Management Of Cardiac Surgical Patients Research Articles

Is the diastolic shock index of value in the intra operative management of cardiac surgical patients?

Is the diastolic shock index of value in the intra operative management of cardiac surgical patients?

Optimal management of cardiac surgery patients using direct oral anticoagulants: recommendations for clinical practice.

Literature is scarce on the management of patients using direct oral anticoagulants (DOACs) undergoing elective, urgent and emergency surgery. Therefore, we summarize the current evidence and provide literature-based recommendations for the management of patients on DOACs in the perioperative phase. A general literature review was conducted on the pharmacology of DOACs and for recommendations on the management of cardiac surgical patients on DOACs. Additionally, we performed a systematic review for studies on the use of direct DOAC reversal agents in the emergency cardiac surgical setting. When surgery is elective, the DOAC cessation strategy is relatively straightforward and should be adapted to the renal function. The same approach applies to urgent cases, but additional DOAC activity drug level monitoring tests may be useful. In emergency cases, idarucizumab can be safely administered to patients on dabigatran in any of the perioperative phases. However, andexanet alfa, which is not registered for perioperative use, should not be administered in the preoperative phase to reverse the effect of factor Xa inhibitors, as it may induce temporary heparin resistance. Finally, the administration of (activated) prothrombin complex concentrate may be considered in all patients on DOACs, and such concentrates are generally readily available. DOACs offer several advantages over vitamin K antagonists, but care must be taken in patients undergoing cardiac surgery. Although elective and urgent cases can be managed relatively straightforwardly, the management of emergency cases requires particular attention.

Postoperative stroke assessment inconsistencies in cardiac surgery: Contributors to higher stroke-related mortality?

ObjectivesIn-hospital stroke mortality is surprisingly much worse than for strokes occurring outside of the hospital. Cardiac surgery patients are amongst the highest risk groups for in-hospital stroke and experience high stroke-related mortality. Variability in institutional practices appears to play an important role in the diagnosis, management, and outcome of postoperative stroke. We therefore tested the hypothesis that variability in postoperative stroke management of cardiac surgical patients exists across institutions. Materials and methodsA 13 item survey was employed to determine postoperative stroke practice patterns for cardiac surgical patients across 45 academic institutions. ResultsLess than half (44%) reported any formal clinical effort to preoperatively identify patients at high risk for postoperative stroke. Epiaortic ultrasonography for the detection of aortic atheroma, a proven preventative measure, was routinely practiced in only 16% of institutions. Forty-four percent (44%) reported not knowing whether a validated stroke assessment tool was utilized for the detection of postoperative stroke, and 20% reported that validated tools were not routinely used. All responders, however, confirmed the availability of stroke intervention teams. ConclusionsAdoption of a best practices approach to the management of postoperative stroke is highly variable and may improve outcomes in postoperative stroke after cardiac surgery.

Cardiorenal Syndrome in Patients with Infective Endocarditis Complicated by Acute Heart Failure

Cardiorenal interaction in acute heart failure (AHF) is becoming an increasingly recognized factor to consider in the management of cardiac surgical patients. Achieving adequate control of water balance and simultaneously preserving kidney function is the goal of the optimal management strategy for patients with AHF. The majority of preoperative hospitalizations to intensive care units in patients with infective endocarditis (IE) are associated with the development of AHF. The term “cardiorenal syndrome” (CRS) is used to define kidney dysfunction on the background of AHF. Due to the lack of clear clinical manifestations of CRS in IE, the diagnosis and treatment of this pathology may be delayed and contribute to the increase in the number of postoperative complications. Recent data, both in basic science and in clinical research, have changed our understanding of CRS. To date, several types of impaired interaction between the kidneys and the heart have been identified.
 The aim. To study the peculiarities of CRS in patients with IE complicated by AHF.
 Materials and methods. The basis of this study was the clinical data of 41 patients with active IE who were treated at the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine from 1/1/2020 to 8/31/2020. In order to study the features of clinical manifestation and the course of CRS, a comparative analysis was conducted based on the history and results of laboratory and instrumental research for the group of patients with IE complicated by preoperative AHF, and patients without clinical manifestations of AHF at the time of hospitalization. For an in-depth study of myocardial damage in heart failure, troponin, NT-proBNP, lactate levels were analyzed; dysfunction of the urinary system was assessed by the level of urea and serum creatinine, the volume of diuresis.
 Results. A reliable relationship between the levels of NT-proBNP and serum creatinine at the preoperative stage was revealed (p˂0.001), as an indicator of the presence of CRS in patients with IE. In the early postoperative period, signs of CRS persisted in patients with IE complicated by preoperative AHF (serum creatinine 157.0±8.5 μmol/l [p<0.001], NT-proBNP 8214.9±2390.0 pg/ml [p=0.010]). Normalization of kidney function indicators was reported on the day 14 after surgery.
 Conclusions. Cardiac surgical intervention in patients with IE contributes to reduction of CRS manifestations on the day 14 of the postoperative period.

