Post-cardiac Surgery Patients Research Articles

POStoperative INTELLiVENT-adaptive support VEntilation in cardiac surgery patients (POSITiVE) II—study protocol of a randomized clinical trial

BackgroundOne single-center randomized clinical trial showed that INTELLiVENT-adaptive support ventilation (ASV) is superior to conventional ventilation with respect to the quality of ventilation in post-cardiac surgery patients. Other studies showed that this automated ventilation mode reduces the number of manual interventions at the ventilator in various types of critically ill patients. In this multicenter study in patients post-cardiac surgery, we test the hypothesis that INTELLiVENT-ASV is superior to conventional ventilation with respect to the quality of ventilation.Methods“POStoperative INTELLiVENT-adaptive support VEntilation in cardiac surgery patients II (POSITiVE II)” is an international, multicenter, two-group randomized clinical superiority trial. In total, 328 cardiac surgery patients will be randomized. Investigators screen patients aged > 18 years of age, scheduled for elective cardiac surgery, and expected to receive postoperative ventilation in the ICU for longer than 2 h. Patients either receive automated ventilation by means of INTELLiVENT-ASV or ventilation that is not automated by means of a conventional ventilation mode. The primary endpoint is quality of ventilation, defined as the proportion of postoperative ventilation time characterized by exposure to predefined optimal, acceptable, and critical (injurious) ventilatory parameters in the first two postoperative hours. One major secondary endpoint is ICU team staff workload, captured by the ventilator software collecting manual settings on alarms. Patient-centered endpoints include duration of postoperative ventilation and length of stay in ICU.DiscussionPOSITiVE II is the first international, multicenter, randomized clinical trial designed to confirm that POStoperative INTELLiVENT-ASV is superior to non-automated conventional ventilation and secondary to determine if this closed-loop ventilation mode reduces ICU team staff workload. The results of POSITiVE II will support intensive care teams in their choices regarding the use of automated ventilation in postoperative care of uncomplicated cardiac surgery patients.Trial registrationClinicaltrials.gov NCT06178510. Registered on December 4, 2023.

ARISCAT and LAS VEGAS risk scores for predicting postoperative pulmonary complications after cardiac surgery: a cohort study.

Postoperative pulmonary complications (PPCs) could lead to morbidity, mortality, and prolonged hospital stay. Different risk-scoring systems are used to predict the identification of patients at risk of developing PPCs. The diagnostic accuracies of the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) and Local Assessment of Ventilatory Management During General Anaesthesia for Surgery (LAS VEGAS) risk scores are compared in prediction of PPCs taking pulmonary complication as the gold standard in cardiac surgery. A prospective cohort study with consecutive sampling technique. A total of 181 patients were included. Quantitative data is presented as simple descriptive statistics giving mean and standard deviation, and qualitative variables are presented as frequency and percentages. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracies are also calculated. Total 181 post-cardiac surgery patients were analyzed. The median [interquartile range] of age, height, weight, and BMI were 60.0 [52.0-67.0] years, 163.0 [156.0-168.0] cm, 71.0 [65.0-80.0] kg and 27.3 [24.2-30.4] kg/m2. 127 (70.2%) were male, and 54 (29.8%) were female. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of ARISCAT for the prediction of PPCs were (94.9%, 4.65%, 76.1%, 22.9% and 73.4%), whereas LAS VEGAS were (97.1%, 4.65%, 76.5%, 33.3% and 75.1%), respectively. Both the ARISCAT and LAS VEGAS risk scores are of limited value in cardiac surgery patients for the prediction of postoperative pulmonary complications, based on the predicted scores in this study.

