Preoperative Intra-aortic Balloon Pump Research Articles

Preoperative intra-aortic balloon pump in patients with ST-elevation myocardial infarction undergoing urgent cardiac bypass surgery.

In patients with ST-elevation myocardial infarction (STEMI), either with or without cardiogenic shock, mechanical circulatory support with an intra-aortic balloon pump (IABP) is not associated with lower mortality. However, in STEMI patients undergoing urgent coronary artery bypass grafting (CABG), preoperative insertion of an IABP has been suggested to reduce mortality. In this study, the effect of preoperative IABP use on mortality in STEMI patients undergoing urgent CABG was investigated. All consecutive STEMI patients undergoing urgent CABG in asingle centre between 2000 and 2018 were studied. The primary outcome, 30-day mortality, was compared between patients with and without apreoperative IABP. Subgroup analysis and multivariable analysis using apropensity score and inverse probability treatment weighting were performed to adjust for potential confounders. Atotal of 246 patients were included, of whom 171 (69.5%) received apreoperative IABP (pIABP group) and 75 (30.5%) did not (non-pIABP group). In the pIABP group, more patients suffered from cardiogenic shock, persistent ischaemia and reduced left ventricular function. Unadjusted 30-day mortality was comparable between the pIABP and the non-pIABP group (13.3% vs 12.3%, p = 0.82). However, after correction for confounders and inverse probability treatment weighting preoperative IABP was associated with reduced 30-day mortality (relative risk 0.52, 95% confidence interval 0.30-0.88). In patients with STEMI undergoing urgent CABG, preoperative insertion of an IABP is associated with reduced mortality.

Impact of preoperative intra-aortic balloon pump on outcomes in coronary artery bypass grafting for unprotected left-main coronary artery disease.

Preoperative intra-aortic balloon pump (IABP) before coronary artery bypass grafting (CABG) could improve operative outcomes by augmenting the diastolic coronary blood flow. Data on preoperative IABP use in patients with left-main coronary artery (LMCA) disease are limited. This study aimed to characterize patients who received preoperative IABP before CABG for LMCA and evaluate its effect on postoperative outcomes. This multicenter retrospective cohort study that included consecutive 914 patients who underwent CABG for unprotected LMCA disease from January 2015 to December 2019 in 14 tertiary referral centers. Patients were grouped according to the preoperative IABP insertion into patients with IABP (n=101) and without IABP (n=813). Propensity score matching adjusting for preoperative variables, with 1:1 match and a caliber of 0.03 identified 80 matched pairs. The primary outcomes used in propensity score matching were cardiac mortality and major adverse cardiac and cerebrovascular events (MACCE). IABP was commonly inserted in patients with previous myocardial infarction (MI), chronic kidney disease, peripheral arterial disease, and congestive heart failure. IABP patients had higher EuroSCORE [ES >8%: 95 (11.86%) vs. 40 (39.60%), P<0.001] and SYNTAX {29 [interquartile range (IQR) 25-35] vs. 33 (IQR 26-36); P=0.02} scores. Preoperative cardiogenic shock and arrhythmia were more prevalent in patients with IABP, while acute coronary syndrome was more prevalent in patients without IABP. After matching, there was no difference in vasoactive inotropic score between groups [3.5 (IQR 1-7.5) vs. 6 (IQR 1-13.5), P=0.06], and lactate levels were nonsignificantly higher in patients with IABP [2.4 (IQR 1.4-4.5) vs. 3.1 (IQR 1.05-7.75), P=0.05]. There were no differences between groups in acute kidney injury [20 (25%) vs. 26 (32.5%), P=0.34], cerebrovascular accidents [3 (3.75%) vs. 4 (5%), P>0.99], heart failure [5 (6.25%) vs. 7 (8.75%), P=0.75], MI [7 (8.75%) vs. 8 (10%), P>0.99], major adverse cardiac and cerebrovascular events [10 (12.5%) vs. 17 (21.25%), P=0.21], and cardiac mortality [6 (7.50%) vs. 14 (17.50%), P=0.09]. Patients who received IABP had longer ventilation times [8.5 (IQR 6-23) vs. 15.5 (IQR 5-50.5) h, P=0.03] and intensive care unit (ICU) stays [3 (IQR 2-5) vs. 4 (IQR 2-7.5) days, P=0.01]. Preoperative IABP in patients with LMCA might not be associated with reduced cardiac mortality or hospital complications. IABP could increase the duration of mechanical ventilation and ICU stay, and its use should be individualized for each patient.

Outcomes of Patients Presenting with Non-ST Elevation Myocardial Infarction Undergoing Surgical Revascularization.

