Re-exploration For Bleeding Research Articles

Heparin titration protocol with tranexamic acid in cardiac surgery: a pilot study

Aim: Postoperative bleeding related to cardiac surgery is a clinically important condition. Consequently, re-exploration and increased blood utilization lead to adverse outcomes. The aim of this pilot study was to assess the effect of a newly adapted blood conservation strategy, including heparin titration protocol along with antifibrinolytics, regarding to mediastinal bleeding, re-exploration for bleeding and blood and blood products utilization.Methods: This study included 100 patients undergoing cardiac surgery with higher risk for bleeding, such as mitral valve replacement, aortic valve replacement, ascending / arcus aortic surgery, between January 2015 and August 2016. The study group consisted of consecutive patients who underwent new protocol (heparin titration protocol + tranexamic acid). The control group consisted of patients who were administered standard dose heparin(4 mg/kg). Fifty patients in each group (with the new protocol and the standard protocol) were compared by means of amount of heparin applied, blood utilization, mediastinal drainage and rate of re-exploration.Results: Twenty-eight of the 50 study group patients (56%) received a red blood cell (RBC) transfusion for the first 24 hours. RBC transfusion ≥ 3 units was lower in the study group (34% vs 54%; p=0.044). Moreover, mediastinal drainage and blood utilization was found to be lower at the study group, however re-exploration rates remained similar.Conclusion: Based on our study results, the suggested heparin titration protocol seemed to be beneficial for reducing postoperative bleeding and blood product usage. We consider that blood utilization protocols like our heparin titration protocol should be established to reduce the need for blood transfusion in cardiac surgery.

Bilateral internal thoracic artery coronary grafting: risks and benefits in elderly patients.

Whether bilateral internal thoracic artery (BITA) grafting benefits elderly patients in coronary artery bypass grafting (CABG) remains unclear since they tend to have a limited life expectancy and severe comorbidities. We aim to evaluate the outcomes of BITA vs. single internal thoracic artery (SITA) grafting in elderly patients. A meta-analysis was performed by database searching until May 2021. Studies comparing BITA and SITA grafting among elderly patients were included. One randomized controlled trial, nine propensity score matching, and six unmatched studies were identified, with a total of 18146 patients (7422 received BITA grafting and 10724 received SITA grafting). Compared with SITA grafting, BITA grafting had a higher risk of deep sternal wound infection (DSWI) [odds ratio: 1.67; 95% confidence interval (CI): 1.22-2.28], and this risk could not be significantly reduced by the skeletonization technique. Meanwhile, BITA grafting was associated with a higher long-term survival [hazard ratio: 0.83; 95% CI: 0.77-0.90], except for the octogenarian subgroup. Reconstructed Kaplan-Meier survival curves revealed 4-year, 8-year, and 12-year overall survival rates of 85.5%, 66.7%, and 45.3%, respectively, in the BITA group and 79.3%, 58.6%, and 34.9%, respectively, in the SITA group. No significant difference was observed in early mortality, perioperative myocardial infarction, perioperative cerebral vascular accidents, or re-exploration for bleeding. Compared with SITA grafting, BITA grafting could provide a long-term survival benefit for elderly patients, although this benefit remained uncertain in octogenarians. Meanwhile, elderly patients who received BITA were associated with a higher risk of DSWI and such a risk could not be eliminated by the skeletonization technique.

Bilateral internal thoracic artery use in two-vessel disease does not increase the perioperative risk—A propensity score matched analysis

BackgroundBilateral internal thoracic arteries (BITA) are uncommonly used in the every-day practice due to safety concerns and technical challenges with Y-grafts. We hypothesized that in-situ BITA use during coronary artery by-pass grafting (CABG) for two vessel disease is equally safe to standard strategy with left internal thoracic artery-left anterior descending artery revascularization and venous graft to other target vessels.MethodsA propensity score matched analysis was used to compare elective on-pump CABG patients who received in-situ BITA (BITA-group), versus left internal thoracic artery graft to the left anterior descending artery plus vein (SITA-group). Primary end points were 30-days all-cause-mortality, major adverse cardiac events and incidents and deep sternal wound infections.ResultsA total of 50 matched pairs (c-statistics 0.769) were selected from patients operated on between January 2015 and April 2020 using BITA (n = 50) and SITA (n = 2170). There were no inter-group differences in demographics and basic clinical characteristics. The total operation time was longer in the BITA-group (4.0 vs 3.6 hours; p = 0.004). The rate of complete revascularization was similar, as was median aortic cross-clamp time, median extracorporeal circulation time, rate of re-explorations for bleeding, deep sternal wound infections or length of stay. One patient died in BITA group, 3 days after surgery, from a non-cardiac cause. After 36 months, the survival rate was 98% for BITA-group and 96% for controls (log-rank, p = 0.577).ConclusionsIn-situ use of BITA during coronary revascularization for two-vessel disease is as safe and effective, as use of single ITA and vein graft. In-situ strategy abolishes allows to avoid the technically demanding composite graft configuration.

