High-risk Cardiac Surgery Patients Research Articles

The first experience of the combined use of nitric oxide and molecular hydrogen for cardiac surgery in high-risk patients

The purpose of the study was to evaluate the effectiveness of myocardial protection with a combined supply of nitric oxide (NO) (40 ppm) and hydrogen (1.2 ppm) into the gas-air mixture delivery line of the cardiopulmonary bypass (CPB) machine during the entire period of CPB.Methods. The study included patients (n = 91) who had cardiac surgery under cardiopulmonary bypass and pharmacological cold cardioplegia. Patients were randomized into 3 groups. The Group 1 (n = 30) was control. Groups 2 (n = 28) and 3 (n = 33) received an isolated supply of NO (40 ppm) and a combined supply of NO (40 ppm) and hydrogen (1.2 ppm) into the extracorporeal IR circuit, respectively. During the postoperative period, clinical and functional indicators were studied (dynamics of myocardial contractile function according to ultrasound data); duration of artificial pulmonary ventilation (ALV); stay in the intensive care unit; hospital stay; mortality; level of marker of myocardial injury – troponin I (cTnI). Myocardial injury index (MII) was calculated to assess the degree of injury.Results. It was found that the level of cTnI in the postoperative period increased statistically significantly in all groups but was statistically significantly lower in Groups 2 and 3 compared to Group 1 at the end of the surgery and 12 and 24 hours after the surgery. Also, level of cTnI was statistically significantly lower in Group 3 at all stages of the study compared to Group 1 and after 12, 24 and 48 hours compared to Group 2. Statistically significantly lower MII values were revealed at all stages of the postoperative period in Group 3 compared with Groups 1 and 2. Changes in indicators of myocardial contractile function suggest an earlier and more complete recovery in Groups 2 and 3 (the changes were statistically significantly higher than that in Group 1). In Groups 2 and 3, the incidence of acute heart failure was statistically significantly lower (p = 0.046) compared to Group 1, according to Fisher’s exact test. There were no statistically significant differences in the incidence of acute respiratory and multiple organ failure in Groups 2 and 3 compared to Group 1. Also, patients of Groups 2 and 3 did not experience any complications in the early postoperative period. In Group 3, there was a statistically significant decrease in the duration of mechanical ventilation and stay in the intensive care unit after surgery compared to Group 2.Conclusion. Isolated supply of NO into the IR circuit has an additional cardioprotective effect, which is confirmed by statistically lower levels of troponin I and smaller changes in the indicators of myocardial contractile function during the postoperative period compared to standard technology. A more pronounced protective effect on the myocardium was shown with the combined supply of NO and molecular hydrogen to the IR circuit as seen by statistically lower levels of troponin I and MII in the postoperative period compared with the isolated supply of NO.

Identifying a target group for selenium supplementation in high-risk cardiac surgery: a secondary analysis of the SUSTAIN CSX trial

BackgroundRecent data from the randomized SUSTAIN CSX trial could not confirm clinical benefits from perioperative selenium treatment in high-risk cardiac surgery patients. Underlying reasons may involve inadequate biosynthesis of glutathione peroxidase (GPx3), which is a key mediator of selenium's antioxidant effects. This secondary analysis aimed to identify patients with an increase in GPx3 activity following selenium treatment. We hypothesize that these responders might benefit from perioperative selenium treatment.MethodsPatients were selected based on the availability of selenium biomarker information. Four subgroups were defined according to the patient's baseline status, including those with normal kidney function, reduced kidney function, selenium deficiency, and submaximal GPx3 activity.ResultsTwo hundred and forty-four patients were included in this analysis. Overall, higher serum concentrations of selenium, selenoprotein P (SELENOP) and GPx3 were correlated with less organ injury. GPx3 activity at baseline was predictive of 6-month survival (AUC 0.73; p = 0.03). While selenium treatment elevated serum selenium and SELENOP concentrations but not GPx3 activity in the full patient cohort, subgroup analyses revealed that GPx3 activity increased in patients with reduced kidney function, selenium deficiency and low to moderate GPx3 activity. Clinical outcomes did not vary between selenium treatment and placebo in any of these subgroups, though the study was not powered to conclusively detect differences in outcomes. ConclusionsThe identification of GPx3 responders encourages further refined investigations into the treatment effects of selenium in high-risk cardiac surgery patients.Graphical

Myocardial protection with phosphocreatine in high-risk cardiac surgery patients: a randomized trial

