Post-cardiac Surgery Patients Research Articles

Resistance Index of the Superior Mesenteric Artery: Correlation With Lactate Concentration and Kinetics Prediction After Cardiac Surgery.

Objective: This study aimed to measure blood flow changes in the superior mesenteric artery (SMA), using Doppler ultrasound, in post-cardiac surgery patients, to evaluate the correlation between the SMA resistance index (SMA-RI) and lactate concentrations.Methods: The patients' basic hemodynamics, blood gas parameters and lactate concentration were collected at admission. Simultaneously, the SMA blood flow parameters were collected using Doppler ultrasound with the patients in the supine position. The lactate concentrations were measured again at 2, 6, and 12-h time points after the first test. The length of intensive care unit stays and prognoses continued to be monitored.Results: A total of 67 patients were included. The SMA-RI correlated with the admission (r = 0.3117, P = 0.0102), 2-h (r = 0.5091, P < 0.0001), 6-h (r = 0.5061, P < 0.0001), and 12-h (r = 0.2483, P = 0.0428) lactate concentrations. The SMA-RI could predict the 2-h 10% [area under the curve (AUC) = 0.8294, P < 0.0001] and 6-h 40% lactate kinetics (AUC = 0.7708, P = 0.0012). The cut-off value was 0.83. When the SMA-RI was <0.83, the specificity and sensitivity were 86.38 and 75.56%, respectively for the prediction of the 2-h >10% lactate kinetics, and 64.71 and 75.00%, respectively, for the prediction of the 6-h >40% lactate kinetics. The lactate concentrations at admission, 2 and 6-h points were higher in the high-RI group (RI ≥ 0.83) and the intensive care unit stays were significantly longer than in the low-RI group (P = 0.0005).Conclusions: The increase in SMA-RI was associated with higher lactate concentrations and worse lactate kinetics in post-cardiac surgery patients. This may be related to intestinal hypoperfusion. The SMA-RI may be one of the indicators that should be monitored to guide resuscitation in these patients.

Abstract 11589: Hemodynamic Assessment of Inhalational Epoprostenol for Post-Operative Right Ventricular Dysfunction in Cardiac Surgery Patients

Introduction: Right ventricular (RV) dysfunction after cardiac surgery presents a significant challenge. Epoprostenol (EPO) is a pulmonary vasodilator that can be administered via inhalation and is often used in patients with post-operative RV dysfunction. However, the effects of EPO on RV performance have not been well studied. Furthermore, EPO is generally contraindicated in WHO Group 2 pulmonary hypertension. The purpose of this study is to describe the hemodynamic consequences of weaning inhaled epoprostenol (iEPO) in post-operative RV dysfunction and potentially identify any predictive markers for successful weaning. Methods: This is a single-center case series of patients receiving iEPO after cardiac surgery identified by convenience sampling. Inclusion criteria included post-cardiac surgery patients, &gt;18 years, and receiving iEPO for RV dysfunction. Exclusion criteria included pregnancy, open chest, SARS-COV-2 pneumonia, left ventricular assist device use, extracorporeal membrane oxygenation use, heart transplantation, or receiving iEPO for refractory hypoxia. A paired two sample t-test compared the hemodynamic parameters collected pre and post iEPO weaning. Results: EPO weaning was associated with a decrease in mean pulmonary artery pulsatility index (PAPi) (pre-wean 1.81 vs post-wean 1.57, p=0.04) and increase in pulmonary artery systolic pressure (PASP) (46.5mmHg vs 55.1mmHg, p=0.01). Cardiac index and right atrial pressure were not significantly different (p=0.35 and p=0.26 respectively). Case 5 had EPO weaning failure and had the lowest baseline PAPi in the cohort. Conclusion: iEPO weaning is associated with dynamic changes in PASP and PAPI in post-operative cardiac surgery patients. This finding supports the conceptual role of iEPO in improving post-operative RV-PA coupling and RV performance. Baseline PAPi may be a predictive marker to guide the weaning process. However, larger cohorts are needed to confirm these findings.

