Rate Of Re-exploration For Bleeding Research Articles

20 Years of triple-valve surgery in the UK: demographic and outcome trends.

To describe evolving demographic trends and early outcomes in patients undergoing triple-valve surgery in the UK between 2000 and 2019. We planned a retrospective analysis of national registry data including patients undergoing triple-valve surgery for all aetiologies of disease. We excluded patients in a critical preoperative state and those with missing admission dates. The study cohort was split into 5 consecutive 4-year cohorts (groups A, B, C, D and E). The primary outcome was in-hospital mortality, and secondary outcomes included prolonged admission, re-exploration for bleeding, postoperative stroke and postoperative dialysis. Binary logistic regression models were used to establish independent predictors of mortality, stroke, postoperative dialysis and re-exploration for bleeding in this high-risk cohort. We identified 1750 patients undergoing triple-valve surgery in the UK between 2000 and 2019. Triple valve surgery represents 3.1% of all patients in the dataset. Overall mean age of patients was 68.5 ± 12 years, having increased from 63 ±12 years in group A to 69 ± 12 years in group E (P < 0.001). Overall in-hospital mortality rate was 9%, dropping from 21% in group A to 7% in group E (P < 0.001). Overall rates of re-exploration for bleeding (11%, P = 0.308) and postoperative dialysis (11%, P = 0.066) remained high across the observed time period. Triple valve replacement, redo sternotomy and poor preoperative left ventricular ejection fraction emerged as strong independent predictors of mortality. Triple-valve surgery remains rare in the UK. Early postoperative outcomes for triple valve surgery have improved over time. Redo sternotomy is a significant predictor of mortality. Attempts should be made to repair the mitral and/or tricuspid valves where technically possible.

Acute type a aortic intramural hematoma complicated with preoperative hemopericardium: early and late surgical outcome analyses

BackgroundAcute type A aortic intramural hematoma (ATAIMH) is a variant of acute type A aortic dissection (ATAAD), exhibiting an increased risk of hemopericardium and cardiac tamponade. It can be life-threatening without emergency treatment. However, comprehensive studies of the clinical features and surgical outcomes of preoperative hemopericardium in patients with ATAIMH remain scarce. This retrospective study aims to investigate the clinical features and early and late outcomes of patients who underwent aortic repair surgery for ATAIMH complicated with preoperative hemopericardium.MethodsWe investigated 132 consecutive patients who underwent emergency ATAIMH repair at this institution between February 2007 and August 2020. These patients were dichotomized into the hemopericardium (n = 58; 43.9%) and non-hemopericardium groups (n = 74; 56.1%). We compared the clinical demographics, surgical information, postoperative complications, 5-year cumulative survival rates, and freedom from reoperation rates. Furthermore, multivariable logistic regression analysis was utilized to identify independent risk factors for patients who underwent re-exploration for bleeding.ResultsIn the hemopericardium group, 36.2% of patients presented with cardiac tamponade before surgery. Moreover, the hemopericardium group showed higher rates of preoperative shock and endotracheal intubation and was associated with an elevated incidence of intractable perioperative bleeding, necessitating delayed sternal closure for hemostasis. The hemopericardium group exhibited higher blood transfusion volumes and rates of re-exploration for bleeding following surgery. However, the 5-year survival (59.5% vs. 75.0%; P = 0.077) and freedom from reoperation rates (93.3% vs. 85.5%; P = 0.416) were comparable between both groups. Multivariable analysis revealed that hemopericardium, cardiopulmonary bypass time, and delayed sternal closure were the risk factors for bleeding re-exploration.ConclusionsThe presence of hemopericardium in patients with ATAIMH is associated with an elevated incidence of cardiac tamponade and unstable preoperative hemodynamics, which could lead to perioperative bleeding tendencies and high complication rates. However, patients of ATAIMH complicated with hemopericardium undergoing aggressive surgical intervention exhibited long-term surgical outcomes comparable to those without hemopericardium.

1266 Haemostasis Checklists-Are They an Effective Tool?

Abstract Aim Haemostasis checklists have been developed to decrease re-bleeding rates following cardiac surgeries. These checklists aim to identify the most common sites of bleeding, as well as reasons for coagulopathies and prevent them by early identification during surgery. The aim of this study is to Evaluate the effectiveness of the haemostasis checklist as a tool for reducing the rate of Re-exploration for bleeding in Liverpool heart and chest Cardiothoracic Centre. Method Retrospective study carried over the period of 2019 and 2022 (pre and post checklist implementation). This study included all patients who underwent elective cardiac surgery, 614 cases in each year. Data was analysed and classified into 3 categories: Number of Re-exploration cases in each year, Bleeding sites identified and the Number of post-operative days at which re-bleeding was noted. Results Total number of Re-exploration cases for bleeding in 2019 were 39(6.35%), as compared to 14(2.28%) cases in 2022. 60% of the re-bleeding cases in 2019 were identified within first 24 hours post-operative, while 77% were identified in the first 24 hours in 2022. Most common sites of bleeding identified in 2019, were no clear site (38%) and sternal wires (19%). While in 2022, no clear site (46%) and sternal wires (23%) were most identified during re-exploration. Conclusions Significant reduction of 64% was witnessed between the year of 2019 and 2022 after implementation of the checklist, therefore, Haemostasis checklist proved to be an effective tool in reducing the rate of Re-exploration for bleeding in cardiac surgery.