#2593 Comparison of four predictive scoring models as assessment tools for cardiac surgery-associated acute kidney injury in post cardiac surgery patients

Abstract Background and Aims Cardiac surgery-associated acute kidney injury (CSA-AKI) is a predominant contributor to hospital-acquired AKI in ICU following sepsis. Despite a rising frequency of CSA-AKI, currently examined predictive models have not consistently delivered accurate stratification. Utilizing risk stratification systems offers clinicians the opportunity to identify patients at high risk, extend monitoring intervals, facilitate timely referral to nephrology services, and promptly initiate effective preventive and therapeutic interventions known to enhance renal function. This study seeks to identify the most effective model by comparing four established predictive scoring systems. The objective of this single-center retrospective, cross sectional study is to compare the clinical values of the Cleveland Clinical Score, Mehta Score, Simplified Renal Index and Acute Kidney Injury following Cardiac Surgery (AKICS) Score in predicting CS-AKI among patients who underwent cardiac surgery. Method A comprehensive examination of medical records was conducted for all individuals who underwent open-heart surgery between January 2010 and January 2019. Those patients who had CSA-AKI were subsequently identified. These identified individuals underwent assessment using the four predictive scoring models, leading to their categorization into high or low-risk groups for AKI development. Binary logistics regression was then used to describe the association between CSA-AKI development and the four scoring methods as predictors. Results Among the 114 cases of open-heart surgeries, 86 were eligible for inclusion in the study. Half of the patients, specifically 43 individuals (50%), developed CS-AKI, with 5 requiring renal replacement therapy. Among the four scoring methods evaluated, only the Mehta score (95% CI, p 0.019) and AKICS score (95% CI, p 0.011) demonstrated statistical significance in predicting CS-AKI. The odds ratios for both the Mehta Score (1.10) and AKICS Score (1.19) exceeded 1, suggesting that an increase in either score is associated with a higher likelihood of AKI occurrence. Conversely, the Cleveland Clinical Score (p 0.106) and Simplified Renal Index (p 0.399) were not found to be predictive. Conclusion In this single-center study, both the Mehta score and the AKICS scoring system demonstrated predictability for AKI after open-heart surgery. However, the Cleveland Clinical Scoring and Simplified Renal Index did not exhibit predictive capability in this context.

Post-surgery survival and associated factors for cardiac patients in Ethiopia: applications of machine learning, semi-parametric and parametric modelling

IntroductionLiving in poverty, especially in low-income countries, are more affected by cardiovascular disease. Unlike the developed countries, it remains a significant cause of preventable heart disease in the Sub-Saharan region, including Ethiopia. According to the Ethiopian Ministry of Health statement, around 40,000 cardiac patients have been waiting for surgery in Ethiopia since September 2020. There is insufficient information about long-term cardiac patients’ post-survival after cardiac surgery in Ethiopia. Therefore, the main objective of the current study was to determine the long-term post-cardiac surgery patients’ survival status in Ethiopia.MethodsAll patients attended from 2012 to 2023 throughout the country were included in the current study. The total number of participants was 1520 heart disease patients. The data collection procedure was conducted from February 2022- January 2023. Machine learning algorithms were applied. Gompertz regression was used also for the multivariable analysis report.ResultsFrom possible machine learning models, random survival forest were preferred. It emphasizes, the most important variable for clinical prediction was SPO2, Age, time to surgery waiting time, and creatinine value and it accounts, 42.55%, 25.17%,11.82%, and 12.19% respectively. From the Gompertz regression, lower saturated oxygen, higher age, lower ejection fraction, short period of cardiac center stays after surgery, prolonged waiting time to surgery, and creating value were statistically significant predictors of death outcome for post-cardiac surgery patients’ survival in Ethiopia.ConclusionSome of the risk factors for the death of post-cardiac surgery patients are identified in the current investigation. Particular attention should be given to patients with prolonged waiting times and aged patients. Since there were only two fully active cardiac centers in Ethiopia it is far from an adequate number of centers for more than 120 million population, therefore, the study highly recommended to increase the number of cardiac centers that serve as cardiac surgery in Ethiopia.