Left ventricular assist device implants in patients on extracorporeal membrane oxygenation: do we need cardiopulmonary bypass?

OBJECTIVESImplanting a durable left ventricular assist device (LVAD) in a patient on extracorporeal life support (ECLS) is challenging. The goal of this study was to compare the results of patients from a European registry who had a durable LVAD implanted with or without transition from ECLS to cardiopulmonary bypass (CPB).METHODSA total of 531 patients on ECLS support who had an LVAD implant between January 2010 and August 2018 were analysed; after 1:1 propensity score matching, we identified and compared 175 patients in each group.RESULTSThe duration of preoperative ECLS was 7 [standard deviation (SD) 6] vs 7 (SD 6) days in patients with or without CPB (P = 0.984). The surgical time was longer in the CPB group [285 (SD 72) vs 209 [SD 75] min; P ≤ 0.001). The postoperative chest tube output was comparable [1513 (SD 1311) vs 1390 (SD 1121) ml; P = 0.3]. However, re-exploration for bleeding was necessary in 41% vs 29% of patients with or without CPB (P = 0.01) and a significantly higher number of packed red blood cells and fresh frozen plasma [8 (SD 8) vs 6 (SD 4) units; P = 0.001 and 6 (SD 7) vs 5 (SD 5) units; P = 0.03] were administered to patients operated on with CPB. A postoperative mechanical right ventricular support device was necessary in 50% vs 41% of patients (P = 0.08). The stroke rate was not significantly different (P 0.99). No difference in survival was observed.CONCLUSIONSOmitting CPB for an LVAD implant in patients on ECLS is safe and results in shorter operating time, less re-exploration for bleeding and fewer blood products. However, no survival benefit is observed.

Surgical outcomes of minimally invasive aortic valve replacement via right mini-thoracotomy for hemodialysis patients.

Minimally invasive valve surgery has become increasingly accepted as an alternative to conventional median sternotomy in low-risk patients. However, there have been no reports regarding the outcomes of this procedure on high-risk hemodialysis patients. The purpose of this investigation was to assess the surgical outcomes of minimally invasive aortic valve replacement (AVR) via right mini-thoracotomy (MIAVR) in hemodialysis patients compared with those of conventional AVR (CAVR) via full sternotomy. Two hundred and seventy-four patients underwent isolated AVR for severe AS, and 42 hemodialysis patients were included in this study. MIAVR was performed in 17 cases and CAVR in 25 cases. We compared the short-term surgical outcome among the two groups. There was no difference in the aortic cross-clamp or cardiopulmonary bypass time. However, the procedure time was significantly shorter in the MIAVR group. Patients in the MIAVR group had less bleeding and a smaller amount of transfused red blood cells. There were four hospital deaths (18.2%) in the CAVR group. For postoperative complications, there were 2 (9.1%) cerebrovascular incidents, 2 (9.1%) cases of respiratory failure, 1 (4.5%) re-exploration for bleeding in CAVR group. The postoperative ventilation time was significantly shorter in the MIAVR group. There was no difference in the length of postoperative intensive care unit stay or of postoperative hospital stay. The surgical outcomes of MIAVR in hemodialysis patients were acceptable, with a low incidence of morbidity, reasonable lengths of hospital stay, and no mortality among the patients studied.

An off-pump biatrial mini-maze procedure for treatment of long-standing persistent atrial fibrillation