BackgroundThis study was conducted to test the hypothesis that phosphocreatine (PCr), administered intravenously and as cardioplegia adjuvant in patients undergoing cardiac surgery with prolonged aortic cross clamping and cardiopulmonary bypass (CPB) time, would decrease troponin I concentration after surgery.MethodsIn this randomized, double-blind, placebo-controlled pilot study we included 120 patients undergoing double/triple valve repair/replacement under cardiopulmonary bypass in the cardiac surgery department of a tertiary hospital.The treatment group received: intravenous administration of 2 g of PCr after anesthesia induction; 2.5 g of PCr in every 1 L of cardioplegic solution (concentration = 10 mmol/L); intravenous administration of 2 g of PCr immediately after heart recovery following aorta declamping; 4 g of PCr at intensive care unit admission. The control group received an equivolume dose of normosaline.ResultsThe primary endpoint was peak concentration of troponin I after surgery. Secondary endpoints included peak concentration of serum creatinine, need for, and dosage of inotropic support, number of defibrillations after aortic declamping, incidence of arrhythmias, duration of Intensive Care Unit (ICU) stay, length of hospitalization. There was no difference in peak troponin I concentration after surgery (PCr, 10,508 pg/ml [IQR 6,838–19,034]; placebo, 11,328 pg/ml [IQR 7.660–22.894]; p = 0.24). There were also no differences in median peak serum creatinine (PCr, 100 µmol/L [IQR 85.0–117.0]; placebo, 99.5 µmol/L [IQR 90.0–117.0]; p = 0.87), the number of patients on vasopressor/inotropic agents (PCr, 49 [88%]; placebo, 57 [91%]; p = 0.60), the inotropic score on postoperative day 1 (PCr, 4.0 (0–7); placebo, 4.0 (0–10); p = 0.47), mean SOFA score on postoperative day 1 (PCr, 5.25 ± 2.33; placebo, 5,45 ± 2,65; p = 0.83), need for defibrillation after declamping of aorta (PCr, 22 [39%]; placebo, 25 [40%]; p = 0.9),, duration of ICU stay and length of hospitalization as well as 30-day mortality (PCr, 0 (0%); placebo,1 (4.3%); p = 0.4).ConclusionPCr administration to patients undergoing double/triple valve surgery under cardiopulmonary bypass is safe but is not associated with a decrease in troponin I concentration. Phosphocreatine had no beneficial effect on clinical outcomes after surgery.Trial registrationThe study is registered at ClinicalTrials.gov with the Identifier: NCT02757443. First posted (published): 02/05/2016.

The Use of Cardioprotective Devices and Strategies in Patients Undergoing Percutaneous Procedures and Cardiac Surgery.

In the United States, about one million people are seen to visit the operating theater for cardiac surgery annually. However, nearly half of these visits result in complications such as renal, neurological, and cardiac injury of varying degrees. Historically, many mechanisms and approaches have been explored in attempts to reduce injuries associated with cardiac surgery and percutaneous procedures. Devices such as cardioplegia, mechanical circulatory support, and other methods have shown promising results in managing and preventing life-threatening cardiac-surgery-related outcomes such as heart failure and cardiogenic shock. Comparably, cardioprotective devices such as TandemHeart, Impella family devices, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) have also been proven to show significant cardioprotection through mechanical support. However, their use as interventional agents in the prevention of hemodynamic changes due to cardiac surgery or percutaneous interventions has been correlated with adverse effects. This can lead to a rebound increased risk of mortality in high-risk patients who undergo cardiac surgery. Further research is necessary to delineate and stratify patients into appropriate cardioprotective device groups. Furthermore, the use of one device over another in terms of efficacy remains controversial and further research is necessary to assess device potential in different settings. Clinical research is also needed regarding novel strategies and targets, such as transcutaneous vagus stimulation and supersaturated oxygen therapy, aimed at reducing mortality among high-risk cardiac surgery patients. This review explores the recent advances regarding the use of cardioprotective devices in patients undergoing percutaneous procedures and cardiac surgery.

