Previous Cardiac Surgery Research Articles

PO-02-156 THE RISE OF LEFT BUNDLE BRANCH AREA "PACE AND ABLATE"; AV NODAL ABLATION OUTCOMES, WHERE ARE WE NOW?

A “pace and ablate” strategy should be considered for those with symptomatic atrial fibrillation (AF) when other therapies have been unsuccessful. Pacemaker induced cardiomyopathy due to RV pacing is a recognised consequence. Left bundle branch area pacing (LBBAP) mitigates this cardiomyopathy compared to RV pacing. As LBBAP becomes more widespread, we expect greater uptake of AV nodal (AVN) ablation “pace and ablate” strategy in those with symptomatic AF. We undertook a multicentre retrospective registry analysis of our patients who underwent AV nodal ablation to assess current real-world procedure data and patient outcomes. We conducted a retrospective multi-centre registry review of outcome data for our patients who underwent AVN ablation over the period of April 2019 until March 2020. We included patients >18 years old who underwent AVN ablation for the purposes of a “pace and ablate” strategy for symptomatic AF despite other strategies. N=52 patients met inclusion criteria. Median age was 74 years (IQR 67, 82), with 28 males. 18 patients had paroxysmal AF, 12 persistent AF and 22 longstanding persistent AF. 10 patients had other documented arrhythmias including arial flutter (4), ventricular tachycardia (3), SVT (2) or atrial tachycardia (1). 9 patients (17%) had previous cardiac surgery including CABG or valve replacements. All patients had successful AVN ablation with durable lesion creation. Radiofrequency was utilised in all patients, with a median application time of 2.67 minutes (IQR: 2, 5.4). Median skin-to-skin procedure time was found to be 55.5 minutes (IQR: 43.75, 73), with a fluoroscopy median time of 3.5 minutes (IQR: 1.55, 6.48). Median radiation dose was 11 mGy (IQR: 4, 16.27). 11 patients had biventricular pacing devices in situ with 41 patients implanted with a conventional pacemaker. There were no acute complications of the procedure. One patient died due to renal failure and one patient had a stroke within 3 months of the procedure but neither of these were directly linked. Our analysis found durable lesion creation with 100% ablation success in our cohort with a median fluoroscopy time of 3.5 minutes and dose of 11 mGy. There were no acute or subacute complications related to the procedure, as far out as 3 months. 11 (21%) patients had biventricular devices with the rest having conventional pacemakers. No patients had conduction system leads implanted, which is likely to change in the coming years.

Profiles of cognitive impairment in chronic heart failure-A cluster analytic approach.

Cognitive impairment is a major comorbidity in patients with chronic heart failure (HF) with a wide range of phenotypes. In this study, we aimed to identify and compare different clusters of cognitive deficits. The prospective cohort study "Cognition.Matters-HF" recruited 147 chronic HF patients (aged 64.5 ± 10.8 years; 16.2% female) of any etiology. All patients underwent extensive neuropsychological testing. We performed a hierarchical cluster analysis of the cognitive domains, such as intensity of attention, visual/verbal memory, and executive function. Generated clusters were compared exploratively with respect to the results of cardiological, neurological, and neuroradiological examinations without correction for multiple testing. Dendrogram and the scree plot suggested three distinct cognitive profiles: In the first cluster, 42 patients (28.6%) performed without any deficits in all domains. Exclusively, the intensity of attention deficits was seen in the second cluster, including 55 patients (37.4%). A third cluster with 50 patients (34.0%) was characterized by deficits in all cognitive domains. Age (p = 0.163) and typical clinical markers of chronic HF, such as ejection fraction (p = 0.222), 6-min walking test distance (p = 0.138), NT-proBNP (p = 0.364), and New York Heart Association class (p = 0.868) did not differ between clusters. However, we observed that women (p = 0.012) and patients with previous cardiac valve surgery (p = 0.005) prevailed in the "global deficits" cluster and the "no deficits" group had a lower prevalence of underlying arterial hypertension (p = 0.029). Total brain volume (p = 0.017) was smaller in the global deficit cluster, and serum levels of glial fibrillary acidic protein were increased (p = 0.048). Apart from cognitively healthy and globally impaired HF patients, we identified a group with deficits only in the intensity of attention. Women and patients with previous cardiac valve surgery are at risk for global cognitive impairment when suffering HF and could benefit from special multimodal treatment addressing the psychosocial condition.

