Heart Surgery Unit Research Articles

Cardiac surgery during the COVID-19 pandemic.

The COVID-19 pandemic had several specific as well as general implications on cardiac surgery. Acute respiratory distress made extracorporeal oxygenation necessary in asignificant number of patients and accordingly many patients were treated in anesthesiological and even more in cardiac surgical intensive care units, which left only alimited number of beds in the intensive care units available for elective surgery cases. Moreover, the necessary availability of intensive care beds for severely diseased COVID-19 patients in general posed afurther limit, as did the relevant number of diseased personnel. Specific emergency plans were developed for many heart surgery units, limiting the number of elective cases. Increasing waiting lists were of course stressful for numerous elective-surgery patients and the decreased number of heart operations also meant afinancial burden for many units.

The Effect of Acupressure on Severity of Pain and Level of Anxiety for Patients Post Coronary Artery Bypass Graft

Background: Experiencing moderate to severe anxiety and pain are common symptoms after cardiac surgery, which is very challenging to treat with medical treatment. Acupressure is promising because it’s nonpharmacologic, has no apparent side effects, and has been used to improve postoperative outcomes. Aim of this study: This study aimed to evaluate the effect of acupressure on severity of pain and level of anxiety for patients post coronary artery bypass graft. Design: Quasi-experimental research design was used to achieve the aim of this study. Setting: This study was conducted at open heart surgery unit at Misr University for Science and Technology hospital and at Academic Institute for Heart Surgery Ain Shams University hospital. Subjects: A Purposive sample of 80 adult patients was included in the study. Tools: Three tools were used; structured interviewing questionnaire, Numerical scale of pain and State Trait Anxiety Inventory. Results: the 85% and 67.5% of the study group had severe pain and anxiety pre acupressure intervention compared to only 7.5% and 15% of them post intervention, while, about 75% of the control group had severe pain and anxiety pre intervention compared to 52.5% and 65% of them post intervention. There was high statistically significant difference between both groups regarding pain severity and anxiety level pre to post acupressure intervention. Conclusion: The study concluded that acupressure had a positive effect on reduction of severity of pain and level of anxiety post coronary artery bypass graft. Recommendations: It is recommended that nurses should consider using acupressure as an effective technique for pain and anxiety management in addition to drug therapy.

Myocardial revascularization surgery: short and long-term survival analysis

This study sets out to describe the survival and clinical evolution of patients who undergo myocardial re-vascularisation surgery, and identifies the short- and long-term predictive factors for surgical outcomes. Study of a cohort of 175 patients undergoing pure or mixed coronary myocardial revascularisation surgery at a heart surgery unit, recruited between 2008 and 2010 and monitored for ten years. Descriptive and logistic regression (OR and 95%CI) analysis were carried out, along with an analysis of survival by Kaplan Meier and Cox uni- and multivariate regression (HR and 95%CI) in the short- (one year) and long-term (ten years). Predominantly male cohort (85.1%), mean age of 67 years (45-84), and mean EuroSCORE of 5.3%. Mortality was 6.8 and 26.9% at 1 and 10 years, respectively. Mean survival of deceased individuals was 40 months (32.2-47.8). In the short-term, a better NYHA =III preoperative functional level was not significantly associated with lower mortality (OR: 0.11; 95%CI: 0.01-1.08; p=0.058), while being female (OR: 2.94; 95%CI: 1.01-8.57; p=0.048) and having a EuroSCORE of >4% (OR: 4.94; 95%CI: 1.52-16.10; p=0.008) showed an increased risk of presenting adverse cardiac events. In the long-term, greater age (HR: 1.06; 95%CI: 1.01-1.10; p=0.026) and lower rates of body mass index after the first postoperative year (HR: 0.90; 95%CI: 0.81-0.99; p=0.040) were independent predictors of mortality. Age was an independent predictor of long-term mortality, while being female and a EuroSCORE >4% were associated with a higher risk of suffering from short-term cardiovascular events.