Development and validation of a clinical prediction model for early ventilator weaning in post-cardiac surgery

BackgroundWeaning patients from mechanical ventilation is a critical clinical challenge post cardiac surgery. The effective liberation of patients from the ventilator significantly improves their recovery and survival rates. This study aimed to develop and validate a clinical prediction model to evaluate the likelihood of successful extubation in post-cardiac surgery patients. MethodA predictive nomogram was constructed for extubation success in individual patients, and receiver operating characteristic (ROC) and calibration curves were generated to assess its predictive capability. The superior performance of the model was confirmed using Delong's test in the ROC analysis. A decision curve analysis (DCA) was conducted to evaluate the clinical utility of the nomogram. ResultsAmong 270 adults included in our study, 107 (28.84%) experienced delayed extubation. A predictive nomogram system was derived based on five identified risk factors, including the proportion of male patients, EuroSCORE II, operation time, pump time, bleeding during operation, and brain natriuretic peptide (BNP) level. Based on the predictive system, five independent predictors were used to construct a full nomogram. The area under the curve values of the nomogram were 0.880 and 0.753 for the training and validation cohorts, respectively. The DCA and clinical impact curves showed good clinical utility of this model. ConclusionDelayed extubation and weaning failure, common and potentially hazardous complications following cardiac surgery, vary in timing based on factors such as sex, EuroSCORE II, pump duration, bleeding, and postoperative BNP reduction. The nomogram developed and validated in this study can accurately predict when extubation should occur in these patients. This tool is vital for assessing risks on an individual basis and making well-informed clinical decisions.

Sociodemographic association in the hemodynamic challenge of early mobilization post-cardiac surgery.

Decreased functional capacity in post-cardiac surgery often leads to muscle atrophy and inactivity. Prolonged bed rest is the main contributor to the delay in recovery. This study investigates the association between hemodynamic challenge during early mobilization and socio-demographic factors with clinical cardiac monitoring such as gender, Body Mass Index (BMI), EuroSCORE in post-cardiac surgery patients. The finding showed gender, BMI, and EUROScore were associated with a hemodynamic challenge during early mobilization. In conclusion, the study suggests that early mobilization post-cardiac surgery is not only safe but cost-effective for the institution and the government.

Exploring the Prevalence of Low Antithrombin III Level among Post-cardiac Surgery Patients and its Impact on Heparin Efficacy

Exploring the Prevalence of Low Antithrombin III Level among Post-cardiac Surgery Patients and its Impact on Heparin Efficacy

Comparative Effect of High-Frequency Nasal Cannula and Noninvasive Ventilation on the Work of Breathing and Postoperative Pulmonary Complication after Pediatric Congenital Cardiac Surgery: A Prospective Randomized Controlled Trial.

Various forms of commonly used noninvasive respiratory support strategies have considerable effect on diaphragmatic contractile function which can be evaluated using sonographic diaphragm activity parameters. To compare the magnitude of respiratory workload decreased as assessed by thickening fraction of the diaphragm and longitudinal diaphragmatic strain while using high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) modes [nasal intermittent positive pressure ventilation (NIPPV) and bilevel positive airway pressure (BiPAP)] in pediatric patients after cardiothoracic surgery. This prospective randomized controlled trial was performed at a tertiary care surgical intensive care unit in postcardiac surgery patients aged between 1 and 48 months, who were randomly allocated into three groups: 1) HFNC (with flows at 2 L/kg/min), 2) NIPPV via RAMS cannula in PSV mode (pressure support 8 cmH2O, PEEP 5 cmH2O), and 3) BiPAP in nCPAP mode (CPAP of 5 cmH2O). Measurements were recorded at baseline after extubation (R0) and subsequently every 12 hourly (R1, R2, R3, R4, R5) at 12, 24, 36, 48, and 60 hours respectively until therapy was discontinued. Sixty patients were included, with 20 patients each in the NIPPV group, HFNC group, and BiPAP group. Longitudinal strain at crura of diaphragm was lower in the BiPAP group as compared to HFNC group at R2-R4 [R2 (-4.27± -2.73 vs - 8.40± -6.40, P = 0.031), R3 (-5.32± -2.28 vs -8.44± -5.6, P = 0.015), and R4 (-3.8± -3.42 vs -12.4± -7.12, P = 0.040)]. PFR was higher in HFNC than NIPPV group at baseline and R1-R3[R0 (323 ± 114 vs 264 ± 80, P = 0.008), R1 (311 ± 114 vs 233 ± 66, P = 0.022), R2 (328 ± 116 vs 237 ± 4, P = 0.002), R3 (346 ± 112 vs 238 ± 54, P = 0.001)]. DTF and clinical parameters of increased work of breathing remain comparable between three groups. The rate of reintubation (within 48 hours of extubation or at ICU discharge) was 0.06% (1 in NIPPV, 1 in BiPAP, 2 in HFNC) and remain comparable between groups (P = 1.0). BiPAP may provide better decrease in work of breathing compared to HFNC as reflected by lower crural diaphragmatic strain pattern. HFNC may provide better oxygenation compared to NIPPV group, as reflected by higher PFR ratio. Failure rate and safety profile are similar among different methods used.