Algorithms of Perioperative Management of High-Risk Cardiac Surgery Patients with Coronary Artery Disease and Polymorbidity

The aim. To analyze the effectiveness of the developed algorithms for the perioperative management of high-risk cardiac surgery patients with coronary artery disease (CAD) and polymorbidity.
 Materials and methods. We analyzed perioperative management of 354 high-risk cardiac surgery patients with CAD with EuroSCORE II predicted mortality >5%, among which 194 (54.8%) underwent isolated coronary artery bypass grafting, and 160 (45.2%) had surgical myocardial revascularization with accompanying valvular pathology correction or left ventricular postinfarction aneurysm resection. All the patients were discharged after cardiac surgery performed at the Department of Surgical Treatment of CAD of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine in the period from 2009 to 2019. As part of the study, general clinical examinations, electrocardiography, echocardiography, coronary angiography, cardiosurgical treatment were provided, and perioperative patient management protocols were developed and implemented.
 Results. Based on the conducted detailed analysis, it was established that the success of surgical revascularization of the myocardium depends not only on cardiac factors, but also on the compensation of concomitant diseases, the work of an experienced cardiac team consisting of a cardiologist, an interventionist, an anesthesiologist, a cardiac surgeon, and an intensivist. Treatment and prevention measures should be personalized and aimed at timely response to changes in laboratory and hemodynamic indicators of patients at all stages of their management, as well as stabilization of concomitant diseases. An important point in the preoperative preparation of cardiac surgery patients is verification of concomitant diseases with the aim of their timely compensation. The implemented algorithm for searching for comorbid conditions made it possible to improve the diagnosis of initial disorders of glucose metabolism, abnormal uric acid levels and cerebrovascular disease. Lowering the glucose level according to the developed algorithm of management of patients with impaired glucose metabolism in the perioperative period made it possible to reduce the number of postoperative wound infections by 3.4% and arrhythmological complications by 19.4%. Correction of drug therapy taking into account the glomerular filtration rate made it possible to avoid postoperative hemodialysis. Preventive prescription of therapeutic doses of proton pump inhibitors against the background of dual antiplatelet therapy, according to the developed protocol, led to a decrease in postoperative gastroduodenal complications from 5.1% to 0.3%.
 Conclusions. Implementation of the system of personalized treatment and preventive management of patients in the perioperative period made it possible to reduce postoperative complications from 16.7% to 4% (p=0.0190).

Effect of High-Dose Selenium on Postoperative Organ Dysfunction and Mortality in Cardiac Surgery Patients

Selenium contributes to antioxidative, anti-inflammatory, and immunomodulatory pathways, which may improve outcomes in patients at high risk of organ dysfunctions after cardiac surgery. To assess the ability of high-dose intravenous sodium selenite treatment to reduce postoperative organ dysfunction and mortality in cardiac surgery patients. This multicenter, randomized, double-blind, placebo-controlled trial took place at 23 sites in Germany and Canada from January 2015 to January 2021. Adult cardiac surgery patients with a European System for Cardiac Operative Risk Evaluation II score-predicted mortality of 5% or more or planned combined surgical procedures were randomized. Patients were randomly assigned (1:1) by a web-based system to receive either perioperative intravenous high-dose selenium supplementation of 2000 μg/L of sodium selenite prior to cardiopulmonary bypass, 2000 μg/L immediately postoperatively, and 1000 μg/L each day in intensive care for a maximum of 10 days or placebo. The primary end point was a composite of the numbers of days alive and free from organ dysfunction during the first 30 days following cardiac surgery. A total of 1416 adult cardiac surgery patients were analyzed (mean [SD] age, 68.2 [10.4] years; 1043 [74.8%] male). The median (IQR) predicted 30-day mortality by European System for Cardiac Operative Risk Evaluation II score was 8.7% (5.6%-14.9%), and most patients had combined coronary revascularization and valvular procedures. Selenium did not increase the number of persistent organ dysfunction-free and alive days over the first 30 postoperative days (median [IQR], 29 [28-30] vs 29 [28-30]; P = .45). The 30-day mortality rates were 4.2% in the selenium and 5.0% in the placebo group (odds ratio, 0.82; 95% CI, 0.50-1.36; P = .44). Safety outcomes did not differ between the groups. In high-risk cardiac surgery patients, perioperative administration of high-dose intravenous sodium selenite did not reduce morbidity or mortality. The present data do not support the routine perioperative use of selenium for patients undergoing cardiac surgery. ClinicalTrials.gov Identifier: NCT02002247.

Protocol for a randomised controlled trial: reducing reintubation among high-risk cardiac surgery patients with high-flow nasal cannula (I-CAN)

IntroductionHeated, humidified, high-flow nasal cannula oxygen therapy has been used as a therapy for hypoxic respiratory failure in numerous clinical settings. To date, limited data exist to guide appropriate use...

Are Viscoelastic Tests Clinically Useful to Identify Platelet-Dependent Bleeding in High-Risk Cardiac Surgery Patients?