Delayed sternal closure for intractable bleeding after acute type A aortic dissection repair: outcomes and risk factors analyses

BackgroundPerioperative coagulopathy and intractable bleeding are severe complications in acute type A aortic dissection (ATAAD) repair surgery. Mediastinal packing with delayed sternal closure (DSC) is a commonly adapted technique to stabilize the hemorrhagic tendency. This retrospective study aims to investigate the early and late outcomes and risk factors in patients who underwent DSC procedure during ATAAD repair surgery.MethodsThis study investigated 704 consecutive patients who underwent ATAAD repair at this institution between January 2007 and September 2020. These patients were dichotomized into the DSC (n = 109; 15.5%) and primary sternal closure (PSC) groups (n = 595; 84.5%). The clinical features, surgical information, postoperative complications, 5-years cumulative survival, and freedom from reoperation rates were compared. A multivariate logistic regression analysis was used to identify the independent risk factors for patients who underwent DSC.ResultsThe DSC group showed a higher rate of hemopericardium and preoperative malperfusion, and was associated with longer cardiopulmonary bypass and aortic clamping times and a higher rate of intraoperative extracorporeal membrane oxygenation (ECMO) support. The DSC group showed higher blood transfusion volumes and rate of reexploration for bleeding after surgery. However, the in-hospital mortality rates (17.4% vs. 13.3%; P = 0.249), 5-year survival rates (66.9% vs. 68.2%; P = 0.635), and freedom from reoperation rates (89.1% vs. 82.5%; P = 0.344) were comparable between the DSC and PSC groups. Multivariate analysis revealed that hemopericardium, preoperative malperfusion, and intraoperative ECMO support were risk factors for implementing DSC.ConclusionsDSC is an efficient life-saving technique to stabilize patients with intractable bleeding after undergoing ATAAD repair surgery, which leads to acceptable short- and long-term outcomes. Patients who were at risk for intractable bleeding should have early decision-making for implementing DSC.

Outcome of patients undergoing isolated tricuspid repair or replacement surgery.

The interest in isolated tricuspid valve disease has rapidly increased recently. However, clinical trials and registry data are rare in the surgical literature. This study aimed to describe the early and long-term outcomes of a real-world experience in isolated tricuspid procedures comparing repair and replacement strategies. The Surgical-Tricuspid study is a multicentre retrospective study that enrolled adult patients who had undergone isolated tricuspid valve surgery at 13 international sites. Propensity score-matched analysis was used to compare repair versus replacement. A cohort of 426 patients was enrolled [mean age: 55 (16) years; 56% female]. After matching, 175 comparable pairs were analysed. Preoperative left ventricular ejection fraction was 55(9) vs 56(9) (P = 0.8) while moderate-severe tricuspid regurgitation was present in 95% of cases. The 30-day mortality rate was 4.0% vs 8.0% in the repair and replacement groups, respectively (P = 0.115). The rates of re-exploration for bleeding (6.9% vs 13.1% P = 0.050), permanent pacemaker implantation (5.1% vs 12.0%; P = 0.022) and blood transfusion (46% vs 62%; P = 0.002) were higher in the replacement group. Cumulative survival rates at 3, 5 and 7 years in the repair group were 84 (3)%, 75 (4)% and 56 (9)% vs 71 (4)%, 66 (5)% and 58 (5)% in the replacement group (P = 0.001) while cumulative incidence for reoperation at 10 years did not differ between groups [repair 10 (1)% vs replacement 9 (1)%; P = 0.469]. The data from the Surgical-Tricuspid study reported a high risk for patients undergoing tricuspid surgery. Isolated valve repair offered reduced early and late mortality with no difference regarding reoperation rate when compared with replacement.