176-08: Break of circular catheter stuck in a right-inferior pulmonary vein during cryoballon pulmonary vein isolation

Case Report: We report a fifty-year-old male with paroxysmal atrial fibrillation presenting with EHRA III symptoms who underwent pulmonary vein isolation (PVI). The PVI was planned with a 28mm cryoballon under deep sedation. After uncomplicated transseptal puncture, angiography of the left atrium (LA) was done showing four independent pulmonary veins (PV). Heparin was given to maintain an activated clotting time of >300s. Following successful left PV isolation, the circular diagnostic catheter (CDC) was advanced in the right inferior PV (RIPV) and one successful freeze was delivered. After thawing of the cryoballon, it turned out not to be possible to remove the CDC from the RIPV. The fluoroscopy showed that the CDC was stuck in a small branch of the RIPV. While pulling the CDC the patient started to cough. The surrounding lung tissues seemed to be tightened and dragged together with the CDC. While turning the CDC, the shaft of the CDC broke close to the holder of the steerable sheath. With use of the remaining shaft, we further tried to remove the CDC from the PV, however, the CDC was again completely torn from the base of the circular part in the branch of RIPV. We then removed the proximal shaft and isolated the superior right PV with one freeze using a newly unpacked CDC. Final LA angiography demonstrated neither obstructions of major PVs nor exit of contrast agent out of LA, although the circular part of the CDC remained in the small branch of RIPV. After the procedure the patient showed no complaints such as cough, dyspnea or other symptoms. A pericardial effusion was also excluded. Discussion: Due to the tying in a small branch of the RIPV the CDC was stuck and we could not recover the catheter anymore. No practical way to resolve this situation has been described yet. Further catheter pulling was not an option due to the risk of a fatal bleeding because the surrounding lung tissue was tied. Another option could be an open-heart surgery. As the remaining part of the catheter did not move at all, we decided to leave the remaining circular part after a consultation with heart surgery unit. After a follow-up of one month the patient showed neither AF event nor clinical symptoms such as cough, dyspnea. We here reported a break of the CDC shaft during PVI with cryoballoon, which has been not yet reported.

Nurses in post-operative heart surgery: professional competencies and organization strategies.

To analyze nurses' competencies with regard to their work in post-operative heart surgery and the strategies implemented to mobilize these competencies. This was an exploratory study with a qualitative approach and a methodological design of collective case study. It was carried out in three post-operative heart surgery units, consisting of 18 nurses. Direct observation and semi-structured interviews were employed to collect data. Data were construed through thematic analysis. nine competencies were found, as follows: theoretical-practical knowledge; high-complexity nursing care; nursing supervision; leadership in nursing; decision making; conflict management; personnel management; material and financial resources management; and on-job continued education. Organizational and individual strategies were employed to develop and improve competencies such as regular offerings of courses and lectures, in addition to the individual pursuit for knowledge and improvement. the study is expected to lead future nurses and training centers to evaluate the need for furthur training required to work in cardiac units, and also the need for implementing programs aimed at developing the competencies of these professionals. Analisar as competências dos enfermeiros para atuarem no pós-operatório de cirurgia cardíaca e estratégias implementadas para a mobilização dessas competências. Estudo exploratório, com abordagem qualitativa e desenho metodológico estudo de caso coletivo. Foi realizado em três unidades pós-operatórias de cirurgias cardíacas, com 18 enfermeiros. Na coleta de dados utilizou-se observação direta e entrevista semiestruturada. Para interpretação dos dados optou-se pela análise temática. Foram identificadas nove competências, sendo: conhecimento teórico-prático, cuidados de enfermagem de alta complexidade, supervisão e liderança em enfermagem, tomada de decisão, gerenciamento de conflitos, de recursos humanos, materiais, financeiros e educação continuada em serviço. Estratégias organizacionais e individuais são realizadas a fim de desenvolver e aprimorar competências, tais como: oferecimento de cursos e palestras periodicamente, além da busca individual por conhecimento e aperfeiçoamento. O estudo deve provocar a reflexão de futuros enfermeiros e dos centros formadores quanto à formação necessária para atuar em unidades cardíacas e sobre a necessidade de implementação de programas que visam desenvolver competências nestes profissionais.