Pro: Metabolic Acidosis Should be Corrected With Sodium Bicarbonate in Cardiac Surgical Patients

METABOLIC ACIDOSIS, a commonly encountered acute management challenge during cardiac surgery, is typically a symptom of tissue hypoperfusion. It has many etiologies, though up to 30% of total cardiac cases have been associated with hyperlactatemia. 1 Mak NT Iqbal S de Varennes B et al. Outcomes of post-cardiac surgery patients with persistent hyperlactatemia in the intensive care unit: A matched cohort study. J Cardiothorac Surg. 2016; 11: 33 Crossref PubMed Scopus (19) Google Scholar Hypothermia, rewarming, anemia, hypoxia, shock, hypovolemia, ischemia-reperfusion injury, and gut-derived endotoxemia are all potential contributors to tissue hypoperfusion during cardiac surgery. Additionally, vasoconstrictors used commonly during cardiac surgery also may contribute to tissue hypoperfusion. Metabolic acidosis has been associated with increased morbidity and mortality, and an increased need for intraaortic balloon counterpulsation, blood product transfusion, and prolonged intubation and intensive care unit length of stay. 1 Mak NT Iqbal S de Varennes B et al. Outcomes of post-cardiac surgery patients with persistent hyperlactatemia in the intensive care unit: A matched cohort study. J Cardiothorac Surg. 2016; 11: 33 Crossref PubMed Scopus (19) Google Scholar , 2 Toraman F Evrenkaya S Yuce M et al. Lactic acidosis after cardiac surgery is associated with adverse outcome. Heart Surg Forum. 2004; 7: E155-E159 Crossref PubMed Google Scholar , 3 Basaran M Sever K Kafali E et al. Serum lactate level has prognostic significance after pediatric cardiac surgery. J Cardiothorac Vasc Anesth. 2006; 20: 43-47 Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar Although exogenous sodium bicarbonate (SB) administration is a common practice for acidosis correction in cardiac surgical patients, its use is highly controversial. In this manuscript, the authors outline the rationale and merits of using SB for the treatment of metabolic acidosis after cardiac surgery.

1623 Atrial Fibrillation Post Aortic Valve Replacement: Prevalence and Causative Factors

Abstract Aim Atrial fibrillation (AF) is the most prevalent arrhythmia. Post-Operative AF (POAF) occurs in a third of patients post cardiac surgery. We aim to explore the incidence of AF post aortic valve replacement (AVR) and whether clinical and echocardiographic parameters can predict the likelihood of AF and therefore influence the management of patients. Method Our study consisted of 985 patients who underwent AVR between 2018 – 2019 from a single major cardiothoracic surgery centre in the UK. Data was collected from the electronic patient records retrospectively. Results Mean age of the cohort was 71.8 years (27-92). There were more males (68.2%, n = 672) than females (31.8%, n = 313). A majority of patients (51.8%, n = 510) developed an episode of AF in the post-operative period, of which 65.1% was new onset (n = 330). Incidence of post-operative AF was associated with more HTN (p = 0.007), poor left ventricular function as well as increased left atrial diameter (P = &amp;lt;0.001). Conclusions There is a high incidence of AF following AVR surgery. Comorbidities as well as left atrial diameter have a statistically significant relationship with this incidence and could be used as predictors of postoperative atrial fibrillation.

A translational study of Galectin-3 as an early biomarker and potential therapeutic target for ischemic-reperfusion induced acute kidney injury.

We evaluated Galectin-3 (Gal-3) as a potential early biomarker of acute kidney disease (AKI), and the effect of Gal-3 inhibition by modified citrus pectin (P-MCP) on renal ischemia/reperfusion (I/R) induced AKI. Among fifty-two post-cardiac surgery patients, serum and urine Gal-3 levels were examined on intensive care unit (ICU) admission. In a rat renal I/R injury model, Gal-3 levels, renal function, and histopathology were evaluated in rats pretreated with P-MCP for one week (n = 16) compared to controls (n = 16). Among post-cardiac surgery patients, median serum and urine Gal-3 levels on ICU admission were higher in patients who developed AKI than those who did not (AKI vs non-AKI serum: 18.37 vs. 8.08 ng/ml, p < 0.001; AKI vs non-AKI urine:13.27 vs. 6.27 ng/ml, p < 0.001). Serum and urine Gal-3 levels were reliable biomarkers for detecting AKI (AUC: 0.88 and 0.87). In the rat renal I/R injury model, I/R caused an increase of Gal-3 at 0.5 h after reperfusion (p < 0.05). Gal-3 inhibition by P-MCP significantly decreased Gal-3 release and expression (p < 0.05), reduced interleukin (IL-6) release (p < 0.05), decreased renal dysfunction, and reduced renal tubular injury. Gal-3 is a potential early biomarker in the diagnosis of AKI. Inhibition of Gal-3 may provide therapeutic utility in the treatment of I/R-induced AKI.