Abstract Background Surgical treatment has assumed a more prominent role in the therapy of atrial fibrillation (AF) with favorable efficiency and acceptable safety during the last decades. The traditional Cox-Maze procedure and Wolf Mini-Maze procedure focused on left atrial ablation. However, it is ubiquitous that patients with long-standing persistent atrial fibrillation (LSPAF) typically suffer from biatrial electrical and structural remodeling. The left atrial procedures are still not enough in patients with LSPAF. Purpose Herein, we aimed to introduce a modified biatrial off-pump ablation procedure based on the Wolf Mini-Maze procedure and to detect the safety and efficacy of the surgery for patients with LSPAF. Methods Between January 2016 and September 2020, 102 patients of LSPAF underwent our modified Mini-Maze procedure using bipolar radiofrequency ablation. Those patients firstly underwent a Mini-Maze procedure using Dallas lesion set, including video-assisted bilateral mini-thoracotomy, left atrial appendage excision, bilateral pulmonary vein isolation, ganglionic plexi evaluation and destruction, left atrial roof connecting lesion, and a linear lesion connecting this roofline to the root of the aorta at the junction of the left coronary and the non-coronary cusp. Secondly, a purse-string suture was performed on the right atrium, and then four ablation lesions were made to the superior vena cava, to the inferior vena cava, to the appendix of the right atrium, and to the tricuspid valve annulus from the purse-string suture point by the bipolar radiofrequency clamp. After the operation, the patients were followed up at an interval of 3, 6, 12 months, and every 1 year after that. Results No mortality No surgical re-exploration for bleeding. No permanent pacemaker implantation. 99 patients were free from LSPAF upon discharge. A follow-up at interval of 3, 6, 12, 24, 36, and 48 months showed a success rate free from LSPAF was 95.1% (97/102), 94.4% (85/90), 94.8% (73/77), 91.5% (54/59), 90.3% (28/31) and 100% (9/9), respectively Conclusions The modified biatrial Mini-Maze suggested a safe and feasible procedure. Early follow-up demonstrated an acceptable success rate free from AF. It might have the potential to become another option for clinical treatment of LSPAF. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): General Program of the National Natural Science Foundation of China Schematic of the procedure

Early results of multiple coronary artery bypass grafting on arteries less than 1.5 mm in diameter

Abstract The widespread using of coronary artery (CA) stenting has led to the fact that nowadays coronary artery bypass grafting (CABG) is the method of choice for patients with multiple occlusions and diffuse lesions, who can be refused in surgery due to “small”, not specified in the guidelines, CA (diameter less than 1.5 mm). The use of microsurgical technique makes it possible to reconstruct small-caliber vessels, however, no detailed comparative data has been published yet. Aim To analyze the efficacy of CABG using microsurgical techniques for multiple CA bypass with arteries less than 1.5 mm and compare the results with coronary surgery of larger vessels in the early postoperative period. Methods We studied the early results of CABG in two groups of patients. The study group was represented by 100 patients with multiple coronary artery lesions with d<1.5 mm, who underwent control MSCT-shuntography in the postoperative period. We formed a control group of 100 patients who underwent CABG with a target artery d>1.5 mm. In all cases cardiopulmonary bypass and microsurgical technique were used. Results All patients underwent complete revascularization of CA, the average number of distal anastomoses was 4,3±0,5 in the study group versus 3.6±0,3 in the comparison group, p<0,001. Intraoperatively in the study group significantly more often performed complex anastomoses to arteries <1,5mm (47 patients vs 18, p<0,001), onlay-flap anastomoses (23 vs 1, p<0,001), single and multiple endarterectomies (19 vs 1, p<0,001). The need for long-term inotropic support (15 cases vs 13, p=0,684), as well as prolonged artificial lung ventilation (2 vs 3, p=0,651), in hospital stage was similar in both groups. Patients from the study group more often underwent reexploration for bleeding in the early postoperative period, which was explained by a large number of complex reconstructions and prolonged on pump time, nevertheless, the difference did not reach statistical significance (4 vs 2, p=0,407). Perioperative myocardial infarction (MI) were registered in 3 (3%) and 1 (1%) cases in the study and control groups, respectively, p=0,621. All patients in the study group underwent MSCT-shuntography in the early postoperative period, according to which 8 patients (8%) had occlusion of the autovenous coronary grafts to the CA<1.5mm and 4 patients (4%) - occlusion of the bypasses to CA>1.5 mm. Conclusion CABG in patients with coronary arteries less than 1.5 mm in diameter requires complex reconstructive techniques significantly more often. Nevertheless, in the early postoperative period, it is possible to achieve comparable results in the patient groups with and without CA<1,5mm in the anastomotic sites. Funding Acknowledgement Type of funding sources: None.

Impact of concomitant replacement of the ascending aorta in patients undergoing aortic valve replacement on operative morbidity and mortality.