Effect of preoperative risk on the association between intraoperative hypotension and postoperative acute kidney injury in cardiac surgery

BackgroundAcute kidney injury (AKI), a common and severe complication after cardiac surgery, has been demonstrated to be associated with intraoperative hypotension (IOH). The reproducibility of this finding and whether preoperative risk modifies the association remain unclear. We hypothesised that the relationship between IOH and AKI after cardiac surgery varies by preoperative risk. MethodsWe conducted a single-centre, retrospective cohort study to analyse the association between IOH and postoperative AKI by stratifying patients using preoperative risk factors. IOH was defined as a mean arterial pressure (MAP) of less than 65 mmHg and characterised by the cumulative duration and area under the curve (AUC). ResultsTen variables could be identified as risk factors: age, smoking status, NYHA III/Ⅳ, emergency surgery, peripheral vascular disease, cerebrovascular disease, heart failure, hypertension, previous cardiac surgery, and NT-proBNP concentration. The risk prediction model divided the patients into three equal-sized preoperative risk groups. Low-risk patients demonstrated no association between AKI and IOH of any severity, while high-risk patients demonstrated a statistically significant association between AKI and IOH with a cumulative duration greater than 104 min (adjusted odds ratio [OR]: 2.27, 95% confidence interval [CI]: 1.10−4.74; and adjusted OR: 3.63, 95% CI: 1.77−7.58) and an AUC greater than 905 mmHg min (adjusted OR: 2.08, 95% CI: 1.01−4.36; and adjusted OR: 4.00, 95% CI: 1.95−8.43). ConclusionIOH is a significant independent risk factor for AKI after cardiac surgery. Patients with higher baseline risk showed a more prominent relationship between IOH and postoperative AKI than low-risk patients.

(879) Heart Transplant Outcomes in Patients ≥65 Years Old with Previous Non-Transplant Cardiac Surgery

(879) Heart Transplant Outcomes in Patients ≥65 Years Old with Previous Non-Transplant Cardiac Surgery

Potassium Imbalance Leading to Arrhythmias in Patients Undergoing Cardiac Surgery on Cardiopulmonary Bypass

Objective: To determine the frequency of factors that cause potassium imbalance in patients with postoperative arrhythmias after cardiac Bypass surgery Material and methods: During the time period of 2 November 2018 through 10 January 2020, 100 patients with heart disease receiving open-heart surgery were enrolled in a prospective observational research conducted by the cardiac surgery department at the Punjab Institute of Cardiology in Lahore. Both genders of age 17-70 years were included and patients with cyanotic heart disease congenital heart disease, previous cardiac surgery and urgent CABG were excluded. Results: Our results showed that of 100 patients, 59 (59%) were male and 41 (41%) were female and the mean age was14.243 ± 50.12 years. 6 patients had preexisting renal failure and 9 had postoperative renal failure. Overall potassium imbalance was noted in 39 patients, 33 were hypokalemic and 6 were hyperkalemic and the mean potassium with S.D was 3.95±0.83 and 37 had postoperative arrhythmias out of which 18 (54.5%) were hypokalemic and 2 (33.3%) were hyperkalemic. Preoperative drugs, preexisting renal failure, CPB time, aortic cross clamp time, intraoperative potassium levels, time on ventilation, postoperative urine output, potassium infusion, postoperative renal failure, arrhythmias and total hospital stay were found to be statistically significant. Conclusion: Potassium imbalance post-cardiopulmonary bypass is major factor that may lead to increased risk of postoperative arrhythmias. Keywords: Potassium imbalance, cardiopulmonary bypass, postoperative arrhythmias, renal failure, hypokalemia

Long-Term Survival of Multiple Versus Single Arterial Coronary Bypass Grafting in Elderly Patients.

Multiple arterial grafting (MAG) utilizes more than one arterial graft with any additional grafts being saphenous vein grafts (SVG). It remains an infrequently used coronary surgical revascularization technique, especially in elderly patients. Our study aims to evaluate the age-related association with the relative outcomes of multiple versus single arterial grafting (SAG). The Australian and New Zealand national registry was used to identify adult patients undergoing primary isolated CABG with at least two grafts. Exclusion criteria included reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. Propensity score matching was used to match patient groups. The primary outcome was all-cause late mortality and the secondary outcomes were 30-day mortality and 30-day hospital readmission. We selected 69,624 eligible patients with a mean (standard deviation) age of 65.0 (10.2) years old. Matching between MAG and SAG generated 16,882 pairs of patients < 70 years old and 10,921 pairs of patients ≥ 70 years old. At a median [interquartile range] follow-up duration of 5.9 [3.2-9.6] years, MAG was associated with significantly reduced mortality compared to SAG (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.68-0.78; p < 0.001) in the younger subgroup as well as the elderly subgroup (HR, 0.84; 95% CI, 0.79-0.88; p < 0.001). In conclusion, MAG offers a survival benefit over SAG, in both younger and elderly patients.