Manual Hyperinflation, A Novel Technique in Physiotherapy of Pediatric Post Cardiac Surgery Patients

Background: Physiotherapy plays an important role in Pediatric Intensive Care Unit (PICU) after cardiac surgery, and addition of manual hyperinflation (MHI) to physiotherapy program may help early weaning from mechanical ventilation and decrease length of stay in PICU. Objective: To measure the effect of MHI on ventilation period and ICU stay days in pediatric post cardiac surgery patients. Patients and methods: Thirty patients from both sexes were selected from PICU at Academic Institute for Heart Surgery, Ain Shams University. Their ages ranged from 6 to 36 months. Results: There was a significant decrease in PaCO2 post treatment compared with that pre-treatment in the study and control groups (p>0.05). There was a significant increase in PaO2 post treatment compared with that pre-treatment in the study and control groups (p>0.001). Comparison between groups post treatment revealed a significant increase in PaO2 and a significant decrease in PaCO2 of the study group compared with that of the control group (p>0.01). There was a significant decrease in ventilation days and ICU stay days of the study group. Conclusion: Based on this study, it could be concluded that manual hyperinflation improves arterial oxygenation and reduces length of stay in PICU.

Dexmedetomidine Use in Intensive Care Unit Sedation and Postoperative Recovery in Elderly Patients Post-Cardiac Surgery (DIRECT)

This study examined recovery, delirium, and neurocognitive outcome in elderly patients receiving dexmedetomidine or propofol sedation after undergoing cardiac surgery. Open-label randomized trial. Single center. A total of 70 patients older than 75 years without English language limitations and Mini Mental State Examination scores >20. Patients received either propofol (group P) or dexmedetomidine (group D) postoperatively until normothermic and hemodynamically stable. Quality of recovery (QoR) was measured by the QoR-40 questionnaire on postoperative day (POD) three. Secondary outcomes were incidence and duration of delirium, time to extubation, length of hospital stay, hospital mortality rate, postoperative quality of life (QoL; measured by SF-36 performed at baseline and six months postoperatively), and neurocognitive disorder (measured by Minnesota Cognitive Acuity Screen [MCAS] performed at baseline, POD5, and six months postoperatively). A total of sixty-seven patients completed the trial. There was no significant difference in QoR-40 scores (95% confidence interval [CI], -7.6081-to-10.9781; p = 1.000), incidence of delirium (group P, 42%; group D, 24%; p = 0.191), mean hospital stay (95% CI, -5.4838-to-1.5444; p = 0.297), mean time to extubation (95% CI, -19.2513-to-7.5561; p = 0.866), or mean duration of delirium (95% CI, -4.3065-to-1.067; p = 0.206) between groups. No patients died in the hospital. There were no significant differences in changes in SF-36 or MCAS scores over time between groups. There was a decline in MCAS score from preoperatively to POD5 in group P (95% CI, -8.95725-to- -2.61775; p = 0.0005), which was greater than that observed in group D. The authors' findings demonstrated that the use of dexmedetomidine compared with propofol in elderly patients undergoing cardiac surgery was unlikely to improve QoR/postoperative QoL. Although the study was underpowered to detect secondary outcomes, the results suggested no reductions in delirium, time to extubation, and hospital stay, but a potential decrease in delayed neurocognitive recovery.

Relationship Between First 24-h Mean Body Temperature and Clinical Outcomes of Post-cardiac Surgery Patients.