Safety and Outcomes of Outpatient Pleural Drainage in Symptomatic Postoperative Cardiac Surgery Patients.

Symptomatic pleural effusions and anticoagulant/antiplatelet medication use in postoperative cardiac surgery are common. Guidelines and recommendations are currently mixed regarding medication management related to invasive procedure performance. We aimed to describe the outcomes of postoperative cardiac surgery patients referred for outpatient, symptomatic pleural effusion management. A retrospective study of post-cardiac surgery patients undergoing outpatient thoracentesis from 2016 to 2021 was performed. Demographics, operative details, pleural disease characteristics, outcomes, and complications were collected. Odds ratios with confidence intervals were estimated and adjusted by multivariate logistic regression to investigate the association with multiple thoracenteses. A total of 110 patients underwent 332 thoracenteses. The median age was 68 years and most common operation was coronary artery bypass. Anticoagulation or antiplatelet use was identified in 97%. Thirteen complications were identified, with all major complications (n=3) related to bleeding. The amount of fluid present at the time of initial thoracentesis (>1500 milliliters) was associated with increased odds ratio of subsequent multiple thoracentesis (Unadjusted odds ratio, 6.75 (CI - 1.43 to 31.9). No other variables had a significant association with the need for multiple procedures. Within a postoperative cardiac surgery population presenting with symptomatic pleural disease, we observed that thoracentesis performed on antiplatelet and/or anticoagulant medication is relatively safe. We also identified that many patients can be managed as outpatients and that most pleural effusions remain self-limited. The presence of larger amounts of pleural fluid at initial thoracentesis may be associated with increased odds for additional drainage.

Comparing body temperature measurements using the double sensor method within a wearable device with oral and core body temperature measurements using medical grade thermometers-a short report.

Introduction: Body temperature is essential for diagnosing, managing, and following multiple medical conditions. There are several methods and devices to measure body temperature, but most do not allow continuous and prolonged measurement of body temperature. Noninvasive skin temperature sensor combined with a heat flux sensor, also known as the "double sensor" technique, is becoming a valuable and simple method for frequently monitoring body temperature. Methods: Body temperature measurements using the "double sensor" method in a wearable monitoring device were compared with oral and core body temperature measurements using medical grade thermometers, analyzing data from two prospective clinical trials of different clinical scenarios. One study included 45 hospitalized COVID-19 patients in which oral measurements were taken using a hand-held device, and the second included 18 post-cardiac surgery patients in which rectal measurements were taken using a rectal probe. Results: In study 1, Bland-Altman analysis showed a bias of -0.04°C [0.34-(-0.43)°C, 95% LOA] with a correlation of 99.4% (p < 0.001). In study 2, Bland-Altman analysis showed a bias of 0.0°C [0.27-(-0.28)°C, 95% LOA], and the correlation was 99.3% (p < 0.001). In both studies, stratifying patients based on BMI and skin tone showed high accordance in all sub-groups. Discussion: The wearable monitor showed high correlation with oral and core body temperature measurements in different clinical scenarios.

High density mapping of atrial tachycardia in patients post cardiac surgery.