Non-ST-segment elevation myocardial infarction (NSTEMI) is a leading cause of emergency hospitalisation across Europe. This study evaluates the in-hospital and mid-term outcomes of patients undergoing coronary artery bypass grafting (CABG) following NSTEMI. A retrospective analysis of all cases undergoing isolated CABG following NSTEMI from September/2017 to September/2022 at our Centre. Patients were stratified according to in-hospital survival. Patient characteristics, operative details, and procedural complications were compared between those who survived and those who did not. Predictors of in-hospital and mid-term mortality were evaluated using logistic and Cox regression modelling. Kaplan Meier analysis was used to generate a survival curve for all alive patients at the time of discharge. Among 1011 patients (median age 64 [56 - 72] years, 852 [84.3%] male), 735 (72.7%) underwent urgent, 239 (23.6%) elective, and 37 (3.7%) emergency CABG. The in-hospital mortality was 1.5% (15/1011 patients). Those who died were more likely to be NYHA class III/IV, have LVEF <21%, severe renal impairment, peripheral vascular disease (PVD), or poor mobility. Emergency procedures, pre-operative ventilation, inotropic support, and intra-aortic balloon pump (IABP) use were also more prevalent among those who died. Logistic regression modelling revealed new postoperative stroke (OR:22.0; 95% CI:3.6-135.5; p=0.001), pre-operative IABP use (11.4; 2.4-53.7; p=0.002), new haemodialysis (9.6; 2.7-34.7; p<0.001), PVD (5.6; 1.6-20.0; p=0.008), and poor mobility (OR: 4.8; 95% CI: 1.3-18.2; p=0.022) as independent predictors of in-hospital mortality. In conclusion, new postoperative stroke, pre-operative IABP use, new haemodialysis, PVD and poor mobility are independent predictors of mortality in NSTEMI patients undergoing isolated CABG.

Blood perfusion status is important in the prognosis of ventricular aneurysm complicated by ventricular septal rupture.

Due to its low incidence, poor prognosis, and high mortality in the acute phase, the long-term prognosis of the left ventricular aneurysm (LVA) complicated by ventricular septal rupture (VSR) has received little attention. This study focus on the long-term prognosis of patients with LVA complicated by relatively stable VSR. Over a decade of retrospection, 68 patients with both LVA and VSR were compared with 136 patients with LVA alone after propensity score matching. Patients with both LVA and VSR were further divided into two groups depending on whether pre-operative intra-aortic balloon pump (IABP) was used (23 pre-operative IABP vs. 45 non-pre-operative IABP). The primary endpoint was defined as major adverse cardiovascular and cerebrovascular events, a composite endpoint including mortality, myocardial infarction, revascularization, stroke, and heart failure. Patients with both LVA and VSR were generally in a worse condition upon admission compared with those with LVA alone [percentage of patients in New York Heart Association IV: 42.6% (29/68) vs. 11.0% (15/136), P<0.001]. Both pre-operative and post-operative IABP use rates were significantly higher in patients with both LVA and VSR than in patients with LVA alone [pre-operative IABP use rates: 33.8% (23/68) vs. 0.74% (1/136), P<0.001 and post-operative IABP use rates: 33.8% (23/68) vs. 10.3% (14/136), P<0.001]. No significant difference was observed in the primary endpoint between patients with both LVA and VSR and those with LVA alone (log-rank test, P=0.63, median follow-up time 63months). We further investigated the effect of pre-operative IABP on the long-term prognosis of patients with both LVA and VSR. Patients who applied pre-operative IABP had a worse long-term prognosis than those who did not (log-rank test, P=0.0011). The long-term prognosis of LVA combined with VSR was not inferior than LVA alone after surgery, but poor blood perfusion status was associated with a worse prognosis.

Female Gender in Cardiac Surgery: Is it Still a Significant Risk? A Retrospective Study in Saudi Arabia.

Female sex is considered an independent predictor for mortality and morbidity following cardiac surgery. This study is to review the outcomes of adult cardiac surgery between males and females in a Saudi tertiary referral hospital. This was a retrospective study for 925 adult patients operated on for ischemic coronary artery disease and acquired aortic and mitral valvular heart disease from 2015 to August 2023. We analyzed patient characteristics, intraoperative data, and postoperative results to compare outcomes between males and females. Preoperative risk factors were not significantly different in both groups. Postoperative outcomes showed gender-based differences. In univariable analysis, females, compared to males, had significantly greater odds of prolonged postoperative ventilation (>24 hours), 32.8% of females compared to 20.7% of males (p < 0.001). Also, sternal wound infection was notably higher among females (13.3%) (p < 0.001). Mortality also exhibited a significant association, with 14.2% of females experiencing mortality compared to 9.4% of males (p = 0.049). In the multivariable analysis for elevated postoperative troponin, the use of pre-operative intra-aortic balloon pump, urgent/emergent surgery, elevated pre-operative troponin and combined bypass grafting with valve surgery, were also predictive of higher post-operative troponin concentrations (beta = 0.43, 95% CI: 0.25 to 0.62, p < 0.001). Females in Saudi Arabia have an increased risk of short-term morbidity and mortality after cardiac surgery compared to males. Vague and delayed presentation and then the late diagnosis and referral are likely the main contributing factors. This highlights the need to implement preoperative measures to improve early diagnosis and referral to eliminate gender bias.