Background: This study was aimed to investigate the relationship between first 24-h mean body temperature and clinical outcomes of post cardiac surgery patients admitted to intensive care unit (ICU) in a large public clinical database.Methods: This is a retrospectively observational research of MIMIC III dataset, a total of 6,122 patients included. Patients were divided into 3 groups according to the distribution of body temperature. Multivariate cox analysis and logistic regression analysis were used to investigate the association between abnormal temperature, and clinical outcomes.Results: Hypothermia (<36°C) significantly associated with increasing in-hospital mortality (HR 1.665, 95%CI 1.218–2.276; p = 0.001), 1-year mortality (HR 1.537, 95% CI 1.205–1.961; p = 0.001), 28-day mortality (HR 1.518, 95% CI 1.14–2.021; p = 0.004), and 90-day mortality (HR 1.491, 95% CI 1.144–1.943; p = 0.003). No statistical differences were observed between short-term or long-term mortality and hyperthermia (>38°C). Hyperthermia was related to the extended length of ICU stay (p < 0.001), and hospital stay (p < 0.001).Conclusion: Hypothermia within 24h after ICU admission was associated with the increased mortality of post cardiac surgery patients. Enhanced monitoring of body temperature within 24h after cardiac surgery should be taken into account for improving clinical outcomes.

Rapid 500 mL albumin bolus versus rapid 200 mL bolus followed by slower continuous infusion in post-cardiac surgery patients: a pilot before-and-after study

Objective: To evaluate the haemodynamic effects of rapid fluid bolus therapy (FBT) (500 mL of 4% albumin over several minutes) versus combined FBT (rapid 200 mL FBT followed by a 300 mL infusion over 30 minutes).Design: Single centre, prospective, before-and-after trial.Setting: A tertiary intensive care unit in Australia.Participants: Fifty mechanically ventilated post-cardiac surgery patients.Interventions: Rapid 4% albumin FBT versus combined FBT.Main outcome measures: We recorded haemodynamic parameters from before FBT to 30 minutes after FBT. A mean arterial pressure (MAP) response was defined by a MAP increase > 10%, and a cardiac index (CI) response was defined by a CI increase > 15%.Results: Immediately after rapid FBT versus combined FBT, there was a CI response in 13 patients (52%) compared with five patients (20%) respectively (P = 0.038), and a MAP response in 11 patients (44%) in each group. However, from FBT administration to 30 minutes, there was a time and group interaction such that MAP was higher in the rapid FBT group (P = 0.003), as was the case for central venous pressure (P = 0.002) and mean pulmonary artery pressure (P < 0.001). Body temperature fell immediately and was lower with rapid FBT but became warmer than with combined FBT later (P < 0.001). At 30 minutes, a MAP response was seen in ten patients (40%) compared with nine patients (36%) (P < 0.99) and a CI response was present in eight patients (32%) compared with 11 patients (44%) (P = 0.56) in the rapid versus combined FBT groups respectively.Conclusion: Rapid FBT was superior to combined FBT in terms of mean MAP levels and immediate CI response. However, the number of MAP responders or CI responders was similar at 30 minutes.

Multidisciplinary, early mobility approach to enhance functional independence in patients admitted to a cardiothoracic intensive care unit: a quality improvement programme

Early mobilisation following cardiac surgery is vital for improved patient outcomes, as it has a positive effect on a patient’s physical and psychological recovery following surgery. We observed that patients...

A Pilot Study of Blood Pressure Monitoring After Cardiac Surgery Using a Wearable, Non-invasive Sensor.