The aim of this study was to evaluate the impact of concomitant ascending aortic replacement on operative morbidity and mortality in patients undergoing aortic valve replacement (AVR). We retrospectively analysed our institutional database for all patients undergoing elective isolated AVR and AVR with concomitant replacement of the ascending aorta between January 2009 and May 2020. Patients undergoing surgery for infective endocarditis or requiring hypothermic circulatory arrest were excluded. A 3:1 propensity matching was performed for 688 patients to compare isolated AVR (120 patients) with AVR + ascending aortic replacement (40 patients). There were significant differences in median cardiopulmonary bypass (CPB) time [92.5 (75-114) vs 118.5 (104-131) min; P < 0.001], median aortic cross-clamp time [65.0 (51.5-78.5) vs 84.5 (77-94) min; P < 0.001] and median intensive care unit stay [1 (1-3) vs 2 (1-6) days; P < 0.01]. There was no significant difference in the use of intraoperative and postoperative blood products, re-exploration for bleeding, postoperative atrial fibrillation, acute renal failure, incidence of stroke, perioperative myocardial infarction and 30-day mortality. Concomitant replacement of the ascending aorta significantly prolongs CPB and aortic clamp times but does not increase operative morbidity and mortality. Therefore, replacement of a dilated ascending aorta appears to be the most durable and safest treatment option in patients undergoing AVR with an aneurysmatic ascending aorta.

Minimally Invasive versus Conventional Mitral Valve Surgery: Procedures and Early Outcomes

Background: Minimal invasive mitral valve surgery gained wide acceptance. However, criticism continuous about its ability to replace the conventional full sternotomy technique.Aim of the work: The study aimed to compare between the full sternotomy and less invasive approaches for mitral valve surgery.Patients and Methods: The study recruited 100 patients. They were allocated to one of two equal groups [the traditional and minimal invasive approach]. All patients were thoroughly evaluated by history taking, physical examination, laboratory and ancillary radiological investigations. Assessment included incision length, weaning events, aortic cross clamp time, total bypass and operative times, rate of conversion from minimally invasive technique to full sternotomy. In surgical intensive care unit, ventilation hours, post-operative pain and need for analgesia, re-exploration for bleeding, blood loss and blood transfusion, and any complications were documented.Results: Preoperative New York Heart Association [NYHA] class was significantly different between groups A and B. But, no significant difference was reported for patient demographic or preoperative data. The incision length and cross clamp time was shorter in A than B group [6.56±1.88 cm, 61.78±35.91 minutes’ vs 12.54±1.78 cm, and 78.08±36.24 minutes, respectively]. Otherwise, the cannulation, bypass, operative times were significantly longer among group A. The ventilation, ICU stay, hospital stay, bleeding, serum creatinine and pain scores were significantly lower among group A. the postoperative events were comparable between both groups with slight increase of neurological events in A group [3 cases] than B group [2 cases]. At 6 months, both groups yielded non-significant difference, regardless of better outcome at direct postoperative time.Conclusion: Minimal invasive mitral valve surgery had a good short and mid-term outcome as the conventional sternotomy approach. It could replace the conventional approach as a gold-standard for mitral valve surgery.

Comparative study of Short term results between On-pump versus Off-pump CABG in Patients with Preoperative mild to moderate renal impairment

Abstract Background Coronary artery diseases are one of the leading causes of death around the world. Great efforts to diagnose, evaluate, prevent and decreasing morbidity and mortality had been done. CABG is one of the most effective ways for treatment of CAD when compared to PCI or medical treatment. On pump CABG is the basic and gold standard technique for CABG surgery. Yet there are some burdensome complications from the use of CPB so surgeons developed off pump technique to decrease these complications. Objective In this study we compared the early results of isolated CABG, using onpump and off-pump, in patients with preoperative mild to moderate elevation of serum creatinine. We examined if off-pump coronary revascularization offers a superior renal protection and less in post-operative complications when compared with conventional coronary revascularization with cardiopulmonary bypass. Methods This study was prospective cohort, observational study, conducted in post open heart ICU at Ain Shams university hospitals, 6th October insurance hospital and National Heart Institute during the period between October 2018 and April 2019. We enrolled 1st 100 consecutive adult patients scheduled for isolated CABG surgery (with a median sternotomy) with or without cardiopulmonary bypass pump. The patients are allocated in 2 groups where 50 patients in each group (group A – On pump – ONCAB- conventional surgery) and (group B – Off pump –OPCAB – beating heart) after obtaining their written informed consent without cross over between both groups. Results In this study, we found that postoperative AKI among both study group was relatively common defined by AKIN criteria and there was significant difference between the incidences of postoperative AKI among both study groups. It was higher in ONCAB group than OPCAB group (52%, 30% respectively) with (p-value = 0.025). According to AKIN classification for complicated cases with postoperative renal impairment; there were 32% among ONCAB group had AKIN stage 1 renal impairment versus 22% among OPCAB group had the same stage. While, there were 6% versus 2% had AKIN stage 2 renal impairment among ONCAB group versus OPCAB group respectively. Also there were 14% versus 6% had AKIN stage 3 renal impairment among ONCAB group versus OPCAB group respectively. The need for dialysis was much greater in the ONCAB group 20% versus 8% in the OPCAB group with significant p-value (0.029). Early mortality was significantly higher in ONCAB group about 11 cases (22%) VS 4 cases (8%) in OPCAB group with p-value 0.033. Also there was statistically significant difference between ONCAB group and OPCAB group according to drainage amount (p-value 0.028), re-exploration for bleeding (p-value 0.018), mean ICU stay (p-value 0.027) and mean hospital stay (p-value 0.009). Conclusion The off pump CABG is superior and gives more renal protection in patients with preoperative mild to moderate renal impairment. It is also reducing the early mortality and morbidity in these patients.