Association of cardiopulmonary bypass with acute kidney injury in patients undergoing coronary artery bypass grafting: a retrospective cohort study.

Association of cardiopulmonary bypass with acute kidney injury in patients undergoing coronary artery bypass grafting: a retrospective cohort study.

Abstract 18595: Predictors of Prolonged Post-Operative Stay in Patients Undergoing Coronary Artery Bypass Grafting: The Impact of Multi-Disciplinary Quality of Care Protocols, a Single Center Experience From the Middle East

Background: Prolonged postoperative stay (POS) in patients undergoing CABG is associated with increased cost, inefficient utilization of resources, and poor quality of care (QOC). We aim to identify predictors of prolonged POS and evaluate the overtime impact of multidisciplinary team (MDT) QOC protocols on POS at a newly established tertiary care center. Methods: A total of 1168 consecutive patients undergoing isolated CABG between 2015-2022 were evaluated. POS was identified as prolonged (&gt;6 days) and short (≤ 6 days). Short vs. prolonged stay groups were compared by appropriate testing methods. Predictors of prolonged POS were determined by multivariable logistic regression. Trends in prolonged POS were determined using Joinpoint Software to calculate the average annual percentage change (AAPC). Results: Overall, 44.3% (517/1168) of patients had prolonged POS. Patients in the prolonged POS group were older (59.1±10.5 vs. 56.3± 9.5, P&lt;0.001), more likely females (16.6% vs. 9.7%, P&lt;0.001), and had a higher burden of hypertension (88.1% vs. 81.9%, P=0.004), and diabetes (74.8% vs. 62.7%, P&lt;0.001). The prolonged POS group featured worse ejection fraction, higher serum creatinine, and more frequently required preoperative intra-aortic balloon pump insertion (Table) . On multivariable logistic regression, age, female gender, NYHA class ≥II, history of diabetes, preoperative creatinine level, preoperative EF, and preoperative IABP placement were independent predictors of prolonged POS (Figure A) . Between 2015-2022, more QOC protocols were initiated, with a 67% relative reduction in the proportion of patients with prolonged POS (85.7% to 28.3%), with an AAPC of -12.8, 95% CI [-16.3, -9.2], P&lt;0.001 (Figure B). Conclusion: Initiating MDT QOC protocols was associated with a reduction in POS among patients undergoing CABG. Identifying predictors of prolonged POS can help in timely planning of milestones aimed at eliminating unnecessary POS.

Effect of peri-operative intra-aortic balloon pump in patients undergoing coronary artery bypass grafting on outcomes in a resource limited setting.

Intra-aortic balloon pump (IABP) insertion for diminished myocardial function is standard of care in cardiac surgery. Previous studies have suggested a possible benefit to IABP support before surgery with regards to outcomes and complications. However, there are conflicts with other studies suggesting no significant benefit. Optimal time of insertion, whether preoperative or perioperative (intra-operative and post-operative), has yet to be defined. A retrospective, hospital records-based chart review was conducted for patients admitted to our center from January 2015 to December 2019 for coronary bypass surgery necessitating IABP insertion. Cases were stratified according to the timing of insertion and analyzed according to surgical outcomes and complication rates. Out of 97 patients, 84.5% underwent preoperative IABP insertion while 15.5% of patients received perioperative (Intra-operative or post-operative) insertion. In-hospital mortality was significantly higher in patients with perioperative IABP insertion as compared to the preoperative group (60% vs 20.7%, p = 0.003). However, there were no significant differences between 30-day readmission rates in the two groups (9.8% vs 6.7%, p = 1.000). Length of stay was also higher in patients with preoperative insertion of IABP (p = 0.032), with no significant difference in ICU stay (p = 0.107). Perioperative IABP patients had higher rates of arrhythmias (46.7%, p = 0.042) and reopening of patient (33.3%, p = 0.028). Our study shows improved mortality in patients with preoperatively inserted IABP. This may be beneficial for high-risk patients undergoing CABG surgery. Expanding the use of IABP before CABG in third world countries such as Pakistan may improve overall survival for patients.