Stroke and Pump Thrombosis Following LVAD Implantation: The Impact of the Implantation Approach

<h3>Purpose</h3> The aim of this study is to investigate the impact of LVAD (left ventricular assist device) implantation technique on long-term mortality and morbidity, with special focus on stroke and pump thrombosis. <h3>Methods</h3> A retrospective data analysis was performed between 01/2015 and 03/2021 to identify patients who underwent LVAD implantation using either standard sternotomy (ST) approach or less invasive (LIS) approach. The LIS implantation was performed using a partial J-shaped sternotomy and left anterior mini-thoracotomy. All patients were followed up until 08/2021. Postoperative complications were collected according to INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) definitions, including severe RVF (right ventricle failure). The propensity score method was used to create 2 groups. Primary outcome was survival to discharge and during follow-up. Secondary outcomes were incidence of stroke and pump thrombosis during follow-up. <h3>Results</h3> The unmatched cohort included total 335 patients. Sternotomy was used in 242 (72.2%) patients and LIS in 93 (27.8%). Propensity matching produced 2 groups: 98 patients in ST and 67 in LIS. In the matched groups median follow-up was 612 days (IQR, 160-1172) in ST group compared with 463 days (IQR, 204-943) in LIS group (P= .4). In the matched cohort intensive care unit stay for LIS group was significantly lower than for the ST group (2, [IQR, 2-5] days vs 4, [IQR, 2-12] days; P< .01). Hospital mortality was significantly lower in the LIS group 7.5% (5/67) vs 18% (18/98) (P< .05). However, overall mortality, in the matched cohort, did not differ between the groups (ST, n=43 vs LIS, n=23; P=.2). The rate of stroke showed no significant difference in the matched cohort (n=10 ST vs n=9 LIS; P=.6). The pump thrombosis did not differ between groups in the matched cohort (n=6 ST vs n=5 LIS; P=.8). The reexploration rate for bleeding was necessary in 18% (18/98) in the ST group compared with 9% (6/67) in LIS group (P= .09). Severe RVF required temporary RVAD implantation occurred less often in the LIS group (10%, 7/67) in compare to ST group (19%, 19/98); P=.12. <h3>Conclusion</h3> LIS approach for LVAD implantation is a safe procedure with potential advantage in the early postoperative period. Postoperative stroke and pump thrombosis seems to be comparable for both surgical approach.

Impact of Surgical Approach on Outcome in Patients with History of Previous Sternotomy Underwent LVAD Implantation

<h3>Purpose</h3> The purpose of this study is to investigate the impact of the surgical approach on the outcome of patients with previous history of sternotomy. <h3>Methods</h3> Between January 2015 und September 2021, a total of 73 patients with a previous history of sternotomy received LVAD Implantation through two different approaches (less invasive and full sternotomy). The J-Sternotomy and anterolateral thoracotomy was used in all LIS patients. Data collection included baseline demographics, hemodynamic and implant data, adverse events and survival. The outcomes of the LIS and Sternotomy approaches were compared. <h3>Results</h3> Our cohort included 73 patients who underwent LVAD implantation. A total of 60 patients were operated using the old sternotomy approach, the remaining patients underwent LVAD-implantation through a LIS approach. Reexploration rate for bleeding was necessary in 25 % (15/60) in the full sternotomy group compared with 8.3 % (1/12) the less-invasive surgery group. Intensive care unit (ICU) stay for the LIS group was lower than for the sternotomy group (17.3 days vs. 18.2 days). The LIS group had less postoperative blood transfusion. The median operative time was also lower in the LIS group compared to the FS group (85 min vs. 96 min). Finally, the LIS group showed a lower rate of severe right heart failure with the need of right ventricular assist device (RVAD) Implantation (8.3 % vs. 18.3%). <h3>Conclusion</h3> The less-invasive surgery approach is a safe technique for left ventricular assist device implantation also in patients with history of previous sternotomy. Less-invasive surgery was associated with a reduction in the postoperative bleeding complications, duration of ICU stay, and RVAD implantation.

Re-exploration for bleeding after cardiac surgery: revaluation of urgency and factors promoting low rate

BackgroundRe-exploration of bleeding after cardiac surgery is associated with significant morbidity and mortality. Perioperative blood loss and rate of re-exploration are variable among centers and surgeons.ObjectiveTo present our experience of low rate of re-exploration based on adopting checklist for hemostasis and algorithm for management.MethodsRetrospective analysis of medical records was conducted for 565 adult patients who underwent surgical treatment of congenital and acquired heart disease and were complicated by postoperative bleeding from Feb 2006 to May 2019. Demographics of patients, operative characteristics, perioperative risk factors, blood loss, requirements of blood transfusion, morbidity and mortality were recorded. Logistic regression was used to identify predictors of re-exploration and determinants of adverse outcome.ResultsThirteen patients (1.14%) were reexplored for bleeding. An identifiable source of bleeding was found in 11 (84.6%) patients. Risk factors for re-exploration were high body mass index, high Euro SCORE, operative priority (urgent/emergent), elevated serum creatinine and low platelets count. Re-exploration was significantly associated with increased requirements of blood transfusion, adverse effects on cardiorespiratory state (low ejection fraction, increased s. lactate, and prolonged period of mechanical ventilation), longer intensive care unit stay, hospital stay, increased incidence of SWI, and higher mortality (15.4% versus 2.53% for non-reexplored patients). We managed 285 patients with severe or massive bleeding conservatively by hemostatic agents according to our protocol with no added risk of morbidity or mortality.ConclusionLow rate of re-exploration for bleeding can be achieved by strict preoperative preparation, intraoperative checklist for hemostasis implemented by senior surgeons and adopting an algorithm for management.