Less transfusion is still more-red blood cell transfusion affects long-term mortality in cardiac surgery.

Previous studies indicated higher long-term mortality after the transfusion of allogeneic red blood cells and newer recommendations emphasize lower transfusion rates. Consequences of transfusion of red blood cells in cardiac surgery are unclear, as later studies focused on transfusion triggers and short-term outcomes and reports on long-term complications after cardiac surgery are few. The mandatory Western Denmark Heart Registry was used to identify all adult cardiac surgeries performed in four centres from 2000-2019. Patients with multiple entries or previous cardiac surgery, special/complex procedures, dying within 30 days and not eligible for follow-up were excluded. A total of 32,581 adult cardiac surgeries performed in four centres from 2000-2019 were included. The Kaplan-Meier survival plot for low-risk patients undergoing simple cardiac surgery showed a significantly lower 15-year survival (0.384 vs 0.661) when receiving perioperative red blood cell transfusion (OR 2.43 (CL 2.23-2.66)). The risk decreased with increasing comorbidity or age, and in high-risk patients, no difference was found. The adjusted risk ratio, after RBC transfusion, including age, sex, comorbidity and surgery, was 1.62 (1.48-1.77). Despite reduced transfusion rates, long-term follow-up on especially low-risk patients undergoing comparable cardiac surgery still demonstrates a substantially higher mortality in patients receiving perioperative red blood cell transfusion. Even transfusion of 1-2 units is associated with increased long-term mortality.

Long-Term Outcomes and Risk Factors Analysis for Patients Undergoing Thoracic Endovascular Aorta Repair (TEVAR), According to the Aortic Pathologies

Thoracic endovascular aortic repair (TEVAR) has become a standard treatment for acute and chronic thoracic aorta diseases. We analyzed long-term outcomes and risk factors of TEVAR procedures according to the aortic pathology. Demographics, indications, technical details, and outcomes of patients undergoing TEVAR procedures in our institutions were prospectively collected and retrospectively analyzed. Overall survival was determined using Kaplan-Meier methods while log-rank tests were used to compare the survival between groups. Cox regression analysis was used to identify risk factors. Between June 2002 and April 2020, 116 patients underwent TEVAR for different thoracic aorta diseases. Among them, 47 patients (41%) underwent TEVAR for aneurysmatic aortic disease, 26 (22%) for type-B aortic dissection, 23 (20%) for penetrating aortic ulcer, 11 (9%) after previous type-A dissection treatment, and 9 (8%) for traumatic aortic injury. Patients with posttraumatic aortic injury were younger (P<0.01) with less hypertension (P<0.01), diabetes (P<0.01), and prior cardiac surgery (P<0.01). Survival was different based on indication for TEVAR (log rank 0.024). Patients after previous type-A dissection treatment had the worst survival rate (50% at 5years) while survival for aneurysmatic aortic disease was 55% at 5years. No late death occurred in the traumatic group. Cox-regression model identified independent predictors for mortality: age (hazard ratio [HR]: 1.05, 95% confidence interval [CI]: 1.01-1.09, P=0.006), male gender (HR: 3.2, 95% CI: 1.1-9.2, P=0.028), moderate chronic obstructive pulmonary disease (HR: 2.1, 95% CI: 1.02-4.55, P=0.043), previous cardiac surgery (HR: 2.1, 95% CI: 1.008-4.5, P=0.048), and treatment indication for aneurysm (HR: 2.6, 95% CI: 1.2-5.2, P=0.008). TEVAR is a safe and effective procedure with excellent long-term results in case of traumatic aortic injury. The overall long-term survival is affected by aortic pathology, associated comorbidities, gender, and previous cardiac surgery.

Aortic Root Replacement Surgery-A Center Experience with Biological Valve Prostheses.

