臓手術例の検討

Prostaglandin E1 as an Adjunct to Emergency Cardiac Operation in Neonates

DONAHOO, J. S.; ROLAND, J. M.; KAN, J.; GARDNER, T J.; KIDD, B. S. L. Author Information

Ruptured Interventricular Septum Complicating Acute Myocardial Infarction: Clinical Spectrum and Hemodynamic Evaluation with Rapid Bedside Cardiac Catheterization

Clinical, radiologic, hemodynamic, and autopsy correlations were obtained from five patients with acute rupture of the interventricular septum as a complication of myocardial infarction. In such cases, confirmation of the diagnosis and accurate quantification of the wide spectrum of the resulting left-to-right shunt are prerequisites when deciding between medical treatment and emergency cardiac operation. A Swan-Ganz flow-directed catheter enabled measurement of the shunt magnitude and simultaneous exclusion of papillary muscle dysfunction or rupture quickly at the bedside, with minimal inconvenience to the patient The shunt volume correlated with the rupture size at autopsy. Serious biventricular heart failure developed without exception. As a new hemodynamic finding, a patient with excessive volume overload may show signs similar to cardiac tamponade in the atrial pressure tracings. Systolic murmur characteristics were not related to the size of the shunt, but portable chest x-ray examination provided a semiquantitative clinical means of assessing the shunt size.