Mapping and ablation of atrial tachycardia (AT) in patients who have had prior cardiac surgery can be a challenge for clinical electrophysiologists. High density mapping (HDM) technology has been widely used in these patients because it provides a better characterization of the substrate and the mechanisms with an unprecedented high resolution. In this review, we summarize how the latest HDM technologies can reveal the mechanism of AT in different types of patients post-cardiac surgery and guide a specifically tailored ablation strategy.

Magnesium prophylaxis of new-onset atrial fibrillation: A systematic review and meta-analysis.

Atrial fibrillation (AF) is the most common cardiac arrhythmia in intensive care units (ICU) and is associated with increased morbidity and mortality. Magnesium prophylaxis has been shown to reduce incidence of AF in cardiac surgery patients, however, evidence outside this population is limited. The objective of this study is to summarize studies examining magnesium versus placebo in the prevention of NOAF outside the setting of cardiac surgery. We performed a comprehensive search of MEDLINE, EMBASE, and Cochrane Library (CENTRAL) from inception until January 3rd, 2023. We included all interventional research studies that compared magnesium to placebo and excluded case reports and post cardiac surgery patients. We conducted meta-analysis using the inverse variance method with random effects modelling. Of the 1493 studies imported for screening, 87 full texts were assessed for eligibility and six citations, representing five randomized controlled trials (n = 4713), were included in the review, with four studies (n = 4654) included in the pooled analysis. Administration of magnesium did not significantly reduce the incidence of NOAF compared to placebo (OR 0.72, [95% CI 0.48 to 1.09]). Use of magnesium did not reduce the incidence of NOAF, however these studies represent diverse groups and are hindered by significant bias. Further studies are necessary to determine if there is benefit to magnesium prophylaxis for NOAF in non-cardiac surgery patients.

The impact of COVID-19 prevention measures on surgical wound infection rates post-cardiac surgery.

The COVID-19 pandemic had a huge impact on medical services. Several measures have been implemented to reduce the risk of viral transmission. In this paper, we assessed the impact of these measures on surgical wound infection rates in patients post-cardiac surgery. Hypothesis testing was used to compare post-cardiac operation infection rates between the year prior to the COVID-19 pandemic being declared and the first 13 months of the pandemic. The infection rates in 969 patients with operations between 01/03/2019 and 29/02/2020 were compared to those of 925 patients with cardiac surgery between 01/03/2020 and 31/03/2021. Infection rates for various operative urgencies and infection types were analysed. To compare infection rates, a two-tailed pooled z-test using the difference in infection proportions was performed. A 5% significance level was used and only categories with at least 10 patients in both the pre-covid and covid populations were tested. For leg infections, only operations involving coronary artery bypass grafting were included. To ensure that any differences in outcomes were not due to differences in patient demographics resulting in unequal operative risks, Euroscore II values, a measure of cardiac operative risk, were compared between the pre-covid and post-covid cohorts. The Mann-Whitney U-test was used to determine whether the distributions of Euroscore II values were likely to be drawn from the same population. A significance level of 5% was used. A total of 1901 patients (932 during the COVID-19 pandemic) were included in this study. Significant reduction in post-operative infections for all patients undergoing cardiac surgery from 4.3% of patients before COVID to 1.5% during the pandemic. During the pandemic, fewer elective and more urgent operations were performed. This study suggests a significant role of iatrogenic causes in wound infections prior to the pandemic. The implementation of COVID-19 prevention measures in healthcare providers can reduce surgical infection rates. As COVID-19-related restrictions have been eased, we suggest maintaining them in healthcare providers to reduce the incidence of surgical wound infections.