Adult coronary artery bypass grafting by congenital surgeons-a propensity matched analysis.

OBJECTIVESSurgical myocardial revascularization will be increasingly needed in adult patients with congenital heart disease. We investigated the results of coronary artery bypass grafting (CABG) performed on adults by congenital cardiac surgeons at our institution.METHODSWe conducted a retrospective, single-centre study. Adults undergoing isolated or combined CABG from 2004 to 2017 were included. Early and late outcomes were analyzed for the whole cohort. Furthermore, a propensity matched analysis was conducted comparing the results of isolated CABG between congenital and adult surgeons.RESULTSA total of 514 and 113 patients had isolated and combined CABG for acquired heart disease, respectively. A total of 33 patients had myocardial revascularization at the time of surgery for congenital heart disease. Overall early mortality was 1.2%, the rate of re-exploration for bleeding was 4.5%, and an internal mammary artery to left anterior descending artery graft was used in 85.6% patients. One-year survival was 97.5% (96.2–98.8%), and 5-year survival was 88.0% (84.8–91.3%). After propensity matching (468 pairs), early mortality (0.6% vs 1.2%, P = 0.51), re-exploration for bleeding (3.6% vs 3.0%, P = 0.72), use of internal mammary artery to left anterior descending artery graft (92.7% vs 91.9%, P = 0.70) and late survival did not differ between congenital surgeons and adult surgeons, respectively.CONCLUSIONSSurgical myocardial revascularization can be required for adult congenital patients in a broad spectrum of clinical situations. Despite lower volumes, congenital cardiac surgeons perform CABG safely and with results that are comparable to those of the adult surgeons at our centre.

Less-invasive ventricular assist device implantation: A multicenter study

BackgroundLeft ventricular assist device has been shown to be a safe and effective treatment option for patients with end-stage heart failure. However, there is limited evidence showing the effect of the implantation approach on postoperative morbidities and mortality. We aimed to compare left ventricular assist device implantation using conventional sternotomy versus less-invasive surgery including hemi-sternotomy and the minithoracotomy approach. MethodsBetween January 2014 and December 2018, 342 consecutive patients underwent left ventricular assist device implantation at 2 high-volume centers. Patient characteristics were prospectively collected. The propensity score method was used to create 2 groups in a 1:1 fashion. A competing risk regression model was used to evaluate time to death adjusting for competing risk of heart transplantation. ResultsThe unmatched cohort included 241 patients who underwent left ventricular assist device implantation with the conventional sternotomy technique and 101 patients who underwent left ventricular assist device implantation with the less-invasive surgery technique. Propensity matching produced 2 groups each including 73 patients. In the matched groups, reexploration rate for bleeding was necessary in 17.9% (12/67) in the conventional sternotomy group compared with 4.1% (3/73) the less-invasive surgery group (P = .018). Intensive care unit stay for the less-invasive surgery group was significantly lower than for the sternotomy group (10.5 [interquartile range, 2-25.75] days vs 4 [interquartile range, 2-9.25] days, P = .008), as was hospital length of stay (37 [interquartile range, 27-61] days vs 25.5 [interquartile range, 21-42] days, P = .007). Mortality cumulative incidence for conventional surgery was 24% (95% confidence interval, 14.3-34.8) at 1 year and 26% (95% confidence interval, 15.9-37.4) at 2 years for patients without heart transplantation. Mortality cumulative incidence for less-invasive surgery was 22.5% (95% confidence interval, 12.8-33.8) at 1 year and 25.2% (95% confidence interval, 14.5-37.4) at 2 years for patients without heart transplantation. There was no difference in cumulative mortality incidence when adjusting for competing risk of heart transplantation (subdistribution hazard, 0.904, 95% confidence interval, 0.45-1.80, P = .77). ConclusionsThe less-invasive surgery approach is a safe technique for left ventricular assist device implantation. Less-invasive surgery was associated with a significant reduction in the postoperative bleeding complications and duration of hospital stay, with no significant difference in mortality incidence.