Background: Continuous blood pressure (BP) measurement in intensive care units is based on arterial line (AL) transducers, sometimes associated with clinical complications. Our objective was to evaluate continuous BP measurements obtained from a non-invasive, wireless photoplethysmography (PPG)-based device using two distinct configurations (wristwatch and chest-patch monitors) compared to an AL.Methods: In this prospective evaluation study, comparison of the PPG-based devices to the AL was conducted in 10 patients immediately following cardiac surgery. Pulse rate (PR), systolic BP (SBP), diastolic BP (DBP), and mean arterial pressure (MAP) were recorded using both the AL and the PPG-based devices simultaneously for an average of 432 ± 290 min starting immediately after cardiac surgery. Bland-Altman plots and Pearson's correlations were used to assess the accuracy and degree of agreement between techniques.Results: A total of ~4,000 data points were included in the final analysis. AL measurements for PR, SBP, DBP and MAP were significantly (p < 0.001) and strongly correlated with both the wristwatch (r = 0.99, r = 0.94, r = 0.93 and r = 0.96, respectively) and the chest-patch (r = 0.99, r = 0.95, r = 0.93 and r = 0.95, respectively) monitors. Both configurations showed a marginal bias of <1 mmHg for BP measurements and <1 beat/min for PR [95% limits of agreement −3,3 beat/min; BP measurements: (−6)–(−10), 6–10 mmHg] compared to AL measurements.Conclusion: The PPG-based devices offer a high level of accuracy for cardiac-related parameters compared to an AL in post-cardiac surgery patients. Such devices could provide advanced monitoring capabilities in a variety of clinical settings, including immediate post-operative and intensive care unit settings.Clinical Trial Registration:www.clinicaltrials.gov, NCT03603860.

Cerebral microbleed distribution following cardiac surgery can mimic cerebral amyloid angiopathy

Background and aimsHaving anecdotally noted a high frequency of lobar-restricted cerebral microbleeds (CMBs) mimicking cerebral amyloid angiopathy (CAA) in patients with previous cardiac surgery (especially valve replacement) presenting to our...

Is airway pressure release ventilation, a better primary mode of post-operative ventilation for adult patients undergoing open heart surgery? A prospective randomised study.

Context:Cardiopulmonary bypass (CPB) induced acute lung injury is accounted for most of the post-operative pulmonary dysfunction which leads to decreased compliance and hypoxemia. Airway Pressure Release Ventilation (APRV) as compared to other modes of ventilation has shown to improve gas exchange in Acute lung injury (ALI)/Acute respiratory distress syndrome (ARDS) lungs.Aims:We hypothesized APRV as a better primary mode of postoperative ventilation in adult post-cardiac surgery patients.Methodology:The study included 90 postoperative surgical patients, which were randomized into three groups: SIMV-PC(P), APRV(A), and SIMV-VC(V) with 30 patients in each group.Subjects and Methods:Lung compliance and serial arterial blood gas were assessed at regular intervals. PaO2/FiO2 ratio (a measure of oxygenation) and lung compliance were used as an indirect indicator for improvement in lung function. Hemodynamic parameters were closely observed for all the patients.Statistical Analysis Used:Statistical analysis was done using ‘R’ software.Results:There was a statistically significant improvement in PaO2/FiO2 ratio in the APRV group as compared to other groups. There was also an improvement in lung compliance after 6 h of ventilation and lesser duration of ventilation in the APRV group. However, it was not statistically significant.Conclusions:Our study suggests that APRV can be a useful alternative primary mode of ventilation to improve lung compliance and oxygenation in adult post-cardiac surgical patients.

Effect of flow and volume-oriented incentive spirometer exercise on the hemodynamic parameters in cardiac surgery patients. Pilot interventional study

Background: The 2 types of incentive spirometers (flow and volume-oriented) prescribed after cardiac surgery demonstrate a difference in the pattern of breathing, diaphragm mobility, pulmonary function test. Limited research is available on effect of incentive spirometer on hemodynamic parameters. Purpose: To provide hemodynamic perspective for preference of a specific type of incentive spirometer after cardiac surgery. Method: Ideal method of performing breathing on their prescribed incentive spirometer was explained. On 2nd day post surgery, heart rate, respiratory rate, oxygen saturation and blood pressure were noted immediately before and after performing 8 breaths on incentive spirometer. Results: The intergroup comparison i.e., difference between changes caused by flow and volume-oriented incentive spirometers are statistically insignificant. The intra group comparison, the changes in hemodynamic parameters by flow and volume-oriented incentive spirometers are statistically insignificant, except for heart rate with flow-oriented incentive spirometers showed statistically significant increase. Conclusions: There is no difference in the impact of flow oriented and volume-oriented Incentive spirometers on hemodynamic parameters in post cardiac surgery patients. KEY WORDS: Incentive spirometer, Cardiac surgery, Heart rate, Blood pressure, Respiratory Rate, Oxygen saturation.