THU247 Characterizing Inpatient Cases Of DKA Precipitated By SGLT2 Inhibitor Use

Abstract Disclosure: A. Aslamy: None. R. Nazemi: Speaker; Self; Eli Lilly &amp; Company, AstraZeneca. C. Tseng: None. S. Kim: None. R. Gianchandani: None. Background: SGLT2 inhibitors are a unique class of anti-hyperglycemic medications that can increase the risk of DKA in patients with diabetes (1). The overall incidence of DKA precipitated by SGLT2 inhibitor use is estimated to be 0.1%, however, this is likely higher in practice with increasing usage of these medications for treatment of heart failure and renal dysfunction. Herein, we characterize inpatient admissions with SGLT2 inhibitor induced DKA to further understand associated risk factors. Clinical Case: Euglycemic and hyperglycemic DKA cases (n=7) over a four-month period were identified, all of whom had been on SGLT2 inhibitors for an average of 8.5 (± 5.4) months prior to presentation. Six patients had T2D and one patient had known T1D. The average patient age was 69 (±8) years. The average A1c was 9.2% (±1.9%). Patients on dapagliflozin (n=3) had significantly higher A1c on admission compared to those on empagliflozin (n=4) (p=0.017). Average glucose on presentation of the six T2D patients was 206.5 (± 55.61) mg/dL (euglycemic DKA range) while the T1D patient presented with glucose of 605 mg/dL. All seven patients had elevated anion gap (mean 25.5 ± 7.2mEq/L), low bicarbonate (mean 8.9 ± 4.1 mmol/L), pH less than 7.4, and evidence of either ketonemia or ketonuria. Five out of the seven cases had a concurrent infection, and the remaining two cases were readmissions after recent cardiac surgery. All patients were treated with intravenous/subcutaneous insulin and intravenous dextrose with resolution of DKA within 24 hours. SGLT2 inhibitors were immediately discontinued. Average length of stay was 9 (±6) days, and was higher in the postcardiac surgery patients. Notably, the type of SGLT2 inhibitor (dapagliflozin vs. empagliflozin), age, sex, A1c on presentation, number of comorbidities, presence of infection, prior insulin usage, duration of diabetes, and duration of SGLT2 use had no significant effect on length of stay. Conclusion: Clinical characteristics of SGLT2 inhibitor induced DKA cohort were older age, uncontrolled diabetes (A1c &amp;gt;7), and concurrent infections or recent major surgery. Resolution of DKA was quick and length of stay longer for major surgery. When placed on SGLT2 inhibitors, diabetes patients should be warned of these potential clinical scenarios that can increase their risk of DKA. Reference: (1) Blau JE, Tella SH, Taylor SI, Rother KI. Ketoacidosis associated with SGLT2 inhibitor treatment: Analysis of FAERS data. Diabetes Metab Res Rev. 2017 Nov; 33 Presentation: Thursday, June 15, 2023

Experiences and care needs of post-discharge patients who underwent cardiac surgery: A qualitative study.

This study clarifies the physical, psychological, and social forms of distress in, and care needs of, cardiac surgery patients, including optimal times for supporting them in their post-hospital discharge daily lives. Semi-structured qualitative interviews were conducted. Participants included 12 adults (11 male and one female, mean age = 66.5 years) who had undergone cardiac surgery, experienced intensive care, and received outpatient care at the first post-discharge visit (around 2 ~ 3 weeks after discharge), around 3 months after discharge, and between 3 months and 1 year after discharge. Verbatim transcripts were analyzed based on similarities and differences for codes based on assessment items, and subcategories and categories were generated. After surgery, patients experienced physical, psychological, and social distress. First, they experienced physical pain shortly after discharge. Moreover, as they recovered at home, a gap between their sense of their recovery and the perceptions of those around them about their recovery often persisted, which led to psychological and social distress. Patients gained a sense of safety through "assurance of physical recovery" and security through "shared subjective distress." Post-cardiac surgery patients seek reassurance and safety by sharing experiences owing to daily life distress. Our findings could help provide better support to meet the care needs of such patients.