Minimally invasive mitral valve repair for degenerative etiology: a comparative study

BackgroundThere is a paucity of data comparing the minimally invasive mitral valve repair (MiMVr) to the conventional approach in patients with degenerative disease. Our objective was to compare the outcomes of MiMVr to the traditional mitral valve repair through median sternotomy in patients with degenerative mitral valve disease. We conducted a retrospective study on 215 patients classified into two groups. Group 1 (n = 80) included those who had mitral valve repair through a right anterolateral video-assisted mini-thoracotomy, and group 2 (n = 135) was approached through a conventional median sternotomy. We compared the preoperative, operative, and postoperative data between groups. Both groups had echocardiographic follow-ups after 6 and 12 months.ResultsThere was no difference in gender distribution between both groups, and patients who had median sternotomy were significantly older (median 37 (Q1-Q3, 29-44) vs. 54 (48-60) years; P < 0.001). Cardiopulmonary bypass (134.5 (130-138.5) vs. 99 (97-104) min; P < 0.001) and ischemic times (99 (95-105.5) vs. 78 (75-81) min; P < 0.001) were significantly shorter in patients who had median sternotomy. Patients with MiMVr had significantly lower blood loss (370 (315-390) vs. 550 (490-600) ml; P < 0.001) and ICU stay (5 (4.5-6) vs. 7 (7-8) days; P < 0.001). There was no difference between both groups regarding re-exploration for bleeding, postoperative stroke, wound infection, renal failure, and mortality. As regards postoperative echocardiography follow-up at 6 and 12 months after the operation, there were no significant changes in the mean mitral valve gradient within each group; however, the mean gradient was lower in the MiMVr group (3 (3-3.5) vs. 4 (3-5) mmHg; P < 0.001). There was no significant difference between both groups regarding mitral regurgitation severity during 6 and 12 months follow-up.ConclusionMinimally invasive mitral valve repair in patients with degenerative pathology could be an alternative to conventional mitral valve surgery with comparable short-term and long-term outcomes.

The impact of surgical training on early and long-term outcomes after isolated aortic valve surgery.

OBJECTIVESPatients presenting with more comorbidities, requiring more complex cardiac surgical procedures and an increase in public scrutiny are impacting on training programme because of the perceived risk of worse outcomes. Hence, we aimed to provide evidence that trainees as the first operator can achieve comparable results to consultants when performing isolated surgical aortic valve replacement. METHODSFrom 1996 to 2017, 2919 patients underwent surgical aortic valve replacement at the Bristol Heart Institute, operated on by either a consultant (n = 2220) or a trainee (n = 870) as the first operator. Propensity score matching was used to adjust for imbalance in the baseline characteristics of the 2 groups.RESULTSOver a 21-year period, the proportion of trainee cases dropped from 41.5% to 25.9%. No differences in the rates and risk of in-hospital mortality, new cerebrovascular accidents, re-exploration for bleeding, deep sternal wound infection and length of stay were found between patients operated on in the 2 groups. Also, there was a comparable risk of late death between the 2 groups (HR 0.88; 95% CI 0.73–1.06; P = 0.27) and this was present regardless of trainees career level and patients surgical risk based on the EuroSCORE. Finally, we showed an increase in patients risk profile in the latest year but, this was not associated with the worst outcomes when trainees performed the operation.CONCLUSIONSSurgical aortic valve replacement is a safe and reproducible technique and regardless of the patient’s risk profile, and no differences in the outcomes between trainees and consultant cases were found.