Impact of prophylactic intra-aortic balloon pump on early outcomes in patients with severe left ventricular dysfunction undergoing elective coronary artery bypass grafting with cardiopulmonary bypass

ObjectiveOur aim was to analyse whether prophylactic preoperative intraaortic balloon pump (IABP) improves outcomes in hemodynamically stable patients with low left ventricular ejection fraction (LVEF ≤30%) undergoing elective myocardial revascularization (CABG) using cardiopulmonary bypass (CPB). Secondary aim was to identify the predictors for low cardiac output syndrome (LCOS). MethodsProspectively collected data of 207 consecutive patients with LVEF ≤30% undergoing elective isolated CABG with CPB from 01/2009 to 12/2019, 136 with and 71 patients without IABP, were retrieved retrospectively. Patients with prophylactic IABP were matched 1:1 with patients without IABP by a propensity score matching. Stepwise logistic regression was conducted to identify predictors of postoperative LCOS in the propensity-matched cohort. P value ≤0.05 was considered significant. ResultsReduced postoperative LCOS (9.9% vs. 26.8%, P = 0.017) was observed in patients receiving prophylactic IABP. Stepwise logistic regression identified preoperative IABP as preventive factor for postoperative LCOS [Odds Ratio (OR) 0.19,95% Confidence Interval (CI), 0.06–0.55, P = 0.004]. The need of vasoactive and inotropic support was lower in patients with prophylactic IABP at 24, 48 and 72 h after surgery (12.3 [8.2–18.6] vs. 22.2 [14.4–28.8], P < 0.001, 7.7 [3.3–12.3] vs.16.3 [8.9–27.8], P < 0.001 and 2.4 [0–7] vs. 11.5 [3.1–26], P < 0.001, respectively). The patients in both groups did not differ in terms of in-hospital mortality (7.0% vs. 9.9%, P = 0.763). There were no major IABP-related complications. ConclusionsElective patients with left ventricular ejection fraction ≤30% undergoing CABG with CPB and prophylactic IABP insertion had less low cardiac output syndrome and similar in-hospital mortality.

Waitlist Trends in Heart-Liver Transplantation With Updated US Heart Allocation System

BackgroundIn October 2018, the United States implemented a change in the donor heart allocation policy from a three-tiered to a six-tiered status system. The purpose of the current study was to examine changes in waitlist patterns among patients listed for concomitant heart-liver transplantation with implementation of the new allocation system. MethodsPatients listed for heart-liver transplantation between January 1, 2012, and June 30, 2021, were identified from the United Network for Organ Sharing database. Patients were grouped by era according to initial list date before or after October 18, 2018. Competing risks regression for mortality, transplantation, removal from waitlist due to illness was performed according to the method of Fine and Gray. Waitlist data were censored at 3 years from initial listing. ResultsOverall, 523 patients were identified, of whom 310 were listed before (era 1, 59%) and 213 after (era 2, 41%) allocation change. Patients in era 1 were older, had more restrictive cardiomyopathy, and more preoperative inotrope use (all P < .05). However, patients in era 2 has longer ischemic times (3.5 ± 1.1 vs 3.1 ± 1.1 hours, P < .01) and more intraaortic balloon pump use (8.9% vs 3.9%, P = .016). Era 2 was associated with lower subdistribution hazard for death (hazard ratio 0.37; 95% CI, 0.13-1.02; P = .054) and increased transplantation (hazard ratio 1.35; 95% CI, 1.06-1.72; P = .015). ConclusionsThe implementation of the US donor heart allocation policy was associated with more preoperative intraaortic balloon pump use for patients listed for heart-liver transplantation. Despite that, the modern era was associated with lower waitlist mortality and more frequent transplantation, without increased risk of delisting due to illness.

The impact of initiating quality of care improvement protocols on intensive care unit length of stay in patients undergoing coronary artery bypass grafting: An insight from a nascent program