Blood Lactate Level as Predictor of Early Outcome after Off-Pump Coronary Artery Bypass Grafting

Background: Identification of predictors of morbidity and mortality is an important issue for the management of cardiac surgical patients. Elevated lactate concentrations in the immediate postoperative period reflect unmet metabolic demand and may be associated with outcome.
 Methods: A prospective observational study was carried out in the department of cardiac surgery, at National Heart Foundation Hospital& Research Institute(NHFH&RI), Dhaka. commencing from July 2016 to March 2018. In all Adult patients irrespective of sex undergoing elective off-pump coronary artery bypass grafting (OPCABG). Purposive sampling was applied with patient with blood lactate level < 3 mmol/L 6hours after shifting from OT to ICU in Group-A and blood lactate level ≥3mmol/l, 6hours after shifting to the ICU in Group-B.Postoperative early adverse outcomes were analyzed in both the patient groups.
 Results: Blood lactate level 6 hours after ICU transfer is an independent predictor for prolonged mechanical ventilation time, (OR 2.540, 95% CI 1.781-3.621, p= <0.001).prolonged ICU stay, .(OR 1.767, 95% CI 1.348-2.315, p=< 0.001) pulmonary complication (OR 1.503, 95% CI 1.104-2.046, p= 0.010).and renal dysfunction(OR 1.460, 95% CI 1.156-1.843, p= 0.001). following off-pump coronary artery bypass grafting. Other risk factors for adverse outcome including, low LVEF, diabetes mellitus, blood transfusion and inotropic support were also found to be predictors of major complications in our study.
 Conclusion: The findings of this study permits to conclude that blood lactate level 6hours after ICU transfer is associated with an increased risk of postoperative early adverse outcome after off-pump coronary artery bypass grafting. It is found that lactate is an independent predictor of major postoperative complications. So, achieving normal blood lactate level following OPCABG is essential for minimizing postoperative adverse outcome.
 Cardiovasc. j. 2020; 12(2): 120-125

Adult cardiac surgery and the COVID-19 pandemic: Aggressive infection mitigation strategies are necessary in the operating room and surgical recovery

The COVID-19 pandemic necessitates aggressive infection mitigation strategies to reduce the risk to patients and healthcare providers. This document is intended to provide a framework for the adult cardiac surgeon to consider in this rapidly changing environment. Preoperative, intraoperative, and postoperative detailed protective measures are outlined. These are guidance recommendations during a pandemic surge to be used for all patients while local COVID-19 disease burden remains elevated.

Chinese Society of Anesthesiology Expert Consensus on Anesthetic Management of Cardiac Surgical Patients With Suspected or Confirmed Coronavirus Disease 2019

The outbreak of a new coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) in China in December 2019 has brought serious challenges to disease prevention and public health. Patients with severe coronavirus disease 2019 (COVID-19) who undergo cardiovascular surgery necessitate extremely high demands from anesthesia personnel, and face high risks of mortality and morbidity. Based on the current understanding of COVID-19 and the clinical characteristics of cardiovascular surgical patients, the authors provide anesthesia management guidelines for cardiovascular surgery along with the prevention and control of COVID-19.