Prevention of postoperative delirium after cardiovascular surgery: A team-based approach

ObjectiveWe investigated the efficacy of the Delirium Team Approach program for delirium prevention after cardiovascular surgery. MethodsWe retrospectively investigated 256 patients who underwent cardiac or thoracic vascular surgery between May 2017 and May 2020. We compared the outcomes before and after implementation of the Delirium Team Approach program in December 2018. The program included the following components: (a) educational sessions for the medical team regarding delirium and its management, (b) review of preprinted physician orders for insomnia and agitation, and (c) routine screening for delirium. We investigated the early outcomes and effects of the Delirium Team Approach program on postoperative delirium. ResultsThe incidence of postoperative delirium significantly decreased from 53.3% to 37.0% after implementation of the Delirium Team Approach program (P = .008). Although no intergroup differences were observed in the rates of stroke and reexploration for bleeding, the length of intensive care unit stay and the overall length of postoperative hospital stay were shorter in the postintervention group. Hospital costs, excluding surgery, and the cost during intensive care unit stay were lower in the postintervention group. Multivariable analysis showed that the Delirium Team Approach program was associated with a reduction in postoperative delirium (odds ratio, 0.38; 95% confidence interval, 0.21-0.67; P = .001). Other predictors of delirium included age, dementia, chronic kidney disease, and intubation time. After risk adjustment using propensity score matching, the rate of postoperative delirium was lower in the postintervention group. ConclusionsImplementation of the Delirium Team Approach program was associated with a lower incidence of postoperative delirium in patients who underwent cardiovascular surgery.

Effect of an assessment of fibrin-based rotational thromboelastometry on blood transfusion and clinical outcomes in cardiovascular surgery: A cohort study

The clinical importance of viscoelastic testing in patient blood management when performing cardiovascular surgery is increasing. We aimed to examine the effect of a blood transfusion protocol including an assessment of fibrin-based rotational thromboelastometry on transfusion volume, mortality, and bleeding complications in patients undergoing cardiac or thoracic aortic surgery. We retrospectively studied a cohort of 376 consecutive patients who underwent cardiopulmonary bypass before (control group: 150 cardiac and 35 thoracic aortic surgeries) and after (assessment group: 154 cardiac and 37 thoracic aortic surgeries) introducing the fibrin polymerization assessment with thromboelastometry in the blood transfusion protocol. The transfusion volume and clinical outcomes were compared between the control and assessment groups, and the standardized (mean) difference (S[M]D) was calculated as an indicator of statistical effect size. Compared with the control group, the assessment group had a lower total blood transfusion volume (mL) in cardiac (2720 ± 1282 vs. 2034 ± 1330, p < 0.0001, [SMD] = 0.68) and thoracic aortic surgeries (5236 ± 2732 vs. 3714 ± 1768, p < 0.0001, SMD = 0.67). The 1-year mortality rates were 1.9 % and 2.7 % in cardiac and thoracic aortic surgeries, respectively. Significant differences were not observed in the 1-year mortality (3.2 % vs. 1.0 %, p = 0.16, relative risk [RR] = 0.32 with 95 % confidence intervals [CI] = 0.06–1.57, SD = 0.15), re-exploration for bleeding (4.8 % vs. 2.6 %, p = 0.28, RR = 0.53 with 95 % CI = 0.18–1.57, SD = 0.12), and major bleeding (17.3 % vs. 13.0 %, p = 0.31, RR = 0.75 with 95 % CI = 0.46–1.22, SD = 0.12) rates between the control and assessment groups. The assessment of fibrin polymerization with thromboelastometry using the blood transfusion protocol reduced the blood transfusion volume in cardiovascular surgery.

Enoxaparin Reduces Catheter-associated Venous Thrombosis After Infant Cardiac Surgery

BackgroundCentral venous catheter (CVC) related venous thrombosis (VT) after pediatric cardiac surgery increases morbidity and mortality. Although VT prevention using low-dose anticoagulation therapy has proven ineffective, anticoagulation therapy using high-dose enoxaparin to achieve a therapeutic anti-Xa level has not been studied. We hypothesized that high-dose enoxaparin would reduce VT after pediatric cardiac surgery. MethodsEnoxaparin was administered to infants aged less than 150 days when postoperative CVC duration was anticipated to extend beyond 5 days. The primary outcome was the rate of VT, reexploration for bleeding, and postoperative red blood cell transfusions per 1000 CVC days. ResultsFrom 2012 to 2019, 157 infants were treated with enoxaparin. Infants were divided into two groups: (1) subtherapeutic (n = 51), in which therapeutic anti-Xa level (0.5 to 1.0 IU/mL) was not achieved; and (2) therapeutic (n = 106), in which therapeutic anti-Xa level was achieved. Baseline demographics demonstrated a lower age at operation in the therapeutic group. The subtherapeutic group had a higher VT rate per 1000 CVC days (8.2) compared with the therapeutic group (2.6; P = .005). Reexploration for bleeding was similar between groups. The number of postoperative red blood cell transfusions per 1000 CVC days was significantly greater in the subtherapeutic group (109.4 vs 81.6; P = .008). Multivariate analysis demonstrated that higher median anti-Xa levels reduced the risk of VT (odds ratio 0.02; 95% confidence interval, 0.001 to 0.63; P = .02). ConclusionsThese data suggest that enoxaparin treatment resulting in a therapeutic anti-Xa level reduces postoperative CVC-associated VT without increasing bleeding complications.