Postoperative use of platelet function testing to rule out microvascular bleeding due to platelet dysfunction after cardiac surgery still lacks strong reference data and reliable cutoff values, yielding a clinically adequate sensitivity and specificity. The present study aims to investigate the performance of two different point-of-care viscoelastic devices and platelet aggregometry in expressing surgery-dependent platelet dysfunction and anticipating postoperative major bleeding in a cohort of high-risk patients. Prospective cohort study of 50 adult patients who were on antiplatelet drugs discontinued for no more than 7 days (clopidogrel and prasugrel) or 5 days (ticagrelor) undergoing cardiac surgery with cardiopulmonary bypass (CPB). Coagulation and platelet function testing, including QUANTRA, ROTEM, and Multiplate, were assessed preoperatively and postoperatively. Chest drain blood loss was measured in the first 12 postoperative hours. Perioperative bleeding was assessed using a modified version of the Universal Definition of Perioperative Bleeding (UDPB) in cardiac surgery, modified to not consider anemia-correcting packed red cells transfusions in the absence of bleeding >600 mL/12 h. Major bleeding was identified as UDPB class II or higher. Multiplate adenosine diphosphate (ADPtest) was significantly ( P = .001) reduced after CPB, whereas TRAPtest was not. The platelet component (PC) as extrapolated by ROTEM data (EXTEM MCF-FIBTEM MCF) was unchanged after CPB, while the A10 PC (PC at 10 minutes) was significantly ( P = .001) reduced. The QUANTRA platelet contribution to clot stiffness (PCS) was significantly ( P = .001) reduced, as well. At the ROC analysis for the predictive ability of the post-CPB platelet function testing, the best discrimination was obtained by the QUANTRA PCS, with an area under the curve (AUC) (95% confidence interval [CI]) of 0.80 (0.66-0.91), P = .001, followed by the ROTEM A10 PC with AUC (95% CI) of 0.75 (0.51-0.99), P = .004, and PC with AUC (95% CI) of 0.74 (0.50-0.99), P = .009. The Multiplate ADPtest had an AUC (95% CI) of 0.67 (0.42-0.91), and the TRAPtest had an AUC (95% CI) of 0.62 (0.37-0.86). The cutoff values identified were 13 hPa for the QUANTRA PCS, 40 mm for the ROTEM A10, and 48.5 mm for the ROTEM PC, with negative predictive values of 84%, 81%, and 86%, respectively, and positive predictive values of 55%, 53%, and 69%, respectively. QUANTRA PCS, ROTEM A10 PC, and Multiplate ADPtest showed a significant decrease after CPB, whereas ROTEM PC and Multiplate TRAPtest did not. Major bleeding was predicted with a moderate to good discrimination by the post-CPB viscoelastic tests (PCS, PC, and A10 PC).

Perioperative Doppler ultrasound assessment of portal vein flow pulsatility in high-risk cardiac surgery patients: a multicentre prospective cohort study

BackgroundPortal vein Doppler ultrasound pulsatility measured by transoesophageal echocardiography is a marker of the haemodynamic impact of venous congestion in cardiac surgery. We investigated whether the presence of abnormal portal vein flow pulsatility is associated with a longer duration of invasive life support and postoperative complications in high-risk patients. MethodsIn this multicentre cohort study, pulsed-wave Doppler ultrasound assessments of portal vein flow were performed during anaesthesia before initiation of cardiopulmonary bypass (before CPB) and after separation of cardiopulmonary bypass (after CPB). Abnormal pulsatility was defined as portal pulsatility fraction (PPF) ≥50% (PPF50). The primary outcome was the cumulative time in perioperative organ dysfunction (TPOD) requiring invasive life support during 28 days. Secondary outcomes included major postoperative complications. Results373 patients, 71 (22.0%) had PPF50 before CPB and 77 (24.9%) after CPB. PPF50 was associated with longer duration of TPOD (median [inter-quartile range]; before CPB: 27 h [11–72] vs 19 h [8.5–42], P=0.02; after CPB: 27 h [11–61] vs 20 h [8–42], P=0.006). After adjusting for confounders, PPF50 before CPB showed significant association with TPOD. PPF50 after CPB was associated with a higher rate of major postoperative complications (36.4% vs 20.3%, P=0.006). ConclusionsAbnormal portal vein flow pulsatility before cardiopulmonary bypass was associated with longer duration of life support therapy after cardiac surgery in high-risk patients. Abnormal portal vein flow pulsatility after cardiopulmonary bypass separation was associated with a higher risk of major postoperative complications although this association was not independent of other factors. Clinical trial registrationNCT03656263.