Child’s Congenital Heart Diseases: A Follow-Up of 101 Cases at Charles De Gaulle Pediatric Teaching Hospital (CDG-PTH) of Ouagadougou

Introduction: The management of congenital heart diseases in countries with limited technical facilities poses real problems to practitioners. Yet, a good medical follow- up permits to improve these children’s life quality before any eventual surgery. Our study aims at examining the evolutionary and prognostic aspects of these congenital heart diseases in order to understand their evolution in our context. Materials and Methods: Our work is a continuation of a prospective, transversal and descriptive survey concerning all the children with congenital heart diseases in hospitalization or in consultation led from January 1st 2012 to December 31st 2012 in the Charles De Gaulle Center Pediatric Teaching Hospital (CDG-PTH) in Ouagadougou. Results: In 2012, we kept under observation 101 cases of congenital heart diseases representing 69.18% of the 146 cases of heart diseases with an impact of 0.79% of the 12,838 patients who were admitted at CDG-PTH. The interventricular septal defect occupied the first place of all malformative heart diseases with 43.56% of cases. The average age of patients at the moment of the diagnosis was 17 months old with extremes ranging from two (2) days old to fifteen (15) years old. The sex-ratio was 1.06. Throughout the follow-up of the children until the end of the six months’ survey, it was possible for us to meet again 52 patients, we had no longer been in touch with 22 patients and 27 were dead. At the moment of the diagnosis, surgical treatment was recommended for 63.37% of the patients (64 cases) and only 7.81% (5 cases) were operated. The complicated cases were: Eisenmenger syndrome (6 cases representing 5.94%). We recorded a rate of 26.73% of death. Conclusion: Congenital heart diseases are relatively common at CDG-PTH. The high rate of mortality noticed is due to the lack of heart surgery and catheterism units in our country.

Using Value-Based Analysis to Influence Outcomes in Complex Surgical Systems

Value-based analysis (VBA) is a management strategy used to determine changes in value (quality/cost) when a usual practice (UP) is replaced by a best practice (BP). Previously validated in clinical initiatives, its usefulness in complex systems is unknown. To answer this question, we used VBA to correct deficiencies in cardiac surgery at Memorial Healthcare System. Cardiac surgery is a complex surgical system that lends itself to VBA because outcomes metrics provided by the Society of Thoracic Surgeons provide an estimate of quality; cost is available from Centers for Medicare and Medicaid Services and other contemporary sources; the UP can be determined; and the best practice can be established. Analysis of the UP at Memorial Healthcare System revealed considerable deficiencies in selection of patients for surgery; the surgery itself, including choice of procedure and outcomes; after care; follow-up; and control of expenditures. To correct these deficiencies, each UP was replaced with a BP. Changes included replacement of most of the cardiac surgeons; conversion to an employed physician model; restructuring of a heart surgery unit; recruitment of cardiac anesthesiologists; introduction of an interactive educational program; eliminating unsafe practices; and reducing cost. There was a significant (p < 0.01) reduction in readmissions, complications, and mortality between 2009 and 2013. Memorial Healthcare System was only 1 of 17 (1.7%) database participants (n = 1,009) to achieve a Society of Thoracic Surgeons 3-star rating in all 3 measured categories. Despite substantial improvements in quality, the cost per case and the length of stay declined. These changes created a savings opportunity of $14 million, with actual savings of $10.4 million. These findings suggest that VBA can be a powerful tool to enhance value (quality/cost) in a complex surgical system.

Sex differences in congenital heart defects and genetically induced arrhythmias

Sex medicine can be applied to define the effect of male or female sex-associated differences on the prevalence of congenital heart defects (CHDs), on clinical manifestation of the latter, on means of dealing with the defects and facing consequent surgical treatment, as well as on the success of surgery. The widespread use of modern databases has undoubtedly enhanced the possibility of these observations compared to the past, when findings were limited to case series from single cardiology or paediatric heart surgery units. The aim of the present review is to assess all publications present in the literature on sex differences and CHD, placing particular emphasis on both contradictory aspects and less acknowledged issues. Furthermore, a section of the review is devoted to the effect of sex differences on cardiac arrhythmias, particularly the largely genetically predetermined electrophysiological differences observed between men and women.