Re-Operative Aortic Arch Surgery in a Contemporary Series

Re-operative aortic arch operations (REDO) following previous cardiac surgery are challenging procedures associated with significant morbidity and mortality. We investigated post-operative outcomes for patients undergoing REDO and identified risk-factors for mortality in a contemporary series. From 1/2005-6/2018, 365 consecutive patients at an academic center underwent REDO: 257 HEMIARCH and 108 COMPLETE arch (45 stage I elephant trunk, 63 total arch) replacements. Outcomes included mortality and major adverse events. Long-term survival was determined with Kaplan-Meier analysis, and risk-factors for mortality were assessed with Cox proportional hazards regression. Operative mortality for the entire cohort was 6.8%, and rates of stroke, cardiac arrest, and renal failure were 6.0%, 7.4%, and 10.4%. Compared to HEMIARCH, COMPLETE patients had an increased incidence of renal failure requiring dialysis (15.7% vs 8.2%, p = 0.031) and re-exploration for bleeding or delayed chest closure (19.4% vs. 11.7%, p = 0.051). Although operative mortality was similar in both cohorts, long-term follow-up mortality (38.0% vs 26.8%, p = 0.047) was higher among COMPLETE vs. HEMIARCH. Predictors ofoverall mortalityamong all-comers undergoing REDO included older age, low body surface area, endocarditis, ejection fraction <30%, emergent status of operation, extended cardiopulmonary bypass duration, intra-aortic balloon pump use, and a more extensive arch operation. Previous aortic surgery was not a risk-factor for mortality. Among all-comers undergoing REDO, survival was 81.4% at 1 year, 66.7% at 5 years, and 56.4% at 10 years of follow-up. While early postoperative outcomes are similar among HEMIARCH and COMPLETE, a more extensive arch-replacement is an independent risk-factor for overall mortality in REDO. Using appropriate clinical indications in the current era, REDO remains a viable option for selected patients.

Thoracotomy versus sternotomy? The effect of surgical approach on outcomes after left ventricular assist device implantation: Areview of the literature and meta-analysis.

Thoracotomy approaches to left ventricular assist device (LVAD) implantation may reduce surgical morbidity and, through preservation of the pericardial restraint over the right heart, may reduce the incidence of right ventricular failure (RVF). A meta-analysis of all original studies describing the effect of the surgical approach on postoperative outcomes after LVAD implantation was performed. Postoperative outcomes analyzed. Thirteen studies were included with 692 patients undergoing a sternotomy and 373 a thoracotomy approach. Patients undergoing a thoracotomy approach had a higher comorbid status (INTERMACS 1-2: 56% vs. 44%; p = .0004), but were less likely to undergo a concomitant procedure (4% vs. 15%;p = .0002) than patients undergoing a sternotomy approach. Patients undergoing a thoracotomy approach demonstrated a reduced incidence of RVF (OR,.47; CI, .23-.97; p = .04), reexploration for bleeding (OR, .55; CI,.32-.94;p = .03), perioperative blood transfusion (SMD, -.30; CI, -.49 to -.11; p = .002), LOS (-5.57; -10.56 to -.59;p = .03), and mortality (OR,.57; CI,.33-.98;p = .04), but no difference in RVAD requirement or stroke were noted. Metaregression demonstrated that the performance of a concomitant procedure did not modify the effect of the surgical approach on the primary endpoints of RVF or RVAD requirement. In the current meta-analysis including over 1000 patients undergoing LVAD implantation, a thoracotomy approach was associated with a reduced incidence of RVF (but not RVAD requirement), bleeding, LOS, and mortality. No difference in stroke rates was noted. These findings not only offer additional support as to the feasibility of a thoracotomy approach for LVAD implantation but also suggest a potential superiority over a sternotomy approach.