Postoperative management of patients undergoing cardiac surgery in Austria : A national survey on current clinical practice in hemodynamic monitoring and postoperative management.

SummaryBackgroundNo data are currently available regarding the current clinical practice in postoperative care of cardiac surgical patients in Austria.ObjectiveThe study investigated the current intensive care management concerning hemodynamic monitoring and strategies to treat common perioperative disorders of patients after cardiac surgery in Austria.MethodsA survey consisting of 31 questions was sent to intensivists at all 9 hospitals offering cardiac surgery in Austria.ResultsThe response rate was 100%. The mean number of procedures on cardiopulmonary bypass per centre was 722 ± 223. In the majority of cases postoperative critical care is performed by anesthesiologists. Blood gas analysis, pulse oximetry, electrocardiogram, temperature, central venous pressure, arterial pressure and hourly urine output are de facto standard monitoring in all centers. Transesophageal echocardiography is available in all centers and is frequently used. Crystalloids are the first choice for volume replacement, whereas levosimendan and adrenaline are employed for the treatment of low cardiac output syndrome.ConclusionsThis study provides insights into the current state of postoperative management of cardiac surgical patients in Austria. Standard monitoring as proposed by international guidelines is well established in Austrian intensive care units. Echocardiography is widely seen as a very important tool in the postoperative care of cardiac surgical patients. Knowledge about the status quo of postoperative intensive care management of cardiac surgical patients enables further development of patient care.Electronic supplementary materialThe online version of this article (10.1007/s00508-018-1403-3) contains supplementary material, which is available to authorized users.

International consensus statement on the peri-operative management of direct oral anticoagulants in cardiac surgery.

Despite current recommendations on the management of severe peri-operative bleeding, there is no pragmatic guidance for the peri-operative monitoring and management of cardiac surgical patients taking direct oral anticoagulants. Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology, of their own volition, performed an independent systematic review of peer-reviewed original research, review articles and case reports and developed the following consensus statement. This has been endorsed by the European Association of Cardiothoracic Anaesthesiology. In our opinion, most patients on direct oral anticoagulant therapy presenting for elective cardiac surgery can be safely managed in the peri-operative period if the following conditions are fulfilled: direct oral anticoagulants have been discontinued two days before cardiac surgery, corresponding to five elimination half-live periods; in patients with renal or hepatic impairment or a high risk of bleeding, a pre-operative plasma level of direct oral anticoagulants has been determined and found to be below 30 ng.ml-1 (currently only valid for dabigatran, rivaroxaban and apixaban). In cases where plasma level monitoring is not possible (e.g. assay was not available), discontinuation for 10 elimination half-live periods (four days) is required. For FXa inhibitors, a standard heparin-calibrated anti-Xa level of < 0.1 IU.ml-1 should be measured, indicating sufficient reduction in the anticoagulant effect. Finally, short-term bridging with heparin is not required in the pre-operative period.

Postoperative Complications and Outcomes Associated With a Transition to 24/7 Intensivist Management of Cardiac Surgery Patients.