Atrioventricular block in coronary artery bypass surgery: perioperative predictors and impact on mortality.

IntroductionDisturbances of the cardiac conduction system are frequent in the postoperative period of coronary artery bypass surgery. They are mostly reversible and associated with some injury of the conduction tissue, caused by the ischemic heart disease itself or by perioperative factors.ObjectivePrimary: investigate the association between perioperative factors and the emergence of atrioventricular block in the postoperative period of coronary artery bypass surgery. Secondary: determine the need for temporary pacing and of a permanent pacemaker in the postoperative period of coronary artery bypass surgery and the impact on hospital stay and hospital mortality.MethodsAnalysis of a retrospective cohort of patients submitted to coronary artery bypass surgery from the database of the Postoperative Heart Surgery Unit of the Sao Lucas Hospital of the Pontifical Catholic University of Rio Grande do Sul, using the logistic regression method.ResultsIn the period from January 1996 to December 2012, 3532 coronary artery bypass surgery were carried out. Two hundred and eighty-eight (8.15% of the total sample) patients had atrioventricular block during the postoperative period of coronary artery bypass surgery, requiring temporary pacing. Eight of those who had atrioventricular block progressed to implantation of a permanent pacemaker (0.23% of the total sample). Multivariate analysis revealed a significant association of atrioventricular block with age above 60 years (OR=2.34; CI 95% 1.75-3.12; P<0.0001), female gender (OR=1.37; CI 95% 1.06-1.77; P=0.015), chronic kidney disease (OR=2.05; CI 95% 1.49-2.81; P<0.0001), atrial fibrillation (OR=2.06; CI 95% 1.16-3.66; P=0.014), functional class III and IV of the New York Heart Association (OR=1.43; CI 95% 1.03-1.98; P=0.031), perioperative acute myocardial infarction (OR=1.70; CI 95% 1.26-2.29; P<0.0001) and with the use of the intra-aortic balloon in the postoperative period of coronary artery bypass surgery (OR=1.92; CI 95% 1.21-3.05; P=0.006). The presence of atrioventricular block resulted in a significant increase in mortality (17.9% vs. 7.3% in those who did not develop atrioventricular block) (OR=2.09; CI 95% 1.46-2.99; P<0.0001) and a longer hospital stay (12.75 days x 10.53 days for those who didn't develop atrioventricular block) (OR=1.01; CI 95% 1.00-1.02; P=0.01).ConclusionsIn most cases, atrioventricular block in the postoperative period of coronary artery bypass surgery is transient and associated with several perioperative factors: age above 60 years, female sex, chronic kidney disease, atrial fibrillation, New York Heart Association functional class III or IV, perioperative acute myocardial infarction and use of an intra-aortic balloon. Its occurrence prolongs hospitalization and, above all, doubles the risk of mortality.

Children’s heart surgery unit in Leeds wins legal battle

Children’s heart surgery unit in Leeds wins legal battle

Evolution of coronary artery bypass graft techniques

The results of coronary surgical revascularization are constantly improving despite the worsening of patient's risk profiles. Nowadays this procedure represents the gold standard for patients with multivessel disease or critical left main stenosis, according to European and American guidelines. Recent data show that these guidelines are poorly implemented in the "real world". Different reasons can explain this phenomenon, among these, the invasiveness and morbidity of surgical procedures, which determine low acceptance rates by the patients. In recent years, several procedures have been developed in order to improve surgical therapy; the most promising include complete arterial revascularization, the "no-touch aorta technique", mini-invasive techniques, improvement of biocompatibility of extracorporeal circulation, and hybrid revascularization. Although these procedures still need statistical evidence, some data support their use in specific patient subsets. If these trends will be confirmed, it will be possible to choose the best surgical strategy for each individual patient. At present, there are no data suggesting the best choice between on-pump and off-pump techniques; there are indications to use arterial conduits in young patients, whereas the no-touch aorta technique, which seems to reduce cerebrovascular complications, requires further statistical confirmation; the mini-invasive and hybrid approaches need additional data to confirm their effectiveness. This accounts for the great variability among centers regarding the strategies of myocardial revascularization, often restricted to few techniques. In our opinion, nowadays, every heart surgery unit should offer all of these modern techniques. In order to decide for the best treatment between medical, surgical and percutaneous therapies, the creation of a Heart Team has been demonstrated to be effective. All components of the Heart Team should be familiar not only with the use of anatomical and clinical risk scores, but they should also know the main aspects of each therapeutic option along with their availability. This condition is fundamental in order to discuss and set up the best surgical option for each patient, and consequently improve quality of treatment and clinical outcome. In order to suggest the best therapy to the patient, the Heart Team should take into consideration the guideline recommendations and available operative setting within the cardiac unit.