Preoperative Vitamin K Reduces Blood Transfusions at Time of Left Ventricular Assist Device Implant

Congestive heart failure patients have hepatic congestion and abnormal coagulation profiles, increasing perioperative bleeding at time of ventricular assist device implantation. This study examined the impact of the preoperative administration of vitamin K on perioperative blood transfusion requirements. Retrospectively, 190 patients met inclusion criteria. Patients received no vitamin K (n= 62) or two 10-mg doses of intravenous vitamin K (n= 128) in the 24 hours before assist device implantation. Primary end points included transfusion requirements and reexploration rates for bleeding. Secondary outcomes were pump thrombosis and in-hospital mortality. Baseline characteristics were similar between the 2 groups, with slight differences (not statistically significant) noted in the Interagency Registry for Mechanically Assisted Circulatory Support profile and total bilirubin levels. The only significant difference noted was the year of implantation (P < .001). Blood product usage was significantly lower in the vitamin K group compared to the no vitamin K group (P < .001). Higher rates of reexploration for bleeding (29.7% vs 13.6%, P= .023) and death at hospital discharge (16.2% vs 2.8%, P= .004) were noted for the no vitamin K group compared with the vitamin K group. After adjusting for age, sex, race, body mass index, Interagency Registry for Mechanically Assisted Circulatory Support profile, total bilirubin, surgeon, and year of operation, reexploration rates and death did not achieve statistical significance. No statistically significant difference was observed in stroke and pump thrombosis rates between the 2 groups. Preoperative vitamin K administration may help reduce blood product use without any increased risk for strokes or pump thrombosis.

Minimally Invasive Versus Conventional Aortic Root Replacement − A Systematic Review and Meta-Analysis

Mini-sternotomy has been proven superior to full sternotomy in aortic valve replacement by providing better perioperative outcomes. We investigated whether such technique provides better outcomes in patients undergoing aortic root surgery. A comprehensive electronic literature search was undertaken among the four major databases (PubMed, Ovid, Scopus and EMBASE) to identify all published studies up to June 2018. The search terms used related to mini-sternotomy versus full sternotomy, aortic root, valve sparing, Bentall procedure. Only articles that compared mini against full sternotomy were considered in this analysis. After excluding articles based on title or abstract, the full text articles selected had reference lists searched for any potential further articles to be included in this review. A total of 2,765 patients were analysed from across eight comparative studies that were included in the quantitative analysis of the parameters of interest that fulfilled the criteria for meta-analysis. Mini-sternotomy aortic root replacement was associated with significantly shorter cardiopulmonary bypass time (p=0.009), lower rate of blood transfusion (p=0.01). additionally, they had lower operative mortality (p=0.02), and shorter stay at intensive care and at hospital (p=0.0009, p=0.03 respectively). However, there was no difference between mini-sternotomy and conventional aortic root replacement in terms of aortic cross-clamp time (p=0.28), total operation time (p=0.31), re-exploration rate for bleeding (p=0.28), stroke rate (p=0.90), wound infection rate (p=0.96), and length of mechanical ventilation (p=0.10). Mini-sternotomy is a safe, feasible alternative option to full sternotomy in aortic root repair. However, the significant heterogeneity in data points to the need for a larger, well-designed trial to support the currently limited literature evidences.

Active Chest Tube Clearance After Cardiac Surgery Is Associated With Reduced Reexploration Rates

Ineffective evacuation of intrathoracic fluid after cardiac surgery (retained blood syndrome [RBS]) might increase postoperative complications, morbidity, and mortality. Active tube clearance (ATC) technology using an intraluminal clearing apparatus aims at increasing chest tube drainage efficiency. This study evaluated whether ATC reduces RBS in an all-comers collective undergoing scheduled cardiac surgery with cardiopulmonary bypass and full or partial median sternotomy. In this nonrandomized prospective trial, 581 consecutive patients undergoing scheduled cardiac surgery with median sternotomy between January 2016 and December 2016 were assigned to receive conventional chest tubes (control group) or a combination of conventional tubes and as many as two ATC devices (ATC group), depending on their operation date. Postoperative occurrence of RBS (one or more of the following: reexploration for bleeding or tamponade, pericardial drainage procedure, pleural drainage procedure) and other endpoints were compared. Propensity score matching was applied. In 222 ATC patients and 222 matched control patients, RBS occurrence did not differ between the groups (ATC 16%, control 22%; p= 0.15). However, reexploration rate for bleeding or tamponade was significantly reduced in the ATC group compared with the control group (4.1% versus 9.1%, respectively; p= 0.015). The mortality of RBS patients (21%) was higher compared with patients without RBS (3.9%, p < 0.001). Among the RBS components, only reexploration (odds ratio 16, 95% confidence interval: 5.8 to 43, p < 0.001) was relevant for inhospital mortality (ATC 6.8%, control 7.7%; p= 0.71). Active tube clearance is associated with reduced reexploration rates in an all-comers collective undergoing cardiac surgery. Reexploration is the only RBS component relevant for mortality. The ATC effect does not translate into improved overall survival.