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Prolonged intensive care unit (ICU) length of stay (LOS) post coronary artery bypass grafting (CABG) constitutes a major challenge for both patients and cardiac surgery teams. While Identifying predictors of prolonged patients’ stay in the ICU can further optimise ICU resource utilization, the role of initiating QOC improvement protocols aimed to reduce ICU LOS for these patients has been widely advocated. Therefore, we aim in our study to evaluate the overtime impact of initiating QOC improvement protocols on ICU LOS and present patient characteristics predicting prolonged ICU stay in patients undergoing CABG in a nascent program. Methods We included consecutive patients (n=976) undergoing CABG at a newly established tertiary centre between June 2015 and September 2021. Data on baseline characteristics and presentation, in addition to intraoperative details and outcomes, were collected retrospectively. Patients with prolonged (≥48h) and short (&amp;lt;48h) ICU LOS were compared by appropriate testing methods. Predictors of prolonged ICU LOS were determined by multivariable logistic regression. Continuous development of ongoing protocols to improve QOC was taken, including but not limited to; enhancing diabetic control, coronary perfusion and renal function. Trends in prolonged ICU LOS were determined using Joinpoint Software of the National Cancer Institute to calculate the average annual percentage change (AAPC). Results QOC improvement protocols initiation was associated with a 33.7% reduction in the proportion of patients having prolonged ICU LOS post- CABG between 2015 to 2021 ( AAPC: -5.3 , 95%CI [-7.7, -2.9], p&amp;lt;0.001) . Overall, 56.4% (551/976) of patients had prolonged ICU LOS. In comparison to individuals with short ICU LOS, patients who overstayed in the ICU were significantly older, females, diabetic, with higher burden of peripheral vascular disease (Table). On presentation, the prolonged LOS group was featured by worse NYHA class, higher rates of acute myocardial infarction (MI), lower ejection fraction (EF), higher serum creatinine and more frequently required preoperative intra-aortic balloon pump (IABP) insertion (Table). Aortic cross-clamp time and type of surgery were comparable between groups. Unfavorable outcomes were noticed in the prolonged ICU LOS group regarding postoperative adverse events and mortality. On multivariable logistic regression, age, female gender, NYHA class ≥II, MI on presentation, preoperative creatinine level, preoperative EF and preoperative IABP placement were independent predictors for prolonged ICU LOS (Figure). Conclusion In this study, initiation of QOC improvement protocols was associated with a significant reduction in prolonged ICU LOS. While multiple risk factors prolonging ICU LOS were identified, future studies are required to further incorporate these risk factors into ongoing protocols aimed to optimise resources utilisation and enhance the QOC in CABG patients.

Long-term effects of primary graft dysfunction after heart transplantation.

We studied the incidence of primary graft dysfunction (PGD), its impact on in-hospital and follow-up outcomes and searched for independent risk factors. During an 18-year period, 508 individuals underwent heart transplantation at our institution. Patients were diagnosed with none, mild, moderate or severe PGD according to ISHLT criteria. Thirty-eight patients (7.5%) met the ISHLT criteria for mild PGD, 92 (18.1%) for moderate PGD and 23 (4.5%) for severe PGD. Patients were classified into none/mild PGD (77.4%) and moderate/severe PGD (22.6%) groups. In-hospital mortality was 12.4% (7.8% for none/mild PGD and 28.7% for moderate/severe PGD; p < .001). Survival at 1, 5, and 15 years was 85.5 ± 1.9% versus 67.2 ± 4.5%, 80 ± 2.2% versus 63.5 ± 4.7%, and 60.4 ± 3.6% versus 45.9 ± 8.4%, respectively (p < .001). Excluding the events occurring during the first month of follow-up, survival was comparable between the two groups (93.1 ± 1.4% vs. 94.7 ± 2.6 at 1 year and 65.6 ± 3.8% vs. 70.4 ± 10.4% at 15 years, respectively; p = .88). Upon multivariate logistic regression analysis preoperative mechanical circulatory support (odds ratio [OR] = 5.86) and preoperative intra-aortic balloon pump (IABP) (OR = 9.58) were independently associated with moderate/severe PGD. Our results confirm that PGD is associated with poor in-hospital outcome. The poor outcome does not extend beyond the first month of follow-up, with comparable survival between patients with none/mild PGD and moderate/severe PGD in the short and long-term. Mechanical circulatory support and preoperative IABP were found to be independent risk factors for moderate/severe PGD.

The Impact of Re-Opening Post Cardiac Surgery on Short and Long- Term Outcomes: 11 Years Follow Up