Outcomes after surgical aortic root replacement using different valved conduits are rarely reported. The present study shows the experience of a single center with the use of the partially biological LABCOR (LC) conduit and the fully biological BioIntegral (BI) conduit. Special attention was paid to preoperative endocarditis. All 266 patients who underwent aortic root replacement by an LC conduit (n = 193) or a BI conduit (n = 73) between 01/01/2014 and 31/12/2020 were studied retrospectively. Dependency on an extracorporeal life support system preoperatively and congenital heart disease were exclusion criteria. For patients with (n = 67) and without (n = 199) preoperative endocarditis subanalyses were made. Patients treated with a BI conduit were more likely to have diabetes mellitus (21.9 vs. 6.7%, p < 0.001), previous cardiac surgery (86.3 vs. 16.6%; p < 0.001), permanent pacemaker (21.9 vs. 2.1%; p < 0.001), and had a higher EuroSCORE II (14.9 vs. 4.1%; p < 0.001). The BI conduit was used more frequently for prosthetic endocarditis (75.3 vs. 3.6%; <0.001), and the LC conduit was used predominantly for ascending aortic aneurysms (80.3 vs. 41.1%; <0.001) and Stanford type A aortic dissections (24.9 vs. 9.6%; p = 0.006). The LC conduit was used more often for elective (61.7 vs. 47.9%; p = 0.043) and emergency (27.5 vs. 15.1%; p = 0-035) surgeries, and the BI conduit for urgent surgeries (37.0 vs. 10.9%; p < 0.001). Conduit sizes did not differ significantly, with a median of 25 mm in each case. Surgical times were longer in the BI group. In the LC group, coronary artery bypass grafting and proximal or total replacement of the aortic arch were combined more frequently, whereas in the BI group, partial replacement of the aortic arch were combined. In the BI group, ICU length of stay and duration of ventilation were longer, and rates of tracheostomy and atrioventricular block, pacemaker dependence, dialysis, and 30-day mortality were higher. Atrial fibrillation occurred more frequently in the LC group. Follow-up time was longer and rates of stroke and cardiac death were less frequent in the LC group. Postoperative echocardiographic findings at follow-up were not significantly different between conduits. Survival of LC patients was better than that of BI patients. In the subanalysis of patients with preoperative endocarditis, significant differences between the used conduits were found with respect to previous cardiac surgery, EuroSCORE II, aortic valve and prosthesis endocarditis, elective operation, duration of operation, and proximal aortic arch replacement. For patients without preoperative endocarditis, significant differences were observed concerning previous cardiac surgery, pacemaker implantation history, duration of procedure, and bypass time. The Kaplan-Meier curves for the subanalyses showed no significant differences between the used conduits. Both biological conduits studied here are equally suitable in principle for complete replacement of the aortic root in all aortic root pathologies. The BI conduit is often used in bail-out situations, especially in severe endocarditis, without being able to show a clinical advantage over the LC conduit in this context.

Sternal Wound Infection Following Open Heart Surgery: Incidence, Risk Factor, Pathogen, and Mortality

Due to its high morbidity and mortality after open-heart surgery, sternal wound infection (SWI) is one of the most important consequences to avoid and manage. To assess the incidence, risk factor, causative organisms, and mortality of SWIs in patients who had open-heart surgery over a 9-year period at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. A retrospective study was done on 634 patients who underwent open heart surgery. Data was collected, including patient demographics, BMI, blood group, diabetes, hyperlipidemia, COPD, previous cardiac surgery, previous myocardial infarction, duration of the operation, blood transfusion during the operation, hospital length of stay, and bypass time with each type of sternal wound infection. The incidence of SSWI and DSWI was 8.6% and 4.1%, respectively. Coagulase-negative staphylococcus was the most frequently isolated organism from SSWI and DSWI patients. A concomitant diabetes mellitus that necessitates blood transfusion was identified as one of the risk variables for SSWI in a multivariate regression study. While concomitant diabetes, being a woman, and a lengthy hospital stay were independently linked with DSWI. Compared with the SSWI group, the 30-day mortality rate for DSWI patients was 3.8% as opposed to 3.7%, and the difference in survival was not statistically significant. Having an older, longer bypass time, and postoperative problems were independent risk factors for 30-day mortality. Future studies in various healthcare settings are required in order to generalize the results because this was a single center study.

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.

Sex differences in type A acute aortic dissection: a systematic review and meta-analysis.