Nighttime intensivist staffing does not improve patient outcomes in general ICUs. Few studies have examined the association between dedicated in-house 24/7 intensivist coverage on outcomes in specialized cardiac surgical ICUs. We sought to evaluate the association between 24/7 in-house intensivist-only management of cardiac surgical patients on postoperative complications and health resource utilization. Before-and-after propensity matched cohort study. Tertiary care cardiac surgical ICU. Patients greater than 18 years old who underwent cardiac surgery between January 1, 2006, and April 30, 2013 (nighttime resident model), were propensity-matched (1:1) to patients from August 1, 2013, to December 31, 2014 (24/7 in-house intensivist model). Cardiac surgical ICU coverage change from a nighttime resident physician coverage model to a 24/7 in-house intensivist staffing model. The primary outcome of interest was a composite of postoperative major complications. Secondary outcomes included duration of mechanical ventilation, all-cause cardiac surgical ICU readmissions, and surgical postponements attributed to lack of cardiac surgical ICU bed availability. A total of 1,509 patients during the nighttime resident model were matched to 1,509 patients during the intensivist model. The adjusted risk of major complications (26.3% vs 19.3%; odds ratio, 0.73; 95% CI, 0.36-0.85; p < 0.01), mean mechanical ventilation time (25.2 vs 19.4 hr; p < 0.01), cardiac surgical ICU readmissions (5.3% vs 1.6%; odds ratio, 0.31; 95% CI, 0.19-0.48; p < 0.01), and surgical postponements (3.4 vs 0.3 per mo; p < 0.01) were lower with the intensivist model. A transition to a 24/7 in-house intensivist care model was associated with a reduction in postoperative major complications, duration of mechanical ventilation, cardiac surgical ICU readmissions, and surgical postponements. These findings suggest that 24/7 intensivist physician care models may improve patient outcomes and health resource utilization in specialized cardiac surgical ICUs.

Safety and efficacy of landiolol hydrochloride for prevention of atrial fibrillation after cardiac surgery in patients with left ventricular dysfunction: Prevention of Atrial Fibrillation After Cardiac Surgery With Landiolol Hydrochloride for Left Ventricular Dysfunction (PLATON) trial

ObjectivesWe previously conducted a prospective study of landiolol hydrochloride (INN landiolol), an ultrashort-acting β-blocker, and reported that it could prevent atrial fibrillation after cardiac surgery. This trial was performed to investigate the safety and efficacy of landiolol hydrochloride in patients with left ventricular dysfunction undergoing cardiac surgery. MethodsSixty patients with a preoperative left ventricular ejection fraction of less than 35% were randomly assigned to 2 groups before cardiac surgery and then received intravenous infusion with landiolol hydrochloride (landiolol group) or without landiolol (control group). The primary end point was occurrence of atrial fibrillation as much as 1 week postoperatively. The secondary end points were blood pressure, heart rate, intensive care unit and hospital stays, ventilation time, ejection fraction, biomarkers of ischemia, and brain natriuretic peptide. ResultsAtrial fibrillation occurred in 3 patients (10%) in the landiolol group versus 12 (40%) in the control group, and its frequency was significantly lower in the landiolol group (P = .002). During the early postoperative period, levels of brain natriuretic peptide and ischemic biomarkers were significantly lower in the landiolol group than the control group. The landiolol group also had a significantly shorter hospital stay (P = .019). Intravenous infusion was not discontinued for hypotension or bradycardia in either group. ConclusionsLow-dose infusion of landiolol hydrochloride prevented atrial fibrillation after cardiac surgery in patients with cardiac dysfunction and was safe, with no effect on blood pressure. This intravenous β-blocker seems useful for perioperative management of cardiac surgical patients with left ventricular dysfunction.

Intravalvular regurgitation of the mitral bioprosthetic valve detected by intraoperative transesophageal echocardiography : A case report .

Intraoperative transesophageal echocardiography (IOTEE) is an invaluable diagnostic method for management of cardiac surgical patients, including patients undergoing valve replacement surgery. We report a patient who underwent reoperation for mitral valve replacement due to intravalvular regurgitation following mitral valve replacement with a bioprosthetic valve. The condition was detected by IOTEE and caused by suture entrapment.

Anesthesia for Cardiac Surgery, 3rd Edition.

Anesthesia for Cardiac Surgery, 3rd Edition.