Comparative Analysis of the Perioperative Period in High-Risk Cardiac Surgery Patients with Stable and Unstable Angina Pectoris


 The aim. To analyze the features of the perioperative period in cardiac surgery patients with stable and unstable angina.
 Materials and methods. Retrospective analysis of random 194 cardiac surgery patients with coronary artery disease (CAD) and EuroSCORE II > 5%, who were operated and discharged from the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine from 2009 to 2019. All the patients underwent standard clinical, laboratory and functional tests, coronary angiography and coronary artery bypass grafting (CABG).
 Results. When assessing the initial clinical picture of randomized patients, 110 (56.7%) were diagnosed with stable angina, and 84 (43.2%) with unstable. On admission, acute myocardial infarction (AMI) was diagnosed in 12 (14.3%) patients (p < 0.0001), and among patients with stable angina 91 (82.7%) had a history of AMI (p = 0.0158). All the patients had polymorbidity: the Charlson comorbidity index was 5.7 ± 1.8 in patients with unstable angina and 5.9 ± 1.9 in stable CAD (p = 0.4583). Patients with unstable angina were more likely to have subocclusive-occlusive lesions of the left main coronary artery (p = 0.0083), left anterior descending artery (p = 0.0392) and left circumflex artery (p = 0.0387). All the patients were discussed by the cardiac team prior to surgery which was performed by experienced cardiac surgeons with 24 ± 12.5 years of experience. Emergency surgery was performed in 43 (51.1%) patients with unstable angina and 12 (10.9%) with stable angina (p <0.0001), off-pump CABG was performed in 82 (97.6%) and 105 (95.4%) patients, respectively (p = 0.4231). The postoperative period in patients with unstable angina was almost no different from that in patients with stable CAD. The patients with unstable angina were discharged on average on day 8.7 ± 4.04, and those with stable CAD were discharged on day 8.2 ± 3.2 (p = 0.3373).
 Conclusions. The outcome of the operation depends on the quality of the heart team work and requires a highly qualified cardiac surgeon with sufficient experience. Performing CABG on a working heart minimizes the occurrence of perioperative complications in patients with both unstable and stable CAD.

Abstract #1183232: Use of a Continuous Glucose Monitoring System in High Risk Hospitalized Non-critically ill Patients with Diabetes after Cardiac Surgery and during their Transition of Care from the Intensive Care Unit during Covid-19-A Pilot Study

Continuous glucose monitoring (CGM) has demonstrated benefits in managing inpatient diabetes. We initiated this prospective pilot study to determine the feasibility and accuracy of CGM in high-risk cardiac surgery patients with diabetes after their transition of care from the intensive care unit(ICU).

Thyroid Pathology in High-Risk Cardiac Surgery Patients with Coronary Artery Disease

The aim. To analyze the features of the perioperative period in high-risk cardiac surgery patients with coronary artery disease (CAD) and thyroid disease.
 Materials and methods. Retrospective analysis of data of 354 high-risk patients with CAD who were operated and discharged from the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine from 2009 to 2019. All the patients underwent standard clinical and laboratory tests, ECG, echocardiography, coronary angiography and surgical myocardial revascularization with correction of concomitant cardiac pathology. Ultrasound screening of thyroid disease and thyroid hormone levels was not performed in all patients, however, patients with severe symptoms were referred for follow-up.
 Results. Thyroid disease was diagnosed in 37 (10.4%) patients, of whom 11 (3.1%) had hypothyroidism and were receiving hormone replacement therapy, and 1 (0.28%) had hyperthyroidism on tyrosol therapy. Ultrasound signs of thyroiditis were detected in 7 (1.9%) patients, nodular goiter in 29 (8.1%), and retrosternal goiter in 1 (0.28%) patient. Dependingonthecardiacsurgicalpathology,theprevalenceofhypothyroidismdidnotdifferinpatientswithuncomplicated and complicated forms of CAD (7 [3.6%] and 4 [2.5%] patients, respectively, p = 0.5498). Patients with hypothyroidism received hormone replacement therapy with levothyroxine in a dosage prescribed by an endocrinologist. The day before the surgery, thyroid-stimulating hormone control was performed to confirm the achievement of compensation. When comparing the course of the operative period in compensated hypothyroidism and clinical euthyroidism, no significant differences were found, and the postoperative period didn’t differ in the occurrence of atrial fibrillation (p = 0.0801), hydrothorax (p = 0.5280), but a decrease in the estimated glomerular filtration rate at discharge was found in patients with hypothyroidism (59.5 ± 16.8 vs. 71.3 ± 19.6 ml/min/1.73 m2, p = 0.0493).
 Conclusions. Timely detection of thyroid dysfunction allows to compensate the condition and avoid postoperative complications. Analysis of the perioperative period in patients with hypothyroidism showed no effect of compensated hypothyroidism on the operative and postoperative periods in high-risk patients with CAD. Decreased glomerular filtration rate after surgery in patients with hypothyroidism requires further study and adherence to the strategy of nephroprotection in polymorbid patients.