Total arterial revascularization in patients with acute myocardial infarction \u2013 feasibility and outcomes

BackgroundIn acute situations such as acute myocardial infarction (AMI) with indication for coronary artery bypass grafting (CABG), total arterial revascularization (TAR) is often rejected in favour of saphenous vein (SV) grafting, which is assumed to allow for quicker vessel harvesting, a simpler anastomosis technique, and thus quicker revascularization and fewer bleeding complications. The aim of this study was to evaluate whether reluctance to apply TAR in AMI is still justified from a technical point of view in the current era and whether superiority of TAR results is also evident in emergency patients with AMI undergoing CABG.MethodsIn this retrospective analysis of 434 consecutive patients undergoing CABG for AMI with either TAR or with a combination of one internal mammary artery and SV grafts between 2008 and 2014, procedural data, short-term and mid-term outcome were compared. Propensity score matching of the groups was performed.ResultsAfter propensity score matching, 250 patients were included in the analysis (TAR group: n = 98; SV group n = 152). The procedural time (TAR group: 211 min vs. SV group: 200 min, p = 0.46) did not differ between the groups. Erythrocyte transfusion rates were higher in the SV group (76% vs. 57%; p < 0.001). Rates of re-exploration for bleeding did not differ. Thirty-day mortality rates were comparable (TAR group: 3.4% vs. SV group: 4.5%, p = 0.68). Kaplan-Meier analysis until 7 years postoperatively revealed a tendency for improved survival after TAR (75% vs. 62%; log-rank p = 0.12).ConclusionTAR neither impairs rapid revascularization nor reduces its safety in patients with AMI. It may result in improved long-term outcome and should be preferred in the clinical setting of AMI.

Preoperative Aspirin Does Not Increase Transfusion or Reoperation in Isolated Valve Surgery

Preoperative aspirin has been studied in patients undergoing isolated coronary artery bypass graft surgery. However, there is a paucity of clinical data available evaluating perioperative aspirin in other cardiac surgical procedures. This study was designed to investigate the effects of aspirin on bleeding and transfusion in patients undergoing non-emergent, isolated, heart valve repair or replacement. Retrospective, cohort study. Academic medical center. A total of 694 consecutive patients having non-emergent, isolated, valve repair or replacement surgery at an academic medical center were identified. Of the 488 patients who met inclusion criteria, 2 groups were defined based on their preoperative use of aspirin: those taking (n = 282), and those not taking (n = 206) aspirin within 5 days of surgery. Binary logistic regression was used to examine relationships among demographic and clinical variables. No significant difference was found between the aspirin and non-aspirin groups with respect to the percentage receiving red blood cell (RBC) transfusion, mean RBC units transfused in those who required transfusion, massive transfusion of RBC, or amounts of fresh frozen plasma, cryoprecipitate, or platelets. Aspirin was not associated with an increase in the rate of re-exploration for bleeding (5.3% v 6.3%, p = 0.478). Major adverse cardiocerebral events (MACE), 30-day mortality, and 30-day readmission rates were not statistically different between the aspirin-and non-aspirin-treated groups. Preoperative aspirin therapy in elective, isolated, valve surgery did not result in an increase in transfusion or reoperation for bleeding and was not associated with reduced readmission rate, MACE, or 30-day mortality.

Minimal invasive aortic valve replacement surgery is associated with improved survival: a propensity-matched comparison†

To compare early and long-term outcomes of minimally invasive surgery (MIS) versus full sternotomy (FS) isolated aortic valve replacement (AVR). We retrospectively analysed all patients who underwent isolated bioprosthetic AVR between 2003 and March 2012 at our institution. Matching was performed based on a propensity score, which was obtained using the output of a logistic regression on relevant preoperative risk factors. Mean follow-up was 3.1±2.7 years (range 0-9.0 years) and was 99.8% complete. A total of 2051 patients (FS, 1572; MIS, 479) underwent isolated bioprosthetic AVR during the study period. MIS patients were significantly younger (67.8±11.2 vs 70.4±9.4 years) and had a lower logistic EuroSCORE (6.6±6.4 vs 11.2±13.4%, both P<0.001). Propensity matching resulted in 477 matched patients from each group, with no significant differences in any of the preoperative variables. Aortic cross-clamp times were significantly longer in MIS patients (59.4±16.0 vs 56.9±14.6 min, P=0.008). Nonetheless, MIS AVR was associated with a significantly lower incidence of intra-aortic balloon pump usage (0.4 vs 2.1%, P=0.042) and in-hospital mortality (0.4 vs 2.3%, P=0.013), while FS patients had a lower rate of re-exploration for bleeding (1.5 vs 4.2%, P=0.019). Five- and 8-year survival post-AVR was significantly higher in MIS patients (89.3±2.4% and 77.7±4.7% vs 81.8±2.2% and 72.8±3.1%, respectively, P=0.034). Cox regression analysis revealed MIS (hazard ratio: 0.47, 95% confidence interval: 0.26-0.87) as an independent predictor of long-term survival. MIS AVR is associated with very good early and long-term survival, despite longer myocardial ischaemic times. MIS AVR can be performed safely with results that are at least equivalent to those achieved through an FS.