Molecular Epidemiology of Aspergillus fumigatus: an In-Depth Genotypic Analysis of Isolates Involved in an Outbreak of Invasive Aspergillosis

We recently reported an outbreak of invasive aspergillosis in the major heart surgery unit of Hospital Gregorio Marañón, Madrid, Spain (T. Peláez, P. Muñoz, J. Guinea, M. Valerio, M. Giannella, C. H. W. Klaassen, and E. Bouza, Clin. Infect. Dis., in press). Aspergillus fumigatus was isolated from clinical samples from 10 patients admitted to the unit during the outbreak period (surgical wound invasive aspergillosis, n = 2; probable pulmonary invasive aspergillosis, n = 4; colonization, n = 4). In the study described here, we have studied the genotypic diversity of the A. fumigatus isolates found in the air and clinical samples. We used short tandem repeats of A. fumigatus (STRAf) typing to analyze the genotypes found in the 168 available A. fumigatus isolates collected from the clinical samples (n = 109) from the patients and from the environmental samples taken from the air of the unit (n = 59). The genotypic variability of A. fumigatus was higher in environmental than in clinical samples. Intrasample variability was also higher in environmental than in clinical samples: 2 or more different genotypes were found in 26% and 89% of clinical and environmental samples, respectively. We found matches between environmental and clinical isolates in 3 of the 10 patients: 1 patient with postsurgical invasive aspergillosis and 2 patients with probable pulmonary invasive aspergillosis. A total of 7 genotypes from 3 different patients and the air grouped together in 2 clusters. Clonally related genotypes and microvariants were detected in both clinical and environmental samples. STRAf typing proved to be a valuable tool for identifying the source of invasive aspergillosis outbreaks and for studying the genotypic diversity of clinical and environmental A. fumigatus isolates.

Calls to merge heart surgery units with specialist centres

The RCN supports having fewer centres with more staff

Calls to merge heart surgery units with specialist centres

Calls to merge heart surgery units with specialist centres

Infective endocarditis at a hospital in Saudi Arabia: epidemiology, bacterial pathogens and outcome

BACKGROUND AND OBJECTIVE:Data on infective endocarditis prevalence, epidemiology and etiology from Saudi Arabia and the Gulf region are sparse. We undertook this study to describe the pattern and the causative agents of endocarditis at a hospital in Saudi Arabia.METHODS:We conducted a retrospective analysis of all reported endocarditis cases at the Dhahran Health Center from January 1995 to December 2008.RESULTS:Of the 83 cases of endocarditis, 54 (65%) were definite endocarditis and the remaining 29 (35%) were possible endocarditis based on the Duke criteria. Patients with definite endocarditis included 39 males and 15 females (ratio of 2.6:1) with a mean age (SD) of 59.7 (18.2) years. Of the definite endocarditis cases, native valve endocarditis occurred in 44 (81.5%) cases of and prosthetic valve endocarditis was observed in 10 (18.5%). The most commonly involved valves were mitral (n=24; 44.4%) and aortic (n=20; 39.2%). The most common organisms were S aureus (n=23; 42.6%), Enterococcus faecalis (n=12; 22.2%) and viridans streptococci (n=9; 16.7%). Surgical intervention was required in 17 (31.4%) cases and the in-hospital mortality rate was 29.4% (n=15). Of all the patients, 3 (5.5%) had embolic stroke as a complication.CONCLUSION:Native valve endocarditis is the predominant type of endocarditis. The patients were older adults and the most common organisms were S aureus, E faecalis and viridans streptococci.