Objective: Re opening immediately post major cardiac surgery is a problematic complication. Studies suggest bleeding and/or tamponade post cardiac surgery significantly affects in hospital mortality and length of stay. The primary objective of this study was to compare the short- and long-term outcomes of patients who were reopened with those who were not reopened (Control) following cardiac surgery using propensity matched analysis. Methods: In total, 7960 patients underwent cardiac surgery. 539 (6.8%) were reopened immediately post cardiac surgery for either bleeding or tamponade. Patients were propensity score matched (525 reopened versus 525 control) by age, gender, operative priority, preoperative arrhythmia, Ejection Fraction, Euroscores, logistic Euroscores, type of cardiac operation, Body Mass Index, bypass time and cross clamp times. Data were collected prospectively and follow up obtained to date on all patients. Statistical analysis was performed using IBM SPSS version 22. Results: The overall rate of re exploration was 6.8%. After propensity score matching the baseline demographics, pre-operative and intra operative variables were comparable between the two groups. Therefore, patients with similar risk profiles were compared between RE and Control group. Significantly higher rate of post-operative arrhythmias, myocardial infarctions, renal complications, wound infections, cerebrovascular accidentsm, ulatnisdystem failure were observed in the RE group compared to Control group (p&gt;0.001). RE group on average had longer ICU stay and total hospital stay (p&gt;0.001). RE group had significantly higher 30-day mortality 23.4% (vs. 6.3% p&lt;0.001) and long term mortality 37% (vs. 22.9% log rank &lt;0.001) compared to Control group. However, patients who were discharged alive had a comparable long-term survival 82.4% vs. 84.9% between the RE and Control group (log rank &lt;0.396). Significant predictors of reopening post cardiac operation were; poor left ventricular function, pre-operative Intra-Aortic Balloon Pump (IABP), and post-operative arrhythmias (p&lt;0.001). However, reopening in itself was a significant predictor of in hospital mortality (p&lt;0.001). Conclusion: Reopening for bleeding and/or Tamponade saves lives. However, in this propensity matched study we have shown that reopening is also associated with a significantly higher rate of post-operative complications; hospital stay, short- and long-term mortality compared to similar risk profile patients who were not reopened. Re opening post cardiac operation is an independent predictor of in hospital mortality. Meticulous haemostasis is required to reduce risk of bleeding/tamponade and prevent re opening post cardiac surgery.

The Impact of Re-Opening Post Cardiac Surgery on Short and Long- Term Outcomes: 11 Years Follow Up

Objective: Re opening immediately post major cardiac surgery is a problematic complication. Studies suggest bleeding and/or tamponade post cardiac surgery significantly affects in hospital mortality and length of stay. The primary objective of this study was to compare the short- and long-term outcomes of patients who were reopened with those who were not reopened (Control) following cardiac surgery using propensity matched analysis. Methods: In total, 7960 patients underwent cardiac surgery. 539 (6.8%) were reopened immediately post cardiac surgery for either bleeding or tamponade. Patients were propensity score matched (525 reopened versus 525 control) by age, gender, operative priority, preoperative arrhythmia, Ejection Fraction, Euroscores, logistic Euroscores, type of cardiac operation, Body Mass Index, bypass time and cross clamp times. Data were collected prospectively and follow up obtained to date on all patients. Statistical analysis was performed using IBM SPSS version 22. Results: The overall rate of re exploration was 6.8%. After propensity score matching the baseline demographics, pre-operative and intra operative variables were comparable between the two groups. Therefore, patients with similar risk profiles were compared between RE and Control group. Significantly higher rate of post-operative arrhythmias, myocardial infarctions, renal complications, wound infections, cerebrovascular accidentsm, ulatnisdystem failure were observed in the RE group compared to Control group (p&gt;0.001). RE group on average had longer ICU stay and total hospital stay (p&gt;0.001). RE group had significantly higher 30-day mortality 23.4% (vs. 6.3% p&lt;0.001) and long term mortality 37% (vs. 22.9% log rank &lt;0.001) compared to Control group. However, patients who were discharged alive had a comparable long-term survival 82.4% vs. 84.9% between the RE and Control group (log rank &lt;0.396). Significant predictors of reopening post cardiac operation were; poor left ventricular function, pre-operative Intra-Aortic Balloon Pump (IABP), and post-operative arrhythmias (p&lt;0.001). However, reopening in itself was a significant predictor of in hospital mortality (p&lt;0.001). Conclusion: Reopening for bleeding and/or Tamponade saves lives. However, in this propensity matched study we have shown that reopening is also associated with a significantly higher rate of post-operative complications; hospital stay, short- and long-term mortality compared to similar risk profile patients who were not reopened. Re opening post cardiac operation is an independent predictor of in hospital mortality. Meticulous haemostasis is required to reduce risk of bleeding/tamponade and prevent re opening post cardiac surgery.

Does the timing of treatment with intraaortic balloon pump in cardiac surgery affect survival?

Background: The intraaortic balloon pump (IABP) is the most common mechanical assist device used as an adjunctive therapy for patients with low cardiac output among cardiac surgery. However, controversy still exists about the optimal time for IABP insertion. The study evaluated the association between timing of IABP insertion and outcome in cardiac surgical patients. Patients and Methods: Patients who underwent cardiac surgery between August 2007 and June 2014 were included. 273 of 3480 patients (7.84%) required perioperative IABP support. Of whom 21 (7.7%) received a preoperative IABP, 180 (65.9%) received an intraoperative IABP and 72 (26.4%) received a postoperative IABP. Predictors of early mortality were measured in stepwise multivariate logistic regression analyses. Results: The overall mortality rate for all patients requiring IABP was 29.3%. The incidence of mortality in patients who underwent pre-, intra- and postoperative IABP insertion was 19.0%, 22.8%, and 48.6%, respectively. The independent predictors of early mortality were age, cross clamp time, and postoperative IABP. However, either pre or intraoperative IABP insertion was not associated with increase in early mortality. Conclusions: IABP treatment in patients undergoing cardiac surgery was relatively safe accompanied by few complications. Timing of IABP insertion appears to be associated with survival as early insertion results are much more desirable compared to postoperative insertion.