In acute aortic dissection (AAD) sex heterogeneity reports are not exhaustive and in part even conflicting. To explore sex differences in clinical features, management, and outcomes among patients with type A AAD. A systematic review and meta-analysis of the literature were conducted for studies (2004-2022) reporting type A AAD sex differences. Among the 1938 studies retrieved, 16 (16 069 patients, 7142 women, and 8927 men) fulfilled all eligibility criteria. Data were aggregated used the random-effects model as pooled risk ratio and mean difference. Due to information reported by considered manuscripts, analysis were performed only among surgically treated type A AAD patients. At the time of hospital presentation type A AAD women were older than men but had lower body mass index (BMI), body surface area (BSA), and creatinine plasma levels. Active smoking, bicuspid aortic valve, and previous cardiac surgery were less common in women while diabetes mellitus was more frequent. Furthermore, women experienced more frequently pericardial effusion/cardiac tamponade than men. Interestingly, in-hospital surgical mortality did not differ between sexes [risk ratio (RR), 1.02; 95% confidence interval (CI), 0.53-1.99; P = 0.95], whereas 5 (RR 0.94; 95% CI: 0.92-0.97; P < 0.001) and 10-year survival (RR 0.82; 95% CI: 0.74-0.92; P = 0.004) was higher among men. A descriptive analysis of in-hospital outcomes among medically treated type A AAD patients confirmed prohibitive high mortality for both sexes (men 58.6% vs. women 53.8%, P = 0.59). A female sex phenotype appears to be evident in type A AAD implying the need for a personalized management patient approach along with tailored preventive strategies. CRD42022359072.

Trend and early outcomes in isolated surgical aortic valve replacement in the United Kingdom.

Surgical aortic valve replacement (SAVR) is traditionally the gold-standard treatment in patients with aortic valve disease. The advancement of transcatheter aortic valve replacement (TAVR) provides an alternative treatment to patients with high surgical risks and those who had previous cardiac surgery. We aim to evaluate the trend, early clinical outcomes, and the choice of prosthesis use in isolated SAVR in the United Kingdom. All patients (n = 79,173) who underwent elective or urgent isolated surgical aortic valve replacement (SAVR) from 1996 to 2018 were extracted from the National Adult Cardiac Surgery Audit database. Patients who underwent additional procedures and emergency or salvage SAVR were excluded from the study. Trend and clinical outcomes were investigated in the whole cohort. Patients who had previous cardiac surgery, high-risk groups (EuroSCORE II >4%), and predicted/observed mortality were evaluated. Furthermore, the use of biological prostheses in five different age groups, that are <50, 50-59, 60-69, 70-79, and >80, was investigated. Clinical outcomes between the use of mechanical and biological aortic valve prostheses in patients <65 years old were analyzed. The number of isolated SAVR increased across the study period with an average of 4,661 cases performed annually after 2010. The in-hospital/30-day mortality rate decreased from 5.28% (1996) to 1.06% (2018), despite an increasing trend in EuroSCORE II. The number of isolated SAVR performed in octogenarians increased from 596 to 2007 (the first year when TAVR was introduced in the UK) to 872 in 2015 and then progressively decreased to 681 in 2018. Biological prosthesis usage increased across all age groups, particularly in the 60-69 group, from 24.59% (1996) to 81.87% (2018). There were no differences in short-term outcomes in patients <65 years old who received biological or mechanical prostheses. Surgical aortic valve replacement remains an effective treatment for patients with isolated aortic valve disease with a low in-hospital/30-day mortality rate. The number of patients with high-risk and octogenarians who underwent isolated SAVR and those requiring redo surgery has reduced since 2016, likely due to the advancement in TAVR. The use of biological aortic prostheses has increased significantly in recent years in all age groups.

Wegetacje na zastawce dwudzielnej u 16-letniej dziewczynki leczonej chirurgicznie metodą małoinwazyjnej rekonstrukcji

Infective endocarditis in children is a rare complication and is most often associated with dental interventions. It may develop in course of congenital and acquired heart defects, as well as previous cardiac surgeries. The case regards a 16-year-old girl reporting significant fatigue, low-grade fever, lack of appetite with a weight loss of 5 kg, apathy, and enlargement of the spleen over six months before admission. Physical examination exposed systolic murmur in the apical region. The patient was admitted to a general paediatric ward and then, after confirming vegetation on the mitral valve, further treatment was carried out in the paediatric cardiology ward. The blood cultures revealed Streptococcus Gordoni infection. Intensive antibiotic treatment was initiated under the control of blood cultures, which were negative after 7 days of treatment. An interdisciplinary council meeting decided to continue the treatment. Cardiosurgical consult resulted in transferring the patient to the adult cardiosurgery ward, even though she was not of age, where a minimally invasive valve reconstruction was performed using artificial tendon threads and an artificial Carpentier–McCarthy–Adams 26 mm mitral ring. The postoperative course was uneventful and the girl was returned to the care of paediatric cardiologists. Currently, she is in good condition and is under constant control.