PILOT STUDY OF PERCUTANEOUS TEMPORARY DIAPHRAGM PACING WIRES IN CARDIAC SURGERY PATIENTS AT RISK OF PROLONGED MECHANICAL VENTILATION DURING THE COVID-19 PANDEMIC

BACKGROUNDProlonged mechanical ventilation (PMV) after cardiac surgery occurs in 12% of patients, and significantly increases morbidity and mortality. Diaphragm pacing (DP) decreases ventilation times by 64% in other patient groups. We investigated the feasibility and outcomes of DP in urgent cardiac surgeries to decrease ventilator burden during the COVID-19 pandemic.METHODS AND RESULTSThis pilot study is an open-label FDA (IDE# G170294) prospective trial of temporary DP electrode use in high risk cardiac surgery patients (ClinicalTrials.gov Identifier–NCT04309123). Prior to sternotomy closure, the pleural space is opened, two electrodes (Figure 1) are placed in each diaphragm muscle, and the wires are tunneled percutaneously. The electrodes record diaphragm burst electromyography (dEMG) continuously for the first 24 hours and then once daily (Figure 2). In PMV patients (MV>24 hours), DP is initiated to prevent diaphragm atrophy and ventilator induced diaphragm dysfunction. The primary outcome was incidence of serious device related adverse events. The secondary outcome was time on MV. From 4/2/20–6/25/20, 44 patients were consented, 32 were implanted, and 12 were not. PMV was required in 10 patients implanted and 4 not implanted. There were no serious adverse events related to DP electrode implantation, all stimulated patients had improved ventilation and diaphragm function, and all electrodes were removed successfully. Criteria that best predicted PMV were: IABP, history of TIA or CVA, COPD, LVEF < 20%, and prior open-heart surgery. Using these criteria, the median time on mechanical ventilation in the first 120 hours was 35.7% versus 80.0% for the stimulated and non-stimulated groups, respectively.CONCLUSIONTemporary DP electrode placement during cardiac surgery is feasible and safe. DP improved diaphragm function and ventilation, and increased the likelihood of extubation by 48 hours. These results provide a catalyst for a prospective randomized controlled trial to decrease the MV burden in an enhanced recovery after surgery (ERAS) protocol.

Determination of comorbidity index for high-risk patients with coronary artery disease before cardiac surgery

The aim: to determine the comorbidity index before cardiac surgery in high-risk patients with coronary artery disease (CAD). Materials and methods. A retrospective analysis of data from 354 random high-risk patients who underwent a surgery and were discharged from National M. Amosov Institute of Cardiovascular Surgery affiliated to National Academy of Medical Sciences of Ukraine during the period 2009–2019. The mean age of patients was 61.9 ± 9.6 years. All the patients were examined: ECG, ECHO CG, coronary angiography before the surgery as well as Charlson comorbidity index was calculated and a risk on the scales EuroSCORE I, EuroSCORE II and STS was stratified. Results. I–III degree obesity was revealed in 133 (37.5 %) patients, patients with type 2 diabetes mellitus (DM) were more likely to have BMI &gt;30 kg/m2 (P = 0.017). Patients with normal weight had a carotid artery stenosis &gt;50 % (P = 0.014) and history of stroke (P = 0.043) significantly more frequently. No differences in comorbidity of overweight and normal weight patients were detected (5.73 ± 1.70 vs. 5.9 ± 1.8, P = 0.4638). Type 2 DM was diagnosed in 90 (25.4 %) patients. In the case of normoglycemia, the comorbidity index was significantly lower than in type 2 DM (4.88 ± 1.38 vs. 6.60 ± 2.03, P = 0.0001) and glucose intolerance 5.8 ± 1.5 (P &lt; 0.0001). Chronic kidney disease (CKD) G3a–G4 stages was diagnosed in 132 (37.2 %) patients. Significant higher comorbidity was found in patients with G3a–G4 stages CKD in comparison to those with G1–G2 stages CKD – 6.33 ± 1.78 vs. 5.46 ± 1.60 (P &lt; 0.0001). Among comorbidities in patients with gouty arthritis, type 2 DM (P &lt; 0.0001), obesity (P = 0.0080), CKD G3a–G4 (P = 0.0020) and varicose veins of the lower extremities (P = 0.0214) were significantly more common. Preoperative risk stratification according to the EuroSCORE II scale averaged 8.8 %. Conclusions. Preoperative analysis of baseline status in CAD patients showed the high Charlson comorbidity index, which averaged 5.7 ± 1.7. The weak direct correlation between the comorbidity index and the high predicted cardiac risk on the ES II scale (r = 0.2356, P = 0.00001), length of stay in the intensive care unit (r = 0.1182, P = 0.0262) and discharge after the surgery (r = 0.1134, P = 0.0330) was found.