Outcomes of Emergency Gastrointestinal Surgery Done on Post-Cardiac Surgery Patients—Analysis From a Tertiary Care Center

Introduction: Abdominal complications following cardiac surgery have high mortality rates. This study analyzes the outcomes of patients who have undergone emergency general surgery (EGS) procedures after cardiothoracic surgery (CTS) at the same hospitalization. Materials and Methods: This was a retrospective analysis of all patients who underwent emergent abdominal surgery after CTS surgery between 2010–2018. The CTS procedures included coronary artery bypass graft (CABG), valve replacement, cardiac transplant, aortic replacement, ventricular assist device, and pericardial procedures. The records were reviewed to obtain demographics, frequency distribution of EGS procedures, complications, outcomes, and the risk factors of mortality. Results: Of 4826 patients who had CTS, 57 (1.2%) underwent EGS procedures during the period of 2010–2018. This cohort of patients had 113 CTS and 85 EGS procedures during the same hospitalization. The mean age was 62 years, and 49% were elderly (40% were females). CABG with or without valve replacement was the most common surgery (28%). After surgical consultation for “acute abdomen” in the post-CTS phase, the three most common findings on exploratory laparotomy were bowel perforation (23%), massive free fluid leading to abdominal compartment syndrome (19%), and acute cholecystitis (16%). Respiratory failure (46%), acute kidney injury (32%), and multiple organ dysfunction (18%) were the most common hospital-acquired complications. Regarding dispositions, 47% were discharged to an acute rehabilitation center, 10% were discharged to a sub-acute rehabilitation center, and a similar proportion of patients went home (10%). On multivariable logistic regression analysis with backward elimination, age (OR=1.10, 95% CI: 1.02–1.18) and serum proteins (OR=0.99, 95% CI: 0.98-0.998) were independently associated with the odds of mortality after EGS in the immediate CTS phase. Conclusions: Respiratory failure is the most common complication of EGS immediately after CTS. The older the patient and the lower the serum proteins, the higher the odds of mortality in patients who undergo EGS after ETS.

Early Chest Re-Exploration for Excessive Bleeding in Post Cardiac Surgery Patients: Does It Matter?

IntroductionRe-explorations after open-heart surgery are often required if the patient is bleeding or shows features of cardiovascular instability and does not improve with conservative measures. Our study aims to determine whether timely re-exploration of patients who are bleeding has an impact on the morbidity and mortality of the patients.MethodsA retrospective analysis of 75 patients that underwent open-heart surgery and subsequently underwent chest re-exploration for excessive bleeding between March 2018 and March 2020. Patients who were reopened post-op for indications other than excessive bleeding were excluded.ResultsA total number of cases were 700, out of which 75 (9.3%) patients were reopened, as compared to the literature, which shows worldwide 2-11% being reopened. Post-operative drain output was 1000ml to 1500ml in 47 (62.7%) and more than 1500ml in 28 (37.3%) patients before they were reopened. In 67 (89.3%) patients, three to five units of blood were transfused, and in eight (10.7%) patients, more than five units of blood were transfused. We believe our mortality in the reopened patients was low, because of timely intervention and early re-exploration, and is probably the reason why our figures land in a higher range (2-11%) of reopened cases (9.3%). Reopening time was less than five hours in 49 (65.3%) patients and less than 10 hours in 26 (34.7%) patients in our study. We tried to minimize the loss of blood and re-explored the patients before they lose excessive blood, the average time for reopening in our study was less than 10 hours. The average intensive care unit (ICU) stay was 4.2 days (range three to six days). Wound infections were reported in one of three patients. There was no mortality in these patients. Surgical site of bleeding was identified in 54 (72%) patients and no particular site was found in 21 (28%) patients. Suggesting that it is common to have a surgical bleeder than coagulopathy induced bleeding in post-cardiac surgery patientsConclusionsWe believe our low mortality (0%) is due to early reopening in patients who are bleeding excessively after cardiac surgery.