Ventricular Fibrillatory Arrest: A Safe Option in Robotic Totally Endoscopic Intracardiac Surgery

BackgroundModerate hypothermic ventricular fibrillatory arrest during heart surgery is an alternative to cardioplegic arrest in selected patients. We reviewed our experience using a ventricular fibrillatory arrest technique in robotic totally endoscopic intracardiac surgery. MethodsFrom February 2014 through July 2022, 128 patients who underwent robotic totally endoscopic intracardiac surgical procedures performed using moderate hypothermic ventricular fibrillatory arrest were reviewed. Patients were chosen based on the risk of aortic manipulation, complexity of the procedure, grade of aortic valve insufficiency and comorbidities, including history of prior cardiac surgery and peripheral vascular disease. ResultsPatients were a mean age of 65 ± 14 years, and the mean The Society of Thoracic Surgeons score was 2.7 ± 2.9. Fourteen patients (11%) had a history of previous cardiac surgery. The intracardiac procedures were mitral valve surgery in 84 patients (66%), isolated cryomaze procedure in 27 (21%), and other in 17 (13%). The mean ventricular fibrillatory arrest time was 79 ± 26 minutes, and the mean cardiopulmonary bypass time was 174 ± 49 minutes. There was no conversion to sternotomy. Seven patients (5.5%) required inotropic support, and 2 patients (1.6%) needed an intra-aortic balloon pump. There was no incidence of postoperative stroke or clinical myocardial infarction. The mean hospital and intensive care unit lengths of stay were 3.1 ± 1.7 and 1.4 ± 0.7 days, respectively. One death (0.78%) occurred due to respiratory failure. ConclusionsModerate hypothermic ventricular fibrillatory arrest in robotic intracardiac surgery may be a safe and effective alternative in selected patients.

1227. Candida Sternal Wound Infections After Cardiac Operations: Uncommon but Deadly

Abstract Background Sternal wound infections (SWI) are a devastating complication of cardiac surgery. The majority of SWI are bacterial infections; however, Candida species are a less common cause and have not been well described. The purposes of this study were (1) to describe clinical characteristics, management and outcomes of Candida SWI and (2) to compare the risk factors and outcomes for Candida to bacterial SWI. Methods Our study reviewed medical records of 41 patients with Candida SWI after cardiac surgeries between 2013 - 2020 at our medical center, then compared them to 76 patients with bacterial SWI during the same timeframe via univariate analysis. We defined superficial SWI as positive culture isolates involving the skin or subcutaneous tissues, deep SWI as involving deep soft tissues or bone, and mediastinitis as involving the mediastinum. Results Of the 41 Candida SWI patients, relevant comorbidities included previous cardiac surgery (46.3%), heart failure (65.9%), and diabetes (58.5%). Candida SWI was diagnosed at an average of 123.6 days after cardiac surgery, with the majority being deep SWI (70.7%). Candida albicans was most common (70.7%). Bacterial co-infections were found in 53.7% (Table 1). Longer bypass and operative times for the initial cardiac surgery were found to be positively correlated to disease severity. Clinical cure rate after completion of antimicrobial treatment was 100% in superficial SWI, 72.4% in deep SWI and 25.0% in mediastinitis. Overall mortality was 29.3%: 25%, 24.1% and 50.0%, respectively. When compared to bacterial SWI, factors significantly associated with Candida SWI included: previous cardiac surgery (46.3% vs. 7.9%, odds ratio (OR): 5.9; 95% confidence interval (CI): 2.2-15.9), heart failure (65.9% vs. 11.8%, OR: 5.6; 95% CI: 2.4-12.9), and &amp;gt;48 hours of postoperative antibiotics (39.0% vs. 3.0%, OR: 9.9; 95% CI: 2.7-35.9). Mortality rates were higher with Candida than with bacterial infections (29.3% vs. 1.3%, OR: 22.2, 95% CI 2.8-177.2) (Table 2). Conclusion This study showed Candida SWI as a serious complication of extensive cardiac surgery with higher mortality rates. Prior history of cardiac surgery and heart failure, prolonged surgeries, and complicated postoperative course were significant risk factors for the development of Candida SWI. Disclosures Barbara Trautner, MD, PhD, Genetech: Advisor/Consultant.