Carga de trabalho de enfermagem para quantificar proporção profissional de enfermagem/paciente em UTI cardiológica

Trata-se de estudo descritivo, cujos objetivos foram comparar a carga de trabalho de enfermagem em unidade de pós-operatório de cirurgia cardíaca indicada pelo NAS, TISS-28 e NEMS, e também verificara proporção profissional de enfermagem por paciente existente na unidade e a proporção necessária, segundo os índices utilizados. Os dados foram coletados em um hospital-escola de outubro a novembro de 2004. A amostra, constituída de 55 pacientes, totalizou 283 medidas de carga de trabalho. A carga de trabalho mensurada pelo NAS (73,7%) foi estatisticamente superior ao do TISS-28 (62,2%) e ao do NEMS (59,7%). A proporção média de profissionais de enfermagem por paciente, estimada pelo NAS (1,0:1), TISS-28 (0,8:1) e NEMS (0,8:1) foi inferior ao observado na unidade (1,2:1). Concluiu-se que o NAS quantificou maior carga de trabalho de enfermagem e apresentou uma relação profissional de enfermagem por paciente mais próxima ao observado na unidade estudada.

Invited commentary

Invited commentary

R2247 Adherence to surgical site infection guidelines in Italian heart surgery units

R2247 Adherence to surgical site infection guidelines in Italian heart surgery units

Heart Failure in Children - Mechanical Assistance

The use of mechanical circulatory support for the treatment of heart failure in the pediatric population has become increasingly important in pediatric heart surgery units; however, the treatment options for the pediatric population have not attained the same level of technological development as we have seen for the adult population. The use of mechanical assistance as a bridge to transplantation or a bridge to recovery are the main indications for mechanical circulatory support in infants and children. The problem of organ donor shortage is even worse compared to the situation in the field of adult heart transplantations. Especially in Europe however, newly developed pulsatile, paracorporeal ventricular assist devices designed for long-term assist in children have demonstrated their ability to provide excellent results beyond the abilities of extracorporeal membrane oxygenation and centrifugal pumps, which are still the mainstay of mechanical support in children worldwide. Especially in the group of the smallest patients, the use of the most appropriate form of circulatory assistance has to be carefully considered as the co-incidence of respiratory failure as well as other complex physiological situations will severely influence the outcome.

Outbreak of acute renal failure due to cefodizime-vancomycin association in a heart surgery unit.

To describe an outbreak of acute renal failure (ARF) occurring in a group of patients undergoing open-heart surgery, simultaneously to a change in perioperative antibiotic prophylaxis. Case series. A nine-bed heart surgery intensive care unit, serving a 1,300-bed University teaching hospital. Thirty-two patients undergoing open-heart surgery during an 11-day period, when the preoperative surgical prophylaxis protocol had been changed from the usual antibiotic association of ceftriaxone + vancomycin to cefodizime + vancomycin. ARF occurred in 16 of the 32 (50%) patients exposed to the new antibiotic prophylaxis regimen; seven patients had oliguric ARF, and nine patients had an increase in serum creatinine (SCr) levels >50% over 24-48 h. In the seven patients with oliguric ARF, SCr increased from a median preoperative level of 88 micromol/l (80-115 micromol/l) to a peak value of 725 micromol/l (521-857 micromol/l) in 5 days (4-6). Eight patients out of the sixteen with ARF (50%) were diabetics, as opposed to none of the 16 patients not experiencing ARF. Renal biopsy (three patients) showed tubular dilation and necrosis, interstitial edema, and lymphomononuclear infiltrate of moderate degree. Only one patient required hemodialysis, and all recovered renal function. No other cases of unexplained ARF occurred in the unit after the original prophylaxis protocol was resumed. The simultaneous infusion of cefodizime and vancomycin may involve a high risk of substantial renal function derangement, especially in diabetics.