The death risk factors of patients undergoing re-exploration for bleeding or tamponade after isolated off-pump coronary artery bypass grafting: a case\u2013control study

BackgroundThe purpose of the study is to identify off-pump patients who are at higher risk of mortality after re-exploration for bleeding or tamponade.MethodsWe analyzed the data of 3256 consecutive patients undergoing isolated off-pump coronary artery bypass grafting (OPCABG) in our heart center from 2013 through 2020. Fifty-eight patients underwent re-exploration after OPCABG. The 58 patients were divided into death group and survival group according to their discharge status. Propensity score matching (PSM) was performed to analysis the risk factors of death. 15 pairs of cases of two groups were matched well.ResultsThe mortality rate of patients underwent re-exploration after OPCABG for bleeding or tamponade was 27.59% (16/58). In the raw data, we found the patients in death group had higher body mass index (BMI) (P = 0.030), higher cardiac troponin T (cTnT) (P = 0.028) and higher incidence of heart failure before OPCABG (P = 0.003). After PSM, the levels of lactic acid before and after re-exploration (P = 0.028 and P < 0.001) were higher in death group. And the levels of creatinine (P = 0.002) and cTnT (P = 0.017) were higher in the death group after re-exploration. The death group had longer reoperation time (P = 0.010). In addition, the perioperative utilization rate of intra-aortic ballon pump (IABP) (P = 0.027), continuous renal replacement therapy (CRRT) (P < 0.001) and platelet transfusion (P = 0.017) were higher than survival group.ConclusionsThe mortality rate of patients undergoing re-exploration for bleeding or tamponade after isolated OPCABG is high. More attention should be paid to patients with above risk factors and appropriate measures should be taken in time.

Impact of ABO blood group on bleeding complications after surgery for acute type A aortic dissection.

Excessive bleeding is a serious complication associated with impaired survival after surgery for acute type A aortic dissection (ATAAD). Different ABO blood groups are associated with variable levels of circulating von Willebrand factor and therefore potentially altered risks of surgical haemorrhage. The current study aimed to assess the impact of blood group on bleeding complications after ATAAD surgery. This was a retrospective cohort study including 336 patients surgically treated for ATAAD between January 2004 and January 2019. Patients with blood group O were compared with non-O patients. In total, 152 blood group O patients were compared with 184 non-O patients. There were no differences in rates of massive bleeding (27.0 vs. 25.5%, P = 0.767) or re-exploration for bleeding (16.4 vs. 13.0%, P = 0.379) in blood group O and non-O patients, respectively. Median chest tube output 12 h after surgery was 520 ml (350-815 ml) in blood group O and 490 ml (278-703 ml) in non-O patients (P = 0.229). Blood group O patients received more fibrinogen concentrate (6.1 ± 4.0 vs. 4.9 ± 3.3 g, P = 0.023) but administered units of packed red blood cells [5 (2-8) vs. 4 (2-9) U, P = 0.736], platelets [4 (2-4) vs. 3 (2-5) U, P = 0.521] or plasma [4 (1-7) vs. 4 (0-7) U, P = 0.562] were similar. This study could not demonstrate any association between blood group and bleeding after surgery for ATAAD. It cannot be ruled out that potential differences were levelled out by blood group O patients receiving significantly more fibrinogen concentrate.

Early Outcomes of Three Total Arch Replacement Strategies for DeBakey Type I Aortic Dissection.

Background: This study employed three surgical techniques: total arch replacement (TAR) with frozen elephant trunk (FET), aortic balloon occlusion technique (ABO) and hybrid aortic arch repair (HAR) on patients with type I aortic dissection in Fuwai Hospital, aiming to compare the early outcomes of these surgical armamentariums.Methods: From January 2016 to December 2018, an overall 633 patients (431 of TAR+FET, 122 of HAR, and 80 of ABO) with type I aortic dissection were included in the study. Thirty-day mortality, stroke, paraplegia, re-exploration for bleeding, and renal replacement therapy were compared using the matching weight method (MWM).Results: After MWM process, the baseline characteristics were comparable among three TAR groups. It showed that ABO group had the longest cardiopulmonary bypass (p < 0.001) and aortic cross-clamp time (p < 0.001), while the operation time was longest in the HAR group (p = 0.039). There was no significant difference in 30-day mortality among groups (p = 0.783). Furthermore, the incidence of stroke (p = 0.679), paraplegia (p = 0.104), re-exploration for bleeding (p = 0.313), and CRRT (p = 0.834) demonstrated no significant difference. Of note, no significant differences were found regarding these outcomes even before using MWM.Conclusions: Based on the early outcomes, the three TAR approaches were equally applicable to type I aortic dissection. We may choose the specific procedure relatively flexibly according to patient status and surgeon's expertise. Importantly, long-term investigations are warranted to determine whether above approaches remain to be of equivalent efficacy and safety.