EVALUATION OF THE IMPLEMENTATION OF ROTATIONAL THROMBOELASTOMETRY GUIDED COAGULATION MANAGEMENT IN ADULT CARDIAC SURGERY

<h3>Objective</h3> To evaluate changes in the administration of blood products and hemostatic drugs following the implementation of rotational thronboelastometry (ROTEM) in cardiac surgery in adult patients. To analyze changes in the rate of reintervention and perioperative complications. Economic analysis on the consumption of blood products, hemostatic drugs and ROTEM cartridges. <h3>Design and method</h3> Single-center retrospective cohort study. Exclusion criteria: interventions without cardiopulmonary bypass (CPB), emergent surgery, circulatory assist devices, heart transplant, ascending aortic dissection, Jehovah's Witness patients, congenital hemostasis disorders, and severe liver disease. In group 1 (before ROTEM), blood products and hemostatic drugs were administered empirically at the anesthesiologist's discretion. Activated clotting time, point-of-care prothrombin time testing, standard laboratory tests and clinical variables were used to guide therapeutic management. In group 2 (after ROTEM), blood products and hemostatic drugs were administered according to the Gorlinger algorithm modified. Variables preoperative period: age, sex, weight, height, BMI, BSA, hemoglobin level, number of platelets, creatinine, glomerular filtration rate, previous cardiac surgery. Variables intraoperative period: type of surgery, duration of CPB, administration of packed red blood cells (PRBC), platelet concentrates (PC), fresh frozen plasma (FFP), fibrinogen concentrate (FC), prothrombin complex concentrate (PCC) and rFVIIa. Variables postoperative period: reintervention (first 24h), mechanical ventilation >24h, acute lung injury (ALI), infection, thrombotic events, death, ICU and hospital length of stay. <h3>Results</h3> 759 patients were included, 438 in group 1 and 321 in group 2. There were no significant differences in age, sex, weight, height, BMI, BSA, preoperative anemia, thrombocytopenia, renal failure, previous cardiac surgery, type of surgey or interventions with CPB time >120 minutes. A significant reduction was observed in the number of patients who received PRBC (19% vs 29.2%; p = 0.001), FFP (1.6% vs 7.5%; p < 0.001), FC (23.4% vs 30.6%; p = 0.028) and rFVIIa (0.3% vs 2.7%; p = 0.011). A significant decrease was observed in the total quantity of PRBC, PC, FFP, FC and rFVIIa administered per patient. A significant reduction was observed in the incidence of postoperative infection (5.3% vs 10.3%; p = 0.013), ICU stay (median of 3 d vs 4 d; p < 0.001) and hospital stay (median of 8 d vs 11 d; p <0.001). There were no significant differences in the need for prolonged mechanical ventilation, surgical revision, incidence of ALI, thrombotic events or death. The economic analysis showed a total cost of 403,394.99 euros for group 1 and 203,292.97 euros for group 2. The average cost per patient was 921.00 euros in group 1 and 633.31 euros in group 2 (reduction of 30%). <h3>Conclusions</h3> Thromboelastometry reduces the administration of blood products and hemostatic drugs, in addition to lowering costs. The decreases in the incidence of infections and ICU and hospital stays cannot be solely attributed to the ROTEM technique as there are other factors that may have contributed.

Ten-Year Experience with Transapical and Direct Transaortic Transcatheter Aortic Valve Replacement to Address Patients with Aortic Stenosis and Peripheral Vascular Disease.