Value of Perioperative Chest X-ray for the Prediction of Sternal Wound Complications after Cardiac Surgery in High-Risk Patients: A "Work in Progress" Analysis.

Background. Sternal wound complications are serious events that occur after cardiac surgery. Few studies have investigated the predictive value of chest X-ray radiological measurements for sternal complications. Methods. Several perioperative radiological measurements at chest X-ray and clinical characteristics were computed in 849 patients deemed at high risk for sternal dehiscence (SD) or More than Grade 1 Surgical Site Infection (MG1-SSI). Multivariable analysis identified independent predictors, whilst receiver operating characteristics (ROC) curve analyses highlighted cut-off values of radiological measurements for the prediction of both complications. Results. SD occurred in 8.8% of the patients, MG1-SSI in 6.8%. Chronic obstructive pulmonary disease (COPD) was the only independent predictor for SD (Odds Ratio, O.R. 12.1; p < 0.001); proximal sternal height (PSH) was the only independent protective factor (O.R. 0.58; p < 0.001), with a cut-off value of 11.7 mm (sensitivity 70.5%, specificity 71.0%; ROC area under the curve (AUC) = 0.768, p < 0.001). Diabetes mellitus (O.R. 3.5; p < 0.001) and COPD (O.R. 21.3; p < 0.001) were independent predictors for MG1-SSI; indexed proximal sternal height (iPSH) was as a protective factor (O.R. 0.26; p < 0.001) with a cut-off of 5.97 mm (sensitivity 70.2%, specificity 69.0%; ROC AUC = 0.739, p < 0.001). No other radiological measurements were independently correlated with SD or MG1-SS (p = N.S.). Conclusion. PSH and iPSH at preoperative chest X-ray may act as indicators of high risk for sternal wound complications, allowing for early preventative measures.

Measurement of mixed venous oxygen saturation (svo2) in high risk cardiac surgery patient

Our study included 112 high risk patients undergoing cardiac surgery in our hospital. Their postoperative hemodynamic parameters were monitored in short intervals using a Swan-Ganz catheter. A ROC curve of SO2 was plotted based on the collected data to evaluate its prognostic performance for patient early postoperative outcome and probability of dying within 30 days after surgery. Results: The best cut-off SO2 value for predicting post-operative complications related to heart failure and the probability of dying within 30 days after surgery in high risk cardiac sugery patients was 55% with a sensitivity of 91.18% and specificity of 31.82%. No death was reported in this study. Conclusions: A SO2value &lt; 55% at the time of admission to ICU indicates poor prognosis for high-risk cardiac surgery patients and more aggressive treatment is required accordingly. This finding is consistent with the results from several studies on patients undergoing surgery for coronary artery disease.

Prevention of Sternal Wound Infections in Women Using an External Sternum Fixation Corset.