Peripheral cannulation for extracorporeal membrane oxygenation yields superior neurologic outcomes in adult patients who experienced cardiac arrest following cardiac surgery.

Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest has improved mortality in post-cardiac surgery patients; however, loss of neurologic function remains one of the main and devastating complications. We reviewed our experience with ECPR and investigated the effect of cannulation strategy on neurologic outcome in adult patients who experienced cardiac arrest following cardiac surgery that was managed with ECPR. Patients were categorized by central versus percutaneous peripheral VA-extracorporeal membrane oxygenation (ECMO) cannulation strategy. We reviewed patient records and evaluated in-hospital mortality, cause of death, and neurologic status 72 hours after cannulation. From January 2010 to September 2019, 44 patients underwent post-cardiac surgery ECPR for cardiac arrest. Twenty-six patients received central cannulation; 18 patients received peripheral cannulation. Mean post-operative day of the cardiac arrest was 3 and 9 days (p = 0.006), and mean time between initiation of CPR and ECMO was 40 ± 24 and 28 ± 22 minutes for central and peripheral cannulation, respectively. After 72 hours of VA-ECMO support, 30% of centrally cannulated patients versus 72% of peripherally cannulated patients attained cerebral performance status 1-2 (p = 0.01). Anoxic brain injury was the cause of death in 26.9% of centrally cannulated and 11.1% of peripherally cannulated patients. Survival to discharge was 31% and 39% for central and peripheral cannulation, respectively. Peripheral VA-ECMO allows for continuous CPR and systemic perfusion while obtaining vascular access. Compared to central cannulation, a peripheral cannulation strategy is associated with improved neurologic outcomes and decreased likelihood of anoxic brain death.

Expanding the potential benefits of colchicine for preventing postpericardiotomy syndrome and atrial fibrillation complications after cardiac surgery: meta-analysis of randomized controlled trials

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Postpericardiotomy syndrome (PPS) and atrial fibrillation (AF) are complications occurred in one-third of cardiac surgery patients that increase morbidity and mortality. Colchicine is an anti-inflammatory drug for treating acute pericarditis and pericardial effusion. Previous studies suggested that colchicine also may prevent PPS and AF after cardiac surgery although the results were still inconsistent. Purpose This study intends to determine the efficacy of colchicine for preventing PPS and AF in post-cardiac surgery patients. Methods We conducted comprehensive literature searching in online databases of Pubmed, EMBASE, ScienceDirect, and The Cochrane Library, to include all relevant studies until November 2020. We included all randomized controlled trials (RCTs) that access the incidence of PPS and AF after cardiac surgery in patients who received colchicine before cardiac surgery compared with placebo. We use revised Cochrane risk-of-bias tool (RoB 2) for accessing the bias risk of included studies. We performed analysis to provide pooled risk ratio (RR) with 95% confidence interval (CI) using fixed-effect heterogeneity test. Results We included 9 RCTs with total of 2,372 participants met our inclusion criteria. The administration of colchicine before cardiac surgery decreases the incidence of PPS significantly (pooled RR = 0.55, 95% CI 0.43 – 0.71, p &amp;lt; 0.00001. I² = 0%). Besides, colchicine also significantly lowers the incidence of postoperative AF compared with placebo (pooled RR = 0.79, 95% CI 0.65 – 0.96, p = 0.02. I² = 20%). Conclusions Colchicine showed potential benefits for preventing PPS and AF after cardiac surgery. However, further trials are needed to establish the efficacies.