Effect of norepinephrine on the vascular waterfall and tissue perfusion in vasoplegic hypotensive patients: a prospective, observational, applied physiology study in cardiac surgery

BackgroundNorepinephrine is a commonly used drug for treating vasoplegic acute circulatory failure in ICU. The prediction of norepinephrine macro- and micro-circulatory response is complicated by its uneven receptors’ distribution between the arterial and the venous structures, and by the presence of a physiological vascular waterfall (VW) that disconnects the arterial and the venous circulation in two pressure systems. The objectives of this study were to describe the VW in patients with arterial hypotension due to vasodilatory circulatory shock, and its behavior according to its response to norepinephrine infusion.MethodsA prospective, observational, bi-centric study has included adult patients, for whom the physician decided to initiate norepinephrine during the six first hours following admission to the ICU after cardiac surgery, and unresponsive to a fluid challenge. The mean systemic pressure (MSP) and the critical closing pressure (CCP) were measured at inclusion and after norepinephrine infusion.ResultsThirty patients were included. Norepinephrine increased arterial pressure and total peripheral resistances in all cohort. The cohort was dichotomized as VW responders (patients with a change of VW over the least significant change (≥ 93% increase in VW)), and as VW non-responders. In 19 (63%) of the 30 patients, VW increased from 3.47 [− 14.43;7.71] mmHg to 43.6 [25.8;48.1] mmHg, p < 0.001) with norepinephrine infusion, being classified as VW responders. The VW responders improved cardiac index (from 1.8 (0.6) L min−1 m−2 to 2.2 (0.5) L min−1 m−2, p = 0.002), capillary refill time (from to 4.2 (1.1) s to 3.1 (1) s, p = 0.006), and pCO2 gap (from 9 [7;10] mmHg to 6 [4;8] mmHg, p = 0.04). No baseline parameters were able to predict the VW response to norepinephrine. In comparison, VW non-responders did not significantly change the VW (from 5 [-5;16] mmHg to -2 [-12;15] mmHg, p = 0.17), cardiac index (from 1.6 (0.3) L min−1 m−2 to 1.8 (0.4) L min−1 m−2, p = 0.09) and capillary refill time (from 4.1 (1) s to 3.7 (1.4), p = 0.44).ConclusionsIn post-cardiac surgery patients with vasoplegic arterial hypotension, the vascular waterfall is low. Norepinephrine did not systematically restore the vascular waterfall. Increase of the vascular waterfall was associated with an improvement of laboratory and clinical parameters of tissue perfusion.

Delivery of virtual acute cardiac care- a pilot study

Abstract Funding Acknowledgements Type of funding sources: None. Background The increasing incidence of chronic conditions, along with the SARS CoV-2 pandemic, put unprecedented capacity restraints on hospital bed access. New models of care are required to meet the increasing clinical demand for hospital services. Digital health technologies to support virtual hospital in the home services may address this need by offering patient-centered, safe and efficient models of care that are not reliant on physical hospital infrastructure. Specific cardiac conditions are well suited to a virtual model of care. Purpose To describe and evaluate a novel virtual model of care for cardiac patients that delivers early supported discharge from the acute inpatient ward to home. Model of Care The cardiac hospital in the home (cHITH) model was designed to provide an early supported discharge in a virtual ward environment by an expert team of advanced practice cardiac nurses, pharmacists and cardiologists. This 48-hour model of care utilized wearable technology to monitor cardiac rhythm and vital signs in conjunction with daily virtual ward rounds to manage recognised post operative/ procedural complications. Escalation pathways for clinical deterioration were designed to support patient safety. Transitional care to discharge was a key element of this model. Quality, safety, efficiency and patient experience were evaluated. Key Results From March-November 2022, 260 patients were referred to cHITH with 191 (74%) patients accepted according to the risk-stratification criteria. This cohort included post cardiac surgery (CSUR) patients (54%); post interventional procedures (31%), post device implant (6%) and other (9%). The cHITH length of stay (LOS) was 1.9 ± 0.1 days reflecting 20% of the episode of acute care delivered in the virtual environment. Re-admission rates were 9.4% at 30-days, with 0% mortality. Patient satisfaction was &amp;gt;90% (net promoter score). The CSUR cohort (n=103) had a mean age of 62 ± 4 years; male 82%; isolated CABG 62%; 30-day re-admission rate 7.8%. Total post-operative LOS was 7.1 ± 2.4 days with 35% of post-operative care delivered in the virtual cHITH environment. A total of 258 bed days were realized. Conclusion This pilot virtual model of care has demonstrated safety, efficiency and high levels of patient satisfaction. Ongoing analysis is required to understand the broader applications of this model and to further evaluate quality, safety and efficiency metrics.