Purpose: Deep sternal wound infection (DSWI) and mediastinitis are devastating complications after median sternotomy. Previous studies demonstrated an effective prevention of sternal wound infection (SWI) using an external sternal corset in high-risk cardiac surgery patients. The aim of this study is to assess the preventive effect of the Stern-E-Fix corset in high-risk poststernotomy female patients.Methods: A total of 145 high-risk female patients undergoing cardiac surgery through median sternotomy were retrospectively analyzed. Patients were divided into group A (n = 71), who received the Stern-E-Fix corset (Fendel & Keuchen GmbH, Aachen, Germany), and group B (n = 74), who received the elastic thorax bandage (SanThorax) postoperatively for 6 weeks. The mean follow-up period was 12 weeks.Results: Incidence of SWI was 7% in group A vs. 17.6% in group B (p = 0.025). One patient presented with DSWI in group A vs. seven patients in group B (p = 0.063). No patient developed mediastinitis in group A vs. four patients in group B (p = 0.121). In all, 4.2% of group A patients required operative wound therapy vs. 16.2% of group B patients (p = 0.026). The length of hospital stay was significantly longer in group B (p = 0.006).Conclusion: Using an external supportive sternal corset (Stern-E-Fix) yields a significantly better and effective prevention against development of sternal dehiscence, DSWI, and mediastinitis in high-risk poststernotomy female patients.

Comparison of the additive, logistic european system for cardiac operative risk (EuroSCORE) with the EuroSCORE 2 to predict mortality in high-risk cardiac surgery

Background:The aim of this study was to compare the new EuroSCORE (ES) 2 prediction model in high-risk patients with the 2 other oldest additive ES (aES) and logistic ES (lES).Methods:Consecutive adult patients undergoing all cardiac surgery except heart transplantation and left ventricular assist device were included. The 3 risk scores were collected before surgery. We defined 4 high-risk groups of patients, patients ≥80 years, combined cardiac surgery, surgery of the thoracic aorta, and emergency cardiac surgery, and 2 low-risk groups, valve surgery and coronary artery bypass surgery. The predicted value of each score has been assessed by the area under the receiver operating characteristics curve (AUC).Results:The study had included 3301 patients. Thirty-day mortality was 3.9% (95% confidence interval (CI), 3.3 − 4.6%). The AUC of ES2 was 0.81 (0.77 − 0.84), 0.82 (0.78 − 0.85), 0.70 (0.64 − 0.76), 0.79 (0.74 − 0.83), 0.85 (0.83 − 0.87), and 0.88 (0.86 − 0.90) for octogenarians, thoracic aortic surgery, combined surgery, emergency surgery, coronary surgery, and valve surgery, respectively. These ES2 AUC values were higher than those obtained with the aES for octogenarians, and with the lES for octogenarians and valve surgery. The ES2 calibration was better than the aES and lES calibration for the whole population, and low-risk groups. The ES2 calibration was superior to aES and lES in high-risk groups, except for octogenarians and thoracic aortic surgery compared to lES.Conclusion:In high-risk cardiac surgery patients, ES2 only marginally improve the predicted 30-day mortality in comparison to other ES.

Right anterolateral thoracotomy as an alternative approach to resternotomy for high-risk cardiac surgery patients

Right anterolateral thoracotomy as an alternative approach to resternotomy for high-risk cardiac surgery patients

Preoperative intra-aortic balloon pump inserted in acute myocardial infarction patients without cardiogenic shock undergoing surgical coronary revascularization.

The benefit of preoperative intra-aortic balloon pump implantation in high-risk cardiac surgery patients is still debated. The role of preoperative intra-aortic balloon pump insertion in acute myocardial infarction patients without cardiogenic shock undergoing off-pump coronary artery bypass grafting remains unknown. This study aimed to determine the efficacy and safety of the preoperative intra-aortic balloon pump insertion in those patients undergoing off-pump coronary artery bypass grafting. A total of 421 consecutive acute myocardial infarction patients without cardiogenic shock who underwent isolated off-pump coronary artery bypass grafting were enrolled in this retrospective observational propensity score-matched analysis study. Patients who received intra-aortic balloon pump before off-pump coronary artery bypass grafting (the intra-aortic balloon pump group, n = 157) were compared with those who had not (control group, n = 264). The 30-day postoperative survival, postoperative complications, and postoperative hospital length of stay were compared between the two groups. A total of 99 pairs of patients were matched. The preoperative intra-aortic balloon pump did not show a 30-day postoperative survival benefit compared with the control group (hazard ratio, 0.9; 95% confidence interval, 0.2-4.2; p = 0.92). Patients with preoperative intra-aortic balloon pump were more likely to have shorter postoperative lengths of stay (8 (6-11) days vs. 10 (6-15) days, p = 0.02) and decreased total days in the hospital (median days: 18.2 vs. 21.8, p = 0.02) compared to patients without balloon pumps. Preoperative intra-aortic balloon pump insertion in acute myocardial infarction patients without cardiogenic shock undergoing off-pump coronary artery bypass grafting improved convalescence as shown by significantly shorter postoperative lengths of hospital stay.