Recombinant activated factor VII (Novo7®) in patients with ventricular assist devices: Case report and review of the current literature

Postoperative bleeding might become a serious problem in the management of cardiac surgical patients, with marked medical and economic impact. In these life-threatening situations, massive haemorrhage represents frequently a combination of surgical and coagulopathic bleeding. Surgical bleeding results from a definite source at the operation site and can be corrected using surgical standard techniques. Acute coagulopathies, in contrast, result from impaired thrombin formation, and require optimized therapeutical strategies. Effective pharmacological treatment will be complicated by the presence of ventricular assist devices (VAD), which necessarily imply effective anticoagulation.In episodes of uncontrolled coagulopathic bleeding, the application of recombinant activated factor VII (rFVIIa) as a effective haemostatic agent has become more and more popular. However, only very few data are available on its use in patients with VAD in place.We researched the PubMed-database for case reports about the use of rFVIIa in patients with VAD and summarized them. In addition, we report a case from our hospital. In all cases cessation of bleeding without any thrombembolic complications could be achieved. In cases of uncontrollable, non-surgical bleeding rFVIIa seems to be a therapeutical option even for patients with VAD.

A Systematic Approach to Substernal Epicardial Echocardiographic Examination

The importance of echocardiography in the perioperative management of cardiac surgical patients is widely appreciated. A modified mediastinal drain has been developed, which allows the introduction of a standard TEE probe in a closed-ended sleeve coupled with the drain to permit epicardial echocardiographic imaging after chest closure (substernal epicardial echocardiography [SEE]). The aim of the present study was to develop a standardized and comprehensive SEE examination sequence to allow repeatable examinations with a single movement of the TEE probe inside the drain. Prospective observational protocol. Tertiary care university hospital. Ten adult patients undergoing elective cardiac surgery. Twenty-three SEE examinations in 10 patients undergoing elective myocardial revascularization to develop a standard examination sequence. The examination sequence includes 11 views with all the structures relevant for postoperative monitoring. The entire sequence is performed with a single in-out movement of the transesophageal probe to minimize discomfort to patients and the risk of damaging the tube. This new approach to the perioperative monitoring of cardiac surgical patients represents an option for patients in whom TEE is contraindicated or multiple examinations are anticipated because SEE examinations can be performed without the need for sedation in awake patients.

Resection of Metastatic Right Ventricular Leiomyosarcoma: The Role of Transesophageal Echocardiography

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) plays an increasing role in the management of cardiac surgical patients. It has shown its superiority over transthoracic echocardiography (TTE) in detecting cardiac masses and estimating their relationship to cardiac structures.1,2 Metastatic leiomyosarcoma to the heart is extremely rare.3 A case of metastatic leiomyosarcoma to the right ventricle that was resected with the guidance of TEE is presented. Central venous pressure (CVP) measurements were unreliable, and TEE findings dictated the intraoperative anesthetic management.

The effects of a treatment protocol for cardiac surgical patients with excessive blood loss on clinical outcomes

Excessive blood loss (EBL) is a common complication of cardiac surgery that is associated with adverse events. The objective of this before/after study was to determine whether the implementation of a protocol for management of cardiac surgical patients with EBL was associated with improved clinical outcomes. In November 2002, a protocol for prompt identification and aggressive management of cardiac surgical patients with EBL was implemented at our institution. The independent relationship between protocol implementation and adverse outcomes was measured by comparing the outcomes of patients who received > or = 4 RBC (red blood cell) units within 1 day of surgery and were operated on before protocol implementation (2000-02) with those operated on after protocol implementation (2003-05), using multivariable logistic regression analysis to control for the effects of confounders. The primary outcome was a composite of adverse events that included death, renal failure, stroke, and sepsis. Bootstrapping was used to confirm the validity of the results. Of the 11,314 patients who underwent surgery during the study period, 1875 (16.6%) received > or = 4 RBC units within 1 day of surgery, with 958 and 917 in the pre- and postprotocol periods, respectively. The composite adverse outcome occurred in 164 (17.1%) patients in the preprotocol period and 115 (12.5%) patients in the postprotocol period (P = 0.005). Protocol implementation was independently associated with reduced odds of the composite adverse outcome (odds ratio 0.67; 95% confidence interval 0.50, 0.91; P = 0.01). This estimate was stable in bootstrap sampling. Implementation of a protocol to manage EBL in cardiac surgery was independently associated with improved outcomes.