New application of saline contrast-enhanced electrical impedance tomography method for right ventriculography besides lung perfusion: detection of right-to-left intracardiac shunt.

Saline contrast-enhanced electrical impedance tomography (EIT) has been used to identify the respiratory failure etiologies through assessment of regional lung perfusion at the bedside. In this study, we introduce a novel approach to detect right-to-left intracardiac shunt based on the center of heart (CoH) parameter determined from the early phase of impedance-time curve after saline bolus injection. The timepoints when the saline bolus enters the heart (T0) and the lung regions (T1) are identified at first. A moving time window from T0 to T1 is then generated with steps of 0.5 s and the slope of the impedance-time curve in each pixel within the window calculated. CoH is calculated as the geometric center of pixel slope values in the right-to-left image direction. To illustrate how this method works in practice, we calculated the CoH values at T0 to T1 in 10 control hypoxic patients with no right-to-left shunt. In addition, we examined two critically ill patients with right-to-left intracardiac shunt. one was postcardiac surgery patient who had a residual atrial septal defect by color doppler of transesophageal echocardiograph. The other patient had a congenital heart disease of ventricular septal defect by color doppler of trans-thoracic echocardiography. A large difference in CoH between T0 to T1 was observed in the two patients with intracardiac shunt than in the control patients (11.06 ± 3.17% vs. 1.99 ± 1.43%, P = 0.030). saline bolus EIT for lung perfusion might be used as ventriculography to identify the right-to-left intracardiac shunt at the bedside.

Incidence and predictors of pacemaker implantation at follow-up after reversible high-degree sinus node dysfunction or atrioventricular block.

A pacemaker implantation is not indicated in cases of reversible high-degree symptomatic sinus node dysfunction (SND) and atrioventricular block (AVB). However, it remains uncertain whether these reversible automaticity/conduction disorders may recur in some patients at follow-up, in the absence of reversible cause. This retrospective study aimed to determine the incidence and predictive factors of permanent pacemaker (PPM) implantation at follow-up and after reversible high-degree SND/AVB. Based on medical electronic files codes, we identified patients who were hospitalized in our cardiac intensive care unit between January 2003 and December 2020 due to reversible high-degree SND/AVB and who were discharged from the hospital alive and without PPM implantation. Acute myocardial infarction and post-cardiac surgery patients were excluded. We categorized the patients according to the need for PPM at follow-up due to non-reversible high-degree SND/AVB. Of the 93 patients included, 26 patients (28%) were readmitted for PPM implantation at follow-up after hospital discharge. Among baseline characteristics, compared with patients who did not have high-degree SND/AVB recurrence, those who had subsequent PPM implantation had less frequent previous hypertension (70%vs. 46%, p=.031). Regarding the initial causes of reversible SND/AVB, isolated hyperkalemia was found more often in the patients readmitted for PPM (19%vs. 3%vs. p=.017). Moreover, recurrence of high-degree SND/AVB was significantly associated with the presence of intraventricular conduction disorders (either bundle branch block or left bundle branch hemiblock) on ECG at discharge (36% in patients without PPM vs. 68% in PPM patients, p=.012). Almost one third of the patients discharged alive from the hospital after a reversible high-degree SND/AVB needed a pacemaker implantation at follow-up. Complete bundle branch block or left bundle branch hemiblock on discharge ECG after recovery of atrioventricular conduction and/or sinus automaticity was associated with a greater risk of recurrence leading to pacemaker implantation.

A Retrospective Case Study Comparing Single Versus Double Dosage of Levosimendan in Post-Cardiac Surgery Patients With Advanced Heart Failure

The study aimed to compare single versus double dosage of levosimendan infusion on left ventricular function, weaning of inotropes and ventilation, intensive care unit stay, and repeat hospitalisation in patients post cardiac surgery.