Objective: Transcatheter aortic valve replacement (TAVR) through alternative access routes is indicated in patients with severe aortic valve stenosis and diseased peripheral arteries. We analysed and compared the outcome of patients undergoing transapical (TA) and direct transaortic (TAO) TAVR procedures. Methods: Preoperative characteristics, procedural details, and thirty-day outcome of patients undergoing transapical (TA-TAVR group) and direct transaortic (TAO-TAVR group) TAVR procedures were prospectively collected and retrospectively analysed. Results: From March 2012 to March 2022, 81 TA and 82 TAO-TAVR (total: 163 cases) were performed with balloon-expanding (n = 120; 73.6%) and self-expandable (n = 43; 26.4%) valves. The mean age was 79.7 ± 6.2 and 81.9 ± 6.7 years for the TA- and TAO-TAVR groups, respectively (p = 0.032). Females were more represented in the TAO-TAVR group (56% vs. 32%; p = 0.003) while TA-TAVR patients showed a higher prevalence of previous vascular surgery (20% vs. 6%; p = 0.01), previous cardiac surgery (51% vs. 3.6%; p < 0.001), and porcelain aorta (22% vs. 5%; p = 0.001). The mean ejection fraction was 49.0 ± 14.6% (TA) and 53.5 ± 12.2% (TAO) (p = 0.035) while mean gradients were 35.6 ± 13.2 mmHg (TA) and 40.4 ± 16.1 mmHg (TAO) (p = 0.045). The median EuroSCORE-II was 5.0% (IQR: 3.0−11.0) and 3.9% (IQR: 2.5−5.4) for the TA- and TAO-TAVR groups, respectively (p = 0.005). The procedural time was shorter for TA procedures (97 min (IQR: 882−118) vs. 102 min (IQR: 88−129); p = 0.133). Mortality at day 30 was 6% in both groups (p = 1.000); the permanent pacemaker implantation rate was similar (8.6% vs. 9.7%; p = 1.000), and hospital stay was shorter for the TAO group (8 days (IQR: 6−11) vs. 10 days (IQR: 7−13); p = 0.025). Conclusions: Our results show that transapical and direct transaortic TAVR in high-risk patients with diseased peripheral arteries provide satisfactory clinical results with similar thirty-day outcomes.

Abstract 14694: Effect of Saphenous Vein Graft on Multiple Arterial Grafting Survival

Introduction: Saphenous vein graft (SVG) is associated with increased mortality and adverse cardiac events compared to arterial conduits, but uncertainty exists whether its presence would influence the outcome in multiple arterial revascularization (MAG). Hypothesis: That use of SVG adversely affects survival even in the setting of MAG. Methods: All patients undergoing primary isolated CABG between June 2001 to Jan 2020 were identified through a national registry. Exclusion criteria were reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. The primary outcome was long-term mortality reported as time-to-event from the date of the operation. We performed a complete case retrospective comparison between MAG and single arterial grafting (SAG). Additional analysis was performed in MAG patients with or without SVG.Propensity score matching (PSM) and Cox proportional hazard model were used with significance defined as two-tailed P&lt;0.05. Results: A total of 72,444 eligible patients had 58,629 (80.9%) males with 32,966 SAG (45.5%) and 39,478 MAG (54.5%). Two PSM was used to generate 29,354 matched pairs for SAG vs. MAG and 12,314 matched pairs for MAG with or without SVG. At a mean follow-up duration of 6.7 years, long-term mortality was significantly lower for MAG than SAG (HR, 0.89; 95% CI, 0.85-0.93). The cumulative Kaplan-Meier survival was 60.6% for SAG and 63.3% for MAG at 15 years postoperative, (P=0.002). In the comparison of MAG with or without SVG, the group without SVG (total arterial revascularization) had a lower risk of late mortality (HR, 0.91; 95% CI, 0.85-0.96). The interaction term analysis confirmed a significant effect for the presence of vein graft on the observed mortality when using MAG, (P=0.02). Sensitivity analyses produced consistent outcomes as the primary investigation. Conclusions: Multiple arterial grafting is associated with significantly improved long-term survival compared to single arterial grafting, and when total arterial revascularization was achieved, there was an incremental survival benefit.

Robotic-assisted beating heart mitral valve surgery: Preliminary report.

Robotic mitral valve surgery is a challenging issue, particularly in patients who are not suitable for aortic cross-clamping. In this study, we aimed to determine the feasibility and benefits of robotic, beating heart mitral valve surgery. From February 2019 to February 2022, 17 patients underwent robotic beating heart mitral valve surgery. Fourteen of the patients had previous cardiac surgery. The mean age was 58.1 ± 10.3. Dense periaortic adhesions, heavily calcified aorta, and low ejection fraction were retained as indications for beating heart surgery. Mitral valve replacement was performed in 14 patients. Mitral ring annuloplasty was performed in two patients with low ejection fraction (EF). A severe paravalvular leak was repaired in one patient. Additional tricuspid annuloplasties were performed in three patients. Cardiopulmonary bypass time were 185.6 ± 55 min. There were no cases of conversion to sternotomy or thoracotomy. No cerebrovascular event occurred in the follow-up. One patient died as a result of secondary hepatorenal syndrome and multiorgan failure. Robotic beating heart mitral valve surgery is a feasible and effective technique with favorable early and mid-term results, especially in patients who are not suitable for aortic cross-clamping, secondary to periaortic adhesions, severe aortic calcifications, and low ejection fraction.