Trends and Outcomes of Surgical Reexploration After Cardiac Operations in the United States

BackgroundSurgical reexploration after cardiac surgery has been associated with increased in-hospital complications and mortality in limited series. The present study examined trends in reoperation and the impact of reoperation on clinical outcomes and resource use in a nationally representative cohort. The study sought to determine patient and hospital factors associated with reexploration and reoperative mortality, defined as failure to rescue surgical (FTR-S). MethodsAdult hospitalizations entailing cardiac operations (coronary artery bypass or valve) were identified using the 2005 to 2018 National Inpatient Sample. Procedures were tabulated using International Classification of Diseases codes. Hospitals were ranked into tertiles according to risk-adjusted mortality, with the lowest stratified as high performing. Multivariable regression models examined factors associated with reexploration, as well as clinical outcomes, including FTR-S and resource use. ResultsOf an estimated 3,490,245 hospitalizations, 78,003 (2.23%) required reexploration with decreasing incidence over time. Valvular procedures, preoperative intraaortic balloon pump use, and liver disease were associated with a greater likelihood of reexploration. Reoperation was associated with increased odds of mortality (adjusted odds ratio [AOR], 3.86; 95% confidence interval [CI], 3.61 to 4.12), perioperative complications, and resource use. Increasing time from index operation to reexploration was associated with higher odds of mortality (AOR,1.10/day; 95% CI, 1.07 to 1.12). High-performing hospitals were associated with lower odds of reexploration (AOR, 0.88; 95% CI, 0.82 to 0.95) and FTR-S (AOR, 0.29; 95% CI, 0.23 to 0.35). ConclusionsSurgical reexploration after cardiac surgery has declined over time. High-performing hospitals demonstrated lower rates of reexploration and subsequent FTR-S. Although unable to identify specific practices, this study highlights the presence of significant variation in takeback rates, and further study of underlying factors is warranted.

Preoperative troponin levels and outcomes of coronary surgery following myocardial infarction.

This study evaluates the impact of peak preoperative troponin level on outcomes of coronary artery bypass grafting (CABG) for non-ST-elevation myocardial infarction (NSTEMI). This was a retrospective review of patients undergoing isolated CABG from 2011 to 2018 with the presentation of NSTEMI. Patients were stratified into low- and high-risk groups based on median preoperative peak troponin (1.95 ng/dl). Major adverse cardiac and cerebrovascular events (MACCE) and mortality were compared. Multivariable analysis was performed to model risk factors for MACCE and mortality. This study included 1211 patients, 607 low-risk (≤1.95 ng/dl) and 604 high-risk (>1.95 ng/dl). Patients were well-matched with respect to age and comorbidity. High-risk patients had lower median preoperative ejection fraction (46.5% [interquartile range {IQR}: 35.0%-55.0%] vs. 53.0% [IQR: 40.0%-58.0%]) and higher incidence of preoperative intra-aortic balloon pump (15.9% vs. 8.73%). Intensive care unit and hospital length of stay were longer in the high-risk group, but increasing troponin level was not associated with prolonged intensive care or hospital length of stay (>4 and >14 days, respectively) after risk adjustment. Postoperative complications and 30-day, 1- and 5-year rates of both MACCE and survival were similar between groups. Peak troponin greater than 1.95 ng/dl was not associated with increased hazards for MACCE, mortality, or readmission in multivariable modeling. In subanalysis, neither increasing troponin as a continuous variable nor peak troponin greater than 10.00 ng/ml were associated with increased hazards for these outcomes. Preoperative troponin levels do not appear to be predictive of short- or long-term outcomes following CABG, and clinical decisions regarding surgical revascularization should not be dictated by these measurements.