Subacute postoperative atrial fibrillation after heart surgery: incidence and predictive factors in cardiac rehabilitation

Abstract Funding Acknowledgements Type of funding sources: None. Background. Postoperative atrial fibrillation (POAF) is the most common arrhythmic complication following cardiac surgery. It may occur between the second and fourth postoperative days as acute POAF, or within 30 days as subacute POAF (sPOAF). The incidence varies from 15% to 60%, with the highest rates observed in patients undergoing valvular surgery. POAF is associated with longer hospital stay and higher thromboembolic risk, which consistently increase patients’ morbidity and mortality. Identification of high-risk categories may allow optimization of in-hospital prevention and treatment, possibly improving clinical outcomes. Aim of the study. The aim of this study was to assess the incidence of sPOAF and to identify possible predictors in patients performing Cardiovascular Rehabilitation (CR) after Cardiac Surgery (CS). Methods. A single-centre retrospective study was performed on 383 post-cardiac surgery patients hospitalised in our CR Unit for inpatient rehabilitation. The entire population was on sinus rhythm at the admission in CR and continuous monitoring with 12-lead ECG telemetry was performed during the hospital stay. We calculated the incidence of sPOAF and then evaluated the predictive value of the following variables: anamnestic data, type of cardiac intervention, clinical course in both CS and CR Unit, laboratory parameters including baseline neutrophil-to-lymphocyte ratio (NLR). Results. Median age was 65 years (63% male). sPOAF was documented in 122 cases (31.9%). Patients developing sPOAF were older [median age 69 (63-76) vs. 61 (51-70); p &amp;lt; 0.001)], more frequently underwent complex surgical procedures (50% vs. 36%; p = 0.009) and were known for previous episodes of atrial fibrillation (27.9% vs. 11.2%; p &amp;lt; 0.001). On the first day after surgery (T1), sPOAF group showed higher values of glycemia [median 155 (126.5–186.8) vs. 129 (106.5–164); p &amp;lt; 0.001] and troponin T [median 721.5 (470.1–1084.3) vs. 488 (301.6-776.2); p &amp;lt; 0.001]. The multivariate analysis identified advanced age (OR 1.04, 95% CI 1.01-1.08; p = 0.023), acute POAF in the Cardiac Surgery Unit (OR 3.51, 95% CI 1.62-7.59; p = 0.001), baseline NLR (OR 1.46, 95% CI 1.10-1.93; p = 0.008) and T1-troponin &amp;gt; 552 ng/L (OR 4.16 95% CI 1.50-11.53; p = 0.006) as independent risk predictors of sPOAF during the CR period. Conclusions. sPOAF is common after cardiac surgery occurring in 31.9% of patients during CR. Age, acute POAF, baseline NLR and elevated troponin T on the first postoperative day were shown predictors of increased sPOAF risk. Recognition of new predictors of POAF could be helpful to better stratify patients, improving management strategies and outcomes.

The hemodynamic effects of warm versus room-temperature crystalloid fluid bolus therapy in post-cardiac surgery patients.

The contribution of fluid temperature to the effect of crystalloid fluid bolus therapy (FBT) in post-cardiac surgery patients is unknown. We evaluated the hemodynamic effects of FBT with fluid warmed to 40°C (warm FBT) versus room-temperature fluid. In this single centre prospective before-and-after study, we evaluated the effects of 500 ml of warm versus room-temperature compound sodium lactate administered over <30 minutes, in 50 cardiac surgery patients admitted to ICU. We recorded hemodynamics continuous before and for 30 minutes after the first FBT. We defined CI responsiveness (CI-R) as an CI increase >15% of baseline immediately after FBT and effect dissipation if the CI returned to <5% of baseline and MAP responsiveness as >10% increase and dissipation as return to <3 mmHg of baseline. Hypotension (56%) and low CI (40%) typically triggered FBT. Temperature decreased >0.3°C in 13 (52%) patients after room-temperature FBT versus 0 (0%) after warm FBT (p < 0.01). CI and MAP responsiveness was similar (16 [64%] versus 11 [44%], p = 0.15 and 15 [60%] versus 17 [68%], p = 0.77, respectively). Among CI responders, CI increased more with room-temperature FBT (+0.6 [IQR, 0.5-1.1] versus +0.5 [IQR, 0.4-0.6] L/min/m2, p = 0.01). However, dissipation was more common after room-temperature versus warm FBT (9/16 [56%] versus 1/11 [9%], p = 0.02). In postoperative cardiac surgery patients, warm FBT preserved core temperature and induced smaller but more sustained CI increases among responders. Fluid temperature appears to impact both core temperature and the duration of CI response.