The Role of Recombinant, Activated Factor VII in Hemorrhage Following Cardiac Surgical Procedures

SUMMARYWhile the usage of aprotinin and other antifibrinolytics has significantly decreased bleeding and transfusion requirements in cardiac surgical patients in general, certain patients still experience massive hemorrhage despite such therapy. Reexploration for bleeding has been identified as a strong independent risk factor for operative mortality, renal failure, prolonged mechanical ventilation, adult respiratory distress syndrome, sepsis, and atrial arrhythmias. Consequently, therapies to effectively limit otherwise uncontrolled hemorrhage have an important role in the clinical management of cardiac surgical patients. The hemostatic efficacy of recombinant factor VIIa (rFVIIa) appears to lie in its ability to activate FX directly to produce thrombin, independent of the presence and/or activity of co‐factors FVIII, FIX or FXI. There is also some evidence for the efficacy of rFVIIa in patients with platelet dysfunction which may also be relevant to its usage in cardiac surgical patients. This review considers the most recent clinical reports of the usage of rFVIIa for the control of massive blood loss and potentially fatal hemorrhage following cardiac surgery, with a view to assessing efficacy and dosing strategies. In addition, concern has been raised that patients undergoing cardiac surgery may have vulnerable plaques in coronary arteries or aorta, thus the risk of intracoronary activation of hemostasis with consequent potential for ischemic and thrombotic events may exist. Controlled clinical trials of rFVIIa assessing dose‐ranging and with adequate power to detect the impact of therapy on morbidity and mortality are necessary before it can be recommended for routine use in patients who present excessive bleeding following cardiac surgery.

The Impact of Intraoperative Echocardiography on Clinical Outcomes Following Adult Cardiac Surgery

Over the past 30 years, intraoperative echocardiography has become an invaluable diagnostic tool and monitor of cardiac performance for the management of cardiac surgical patients. The essential information provided by intraoperative echocardiography regarding hemodynamic management, cardiac valve function, congenital heart lesions, and great vessel pathology has contributed to its widespread popularity. Numerous investigations have been conducted in an attempt to specifically demonstrate a beneficial impact of intraoperative echocardiography in cardiac surgery. However, there is a relative paucity of data derived from prospective trials in which the use of intraoperative echocardiography has been randomized among various cardiac surgical patient populations to formally ascertain, rather than simply infer, its putative impact on perioperative decision-making and clinical outcomes. Ironically, the popularity of intraoperative echocardiography has imposed ethical limitations on performing randomized trials in patient populations for whom significant benefit has been previously inferred. Nonetheless, significant evidence has been published to support its almost universal acceptance as an important perioperative diagnostic tool and monitor for cardiac surgical patients. This review focuses on the impact of intraoperative echocardiography on clinical outcomes in the more common adult cardiac surgical scenarios, including coronary artery bypass graft surgery, mitral and aortic valve surgery, and in evaluating the intrathoracic aorta.

Initial Perioperative Care of the Cardiac Surgical Patient

Recently, changes in the management of cardiac patients have allowed earlier discharge from the cardiac recovery area and reduced hospital length of stay. These changes have been drien by a need to reduce the cost of cardiac surgery and imrove efficiency. This change has been both financially sucessful and safe for patients. To allow for this success, a joint effort is required between the departments of cardiac surgery and anesthesiology involving the preoperative, intraoperative and postoperative treatment of these patients. Through recogition of suitable candidates, modifications in anesthetic techique, and appropriate postoperative management, the goal of extubation within 6 hours of admission to the cardiac recovery area can be achieved. Changes in intraoperative and early postoperative management of cardiac surgical patients are discussed. Specific recovery models are reviewed with disussion of the parallel and integrated models. Methods of preicting prolonged extubation times and intensive care unit length of stay are also discussed. Initial management of the cardiac patient in the cardiac recovery area is presented with a more in-depth review of specific complications: stroke, atril fibrillation, blood loss, left ventricular dysfunction, and pulonary dysfunction.