Long-Term Effects of Primary Graft Dysfunction after Heart Transplantation

<h3>Purpose</h3> Primary graft dysfunction (PGD) is a potentially life-threatening complication that may occur in the immediate postoperative period following heart transplantation. We studied the incidence of PGD, its impact on in-hospital and follow-up outcomes and searched for independent risk factors. <h3>Methods</h3> During an 18-year period (2002-2020), 508 adult individuals underwent isolated heart transplantation at our institution. Patients were diagnosed with none, mild, moderate or severe PGD according to ISHLT criteria. Risk factors for combined moderate/severe PGD were searched with univariate and multivariate analyses. Survival analysis was performed. <h3>Results</h3> Among the 508 patients, 38 (7.5%) met the ISHLT criteria for mild PGD, 92 (18.1%) for moderate PGD and 23 (4.5%) for severe PGD. Patients were classified into none/mild PGD (393; 77.4%) and moderate/severe PGD (115; 22.6%) groups. Overall in-hospital mortality was 12.4% (7.8% for none/mild PGD and 28.7% for moderate/severe PGD; <i>P</i><0.001). Survival at 1, 5 and 15 years was 85.5 ± 1.9% vs. 67.2 ± 4.5%, 80 ± 2.2% vs. 63.5 ± 4.7% and 60.4 ± 3.6% vs. 45.9 ± 8.4%, respectively (<i>P</i><0.001) (figure 1A). When excluding the events occurring during the first month of follow-up, survival was comparable between the two groups (93.1 ± 1.4% vs. 94.7 ± 2.6 at 1 year and 65.6 ± 3.8% vs 70.4 ± 10.4% at 15 years, respectively; <i>P</i>=0.88)(figure 1B). Upon multivariate logistic regression analysis, preoperative mechanical circulatory support (OR=5.86, <i>P</i>=0.029) and preoperative intra-aortic balloon pump (IABP) (OR=9.58, <i>P</i>=0.045) were independently associated with moderate/severe PGD. <h3>Conclusion</h3> Our results confirm that PGD is associated with poor in-hospital outcome. Interestingly, the poor outcome doesn't extend beyond the first month of follow-up, with comparable survival between patients with none/mild PGD and moderate/severe PGD in the short and long-term. We found preoperative mechanical circulatory support and preoperative IABP to be independent risk factors for moderate/severe PGD.

Outcomes of cardiac surgery in senior aged patients with ventricular dysfunction: analysis of a large national database.

OBJECTIVEIn patients undergoing cardiac surgery, reduced preoperative ejection fraction (EF) and senior age are associated with a worse outcome. As most outcome data available for these patients are mainly from Western surgical populations involving specific surgery types, our aim is to evaluate the real-world characteristics and perioperative outcomes of surgery in senior-aged heart failure patients with reduced EF across a broad range cardiac surgeries.METHODSData were obtained from the China Heart Failure Surgery Registry (China-HFSR) database, a nationwide multicenter registry study in mainland China. Multiple variable regression analysis was performed in patients over 75 years old to identify risk factors associated with mortality.RESULTSFrom 2012 to 2017, 578 senior-aged (> 75 years) patients were enrolled in China HFSR, 21.1% of whom were female. Isolated coronary bypass grafting (CABG) were performed in 71.6% of patients, 10.1% of patients underwent isolated valve surgery and 8.7% received CABG combined with valve surgery. In-hospital mortality was 10.6%, and the major complication rate was 17.3%. Multivariate analysis identified diabetes mellitus (odds ratio (OR) = 1.985), increased creatinine (OR = 1.007), New York Heart Association (NYHA) Class III (OR = 1.408), NYHA class IV (OR = 1.955), cardiogenic shock (OR, 6.271), and preoperative intra-aortic balloon pump insertion (OR = 3.426) as independent predictors of in-hospital mortality.CONCLUSIONSIn senior-aged patients, preoperative evaluation should be carefully performed, and strict management of reversible factors needs more attention. Senior-aged patients commonly have a more severe disease status combined with more frequent comorbidities, which may lead to a high risk in mortality.

ELECTIVE INTRA-AORTIC BALLOON PUMP IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFT

Introduction:Preoperative electiveintra-aortic balloon pump (IABP)prompts improve result in helpless left ventricular function patients going throughcoronary artery bypass graft (CABG).The aim of this work was to assess the efficacy of preoperative intra-aortic balloon pump treatment on postoperative cardiac performance, morbidity and mortality. Method:a prospective, cohort study was conducted on 40 patients with preoperative left ventricular ejection fraction&lt; 40%, who went throughcoronary artery bypass graft. These patients were divided preoperatively into two groups:Group I (N.=20) received intraaortic balloon pump insertion 1-2 hours prior to aortic cross clamp.Group II (N.= 20) control group who did not receive intra-aortic balloon pump preoperatively. Results:Both group were matched regarding age, sex distribution and body surface area,mean cardiac index in group I wassignificantly higher(2.5± 0.21 vs. 2±0.32) (P&lt;0.0001). The mean cardiopulmonary bypass time in group I was significantly less (72.56± 21.62 vs. 86.68±20.57) (P=0.04).The ventilation time (hours) and total intensive care unit stay (days) were significantly less in group I (p&lt;0.0001). Conclusion: poor left ventricular function patients going through coronary artery bypass grafting possibly need perioperative intra-aortic balloon pump support to diminish morbidity and mortality.