Implementing a point of care testing (POCT) service improves management of haemostatic dysfunction in cardiac surgery patients

s / Australian Critical Care 27 (2014) 43–63 49 concentration prepared, who usually prepared the drug and what current safety practices were used. Results:Thirty-eight responses to the surveywere received representing 29 ICUs, approximately 17% of all adult ICUs in Australia and NZ. Two specialist peadiatric ICUs also responded. Seventeen respondents (60%) were currently using at least one pre-prepared infusion, most commonly heparin (8/17), epidurals (6/17) or opiates for patient controlled analgesia (11/17). Significant variation in final concentration was observed for all infusionsexcept insulinandesmolol. Thefinal volumevaried significantly for all drugs. Other than the small number of pre-prepared infusions, nursing staff prepared all infusions. Labellingwas usually hand-written with some colour-coding. Ninety percent of respondents identified safety and 68% identified efficiency as likely to be improved by the use of pre-prepared infusions. Conclusion: Significant variation exists in the preparation of commonly used infusions across ICUs in Australia andNZ. Rationalisation and standardisation of practice would improve safety and efficiency. A nationally or regionally coordinated response could potentially reduce the barrier of cost. Disclosureof interest:Anunrestricted researchgrant fromBaxter HealthCare supported the conduct of this study. http://dx.doi.org/10.1016/j.aucc.2013.10.019 Implementing a point of care testing (POCT) service improves management of haemostatic dysfunction in cardiac surgery patients B. Pearse1,∗, D. Wall1, I. Smith1, D. Faulke1, I. Rapchuck1, J. Fraser2, J. McGree3, L. Drake1, P. Tesar1, Yl. Fung2 1 The Prince Charles Hospital, Brisbane, Australia 2 Critical Care Research Group, UQ, 7 School of Mathematical Sciences, QUT, Australia 3 Critical Care Research Group, UQ, Australia Introduction:Somebleeding is anexpectedconsequenceof cardiac surgery. Excessive or uncontrolled bleeding is a complication requiring timelymanagement andmay require blood transfusion/s. Turnaround times for standard laboratory tests (SLT’s) is often too slow to guide treatment. Hence, blood products are often transfused before SLT results are available. Blood product transfusion is not without risk and is independently associated with increased risk for morbidity/mortality. Objectives: To improve diagnosis of haemostatic dysfunction and bleeding management, in July 2012 we commenced the implementation of a clinician driven POCT service using rotationalthromboelastometry (ROTEM) and platelet function (Multiplate) at The Prince Charles Hospital. Methods: A multidisciplinary, multimodal approach was taken and involved appointment of a project lead, identifying stakeholders, developing a project plan, educating POCT operators/interpreters, developing quality control infrastructure and monitoring/analysing outcomes. Results: A comparison of post POCT implementation data with historical controls demonstrated a decrease in percentage patients receiving RBC’s (p=2.965e−08), FFP (p<2.2e−16) and platelets (p<2.2e−16). Units per patient was reduced for RBC (p=1.8413e−09), FFP (p=5.4988e−25) and platelets (p=8.5073e−27). A significant decrease was seen in reexploration rate for bleeding (p=0.0509) and median hospital LOS (p=9.3657e−09). Conclusions: Implementation of our POCT service reduced percentage of patients receiving blood products as well as quantity of products transfused. Timely results allowedclinicians to treat coagulopathy,with only those products required to resolve haemostatic dysfunction. Key to this success is a dedicated project lead and a multidisciplinary, multimodal approach involving all stakeholders. http://dx.doi.org/10.1016/j.aucc.2013.10.020 Measurement of temperature in critically ill adults: A systematic review and clinical practice guideline K. Rolls1,∗, K. Armstrong2, L. Keating3, D. Wrightson4, S. Walker5, J. Masters1 1 ACI-ICCMU, Australia 2 Bankstown ICU, Australia 3 St George ICU, Australia 4 Wollongong ICU, Australia 5 Central Queensland University, Australia Accurate measurement of temperature is important to ensure patients receive appropriate and timely interventions to prevent significantmorbidity andmortality. The clinical questionunderpinning this studywas ‘whatmethod/sofmeasuringbody temperature ensures the timely identification of abnormal temperatures in critically ill adults?’ An expert nursing group undertook a systematic review to identify research published between January 2000 and May 2012, published in English and applicable to critically ill patients aged more than 13. Recommendations for practice were developed at a consensus meeting and refined using internal and external validation panels. Online surveyswere usedwhere panellists indicated their level of agreementusinga9-point Likert scale. Agreementwas set as a median of equal or greater than seven. National Health and Medical Research Council guideline processes and evidence taxonomy were applied. Scottish Intercollegiate Guidelines Network quality criteria were used. Thirty-one paperswere reviewedwith 24, including 17 Level III2 studies, four systematic reviews and three guidelines, included in thefinal review. Themost commonproblemswere failure to ensure adequate inter-rater reliability and sample size, and application of Bland–Altman analysis.

Video-atlas on minimally invasive mitral valve surgery-The David Adams technique.

Median sternotomy has unquestionably evolved over recent decades. Modern sternotomy involves a 7-8 cm lower midline skin incision, tunneling of the subcutaneous tissues with subsequent creation of myocutaneous flaps, full sternotomy, and standard cardiopulmonary bypass techniques with central cannulation. In experienced centers, modern sternotomy may achieve all the goals of minimally invasive surgery, including excellent cosmesis, excellent postoperative pain control, low rates of bleeding and transfusion (our re-exploration rate for bleeding is <1%), and the ability to perform any reconstructive technique that would be used in a standard sternotomy, with very high repair rates (our most recent series documented a repair rate exceeding 99% in an all-comers population of degenerative disease regardless of complexity).

315 * BENEFITS OF MINIMALLY INVASIVE OVER FULL STERNOTOMY AORTIC VALVE REPLACEMENT SURGERY: A PROPENSITY-MATCHED COMPARISON

(FS = 1572, MIS = 479) during the study period. The mean follow-up was 3.1 ± 2.7 years (6367 patient-years). MIS patients were significantly younger (67.8 ± 11.2 vs 70.4 ± 9.4, P< 0.001) and had a lower logistic EuroSCORE (6.6 ± 6.4% vs 11.2 ± 13.4%, P< 0.001). FS patients had a significantly shorter cross-clamp time (56.1 ± 17.3 vs 59.0 ± 16.8 min, P< 0.001), but cardiopulmonary bypass times (82.3 ± 21.7 vs 82.2 ± 25.7 min, P= 0.184) were similar. Propensity matching resulted in 477 patients from each group. After matching, there were no significant differences in any preoperative variables between groups. FS patients had a lower rate of re-exploration for bleeding than MIS patients (1.5 vs 4.2%, P= 0.019). However, MIS AVR was associated with a significantly lower 30-day mortality (0.8 vs 2.9%, P= 0.032), and a better five- and eight-year survival (89.3 ± 2.4% and 77.7 ± 4.7% vs 81.8 ± 2.2% and 72.8 ± 3.1%, P= 0.034). Cox regression analysis revealed MIS (HR 0.47, 95% CI 0.26-0.87), age (HR 1.049, 95% CI 1.021.07), preoperative liver failure (HR 5.027, 95% CI 2.51-10.08), and preoperative dialysis (HR 7.340, 95% CI 2.81-19.17) as independent predictors of long-term survival. Conclusions: MIS AVR is associated with excellent early and long-term survival and should be considered as standard of care for patients undergoing bioprosthetic AVR. Interactive CardioVascular and Thoracic Surgery

High‐dose aprotinin, blood product transfusions, and short‐term outcome in neonates and infants: a pediatric cardiac surgery center experience

The efficacy of aprotinin, the most popular antifibrinolytic agent in congenital cardiac surgery, was still uncertain in small infants when its prophylactic use was suspended for safety reasons. The aim of this study is to describe associations between the prophylactic use of high-dose aprotinin, the need for blood product transfusions, and short-term outcome in neonates and infants with cardiac surgery. This retrospective study included all patients younger than 1 year undergoing surgery with cardiopulmonary bypass through 42 months, before and after withdrawal of aprotinin. Each patient who received aprotinin was matched with a control with similar baseline and surgical characteristics, who have not received any antifibrinolytic agent. Associations between the use of aprotinin and the exposure to red blood cells, fresh frozen plasma, and platelet transfusions were estimated from a logistic regression model, and the exposure to additional transfusions from a polytomous regression model. Matching resulted in two groups of 283 patients each, well balanced except for the priming volume and the ultrafiltration rate, larger in the aprotinin group. After adjustment for the priming volume and ultrafiltration rate, there was no significant association between the use of aprotinin, the exposure to any blood product transfusion, or the exposure to additional transfusions, the rate of re-exploration for bleeding, and short-term outcome. Two patients in the control group required re-exploration for bleeding. No association was found between the prophylactic use of aprotinin, blood product transfusions, and short-term outcome in this